Chronic Obstructive Pulmonary Disease (COPD) affects an estimated 11.7 million Americans, according to the American Lung Association. As tissues thicken and airways narrow, airflow in and out of the lungs is limited, resulting in breathing problems and less oxygen traveling to organs and tissues. This can in turn exacerbate other serious health issues, including heart failure. Rates of COPD are notably higher among smokers, and those with lower levels of income and education. As with many chronic illnesses, COPD is highly prevalent among Montefiore Einstein’s patients in the Bronx.

It’s also tricky to diagnose. The only way to confirm a patient’s respiratory symptoms are caused by COPD is a spirometry test, which measures how much air a patient can breathe in and out of their lungs and also how fast they can empty their lungs. The test must be performed at a patient’s baseline, before symptoms become acute. Many patients with COPD don’t know they have it, and this is doubly true in the Bronx, where social barriers to care mean many people are less likely to visit the doctor regularly.

All of this increases the likelihood that COPD patients in communities such as those served by Montefiore Einstein end up in the hospital with severe cough, shortness of breath, and other serious symptoms. In July 2023, pulmonologists in the Department of Medicine led by Sarah Sungurlu, DO, began collaborating with Montefiore Einstein’s Transitional Care Excellence (TCE) team. Together, they use an inpatient hospital stay as an opportunity to make sure these vulnerable patients get the ongoing care they need to stay healthy—and that they don’t end up back the hospital.

The effort around reducing hospital readmissions for COPD and connecting patients with follow-up care has been a resounding success. In 2024, the TCE team has provided care to 330 patients hospitalized with COPD. As part of the care pathway, 95 new patients attended a post-discharge appointment with the pulmonary team.

Moving the needle

“The secret to the Transitional Care Excellence approach is really digging down to identify that patient's individual needs,” says Katherine Di Palo, PharmD, MBA, MS, senior director of the department. “What's going to help that patient be successful and keep them out of the hospital again, and how can we connect them with those resources? Every time we get a new challenge, the buck stops here.”

When Dr. Di Palo began working at Montefiore Einstein in 2015, she was a clinical pharmacist and patient navigator, working on a multidisciplinary heart failure. The team met with patients in the hospital prior to discharge and then also saw them for a follow-up visit once they were home. “If you didn't have access to doctors, we became your care team,” she says. “If you had doctors, we made sure you reconnected with them. Either way, we ensured there was continuity.”

She continued, “We also recognized and addressed the non-medical needs of our socially vulnerable patients. I remember running down Gun Hill Road one day because I wanted to get certain meds to a patient prior to discharge. She had been readmitted so many times and had no one at home to pick-up her prescriptions. We felt, this is what’s going to help get her back on track.”

In 2016 she began collaborating with Jeffrey Weiss, MD, senior vice president for medical affairs, who was looking at ways to reduce heart failure readmissions as a strategic quality improvement goal. Building off the success of their Hospital Readmissions Reduction Program, the seeds of the Transitional Care Excellence (TCE) were planted. The department was codified under that name in of 2022 and launched its service across Montefiore Medical Center in September 2023, with an expanded scope of COPD, pneumonia, and heart attack as well as heart failure.

Branching out

COPD had similarities to heart failure, in that it was highly prevalent in the Bronx, leading to many readmissions to the hospital. It was also a chronic illness that could be managed with the right support and resources, but which under the wrong circumstances could land patients in the emergency room.

The first step was developing detailed criteria for high-risk patients. “We created guidelines for hospitalists and a system for flagging patients that should have a pulmonary consult,” says Dr. Sungurlu. She or another pulmonologist evaluate the patient while they are in the hospital and make an initial diagnosis and recommendations.

High risk patients now also get flagged for a consult with the TCE team. “Before, not every patient who would benefit from TCE’s involvement was getting it,” says Dr. Sungurlu. “I don’t think all our providers know about all the resources that TCE brings to the table, but awareness is growing.”

From left, TCE team members Patrick Kohn, PharmD, clinical pharmacy manager, cardiology and pulmonology, and Danielle Garcia, PharmD, clinical pharmacy manager, cardiology.

The TCE team consists of eight pharmacists and six nurse practitioners, spread across the Moses, Wakefield, and Weiler hospital campuses. There are also three research associates, who act as patient navigators and bring a “whatever it takes” approach to ensuring people get the care they need once they leave the hospital, including finding transportation, connecting them with meals or housing support, and more.

“Quality improvement and implementation science are embedded into how we approach transitional care in the Bronx,” says Dr. Di Palo. “We view these positions as an opportunity for real-world research to learn from our patients and test novel interventions.” One thing the research associates have been looking at is the “digital divide,” conducting surveys about patients’ access and comfort using technology. In one example of their resourcefulness, they have assisted patients and family members at the bedside to create MyChart accounts so they can receive important information after discharge.

A seamless process from inpatient to outpatient care

Patrick Kohn, PharmD, BCPS, clinical pharmacy manager with the TCE program, is one of the team members who meets with inpatients at the Weiler Hospital. “We always do a full initial assessment with them, which is usually around 45 minutes, depending on their individual needs,” he says.

This includes determining which of several medication options will be best for a patient, based both on their individual needs and their insurance coverage. “Some inhalers require more fine motor coordination to use correctly, while others require a deep, fast inhale, which a patient might not physically be able to do, depending on their disease state,” says Dr. Kohn. “We bring expertise both on how to use the medications and any barriers to patients obtaining them post-discharge.”

Certain COPD medications can also cause side effects, so the team may recommend that the patient starts the therapy in the hospital, to see if they are able to tolerate it well. “It sometimes sounds small, but if they can't use a medicine adequately, they're not getting the full benefit,” Dr. Kohn explains.

After a patient is discharged, those same TCE team members follow up via telephone call or a video visit. They check in on their recovery, make sure they are able to take their medications as directed, and confirm they’ll be able to make it to their follow-up appointments, which have already been scheduled. Within two weeks of discharge, every patient sees either a pulmonologist or a primary care doctor.

“Our motto is no patient left behind,” says Dr. Di Palo. “I think that's been one of our greatest successes in the first year, getting the right patients to our right specialty partners. This is key to avoiding another trip to the hospital and their overall health outcomes.”

Dr. Sungurlu sees patients for follow-ups at the Hutchinson practice location. “Most often, we'll do what's called a complete pulmonary function test, which gives us lung volumes and diffusion volumes, because that helps us distinguish symptoms that look like COPD but actually aren't,” she says. “That way we make sure care is optimized. If it turns out a patient actually has bronchiectasis or interstitial lung disease or many other diagnoses, we can adjust the treatment plan.”

She adds that patients with COPD and other obstructive lung diseases, including asthma, are actually more vulnerable to further problems following a hospital stay, making careful follow-up especially critical. “The lungs take time to recover from any exacerbation,” she explains. “For several months, the lungs remain overly sensitive, and it takes much less for them to be re-injured. That's the biggest difference with COPD compared to a pneumonia or heart failure,” other patients the TCE team works with.

Expanding the playbook

The TCE team is looking at what other patients may benefit from their involvement. And there is still more to be done within their current mandate. “There still is a huge gap for our patients on oxygen at home, who are too sick at times to come in for office visits,” says Dr. Di Palo. “We are looking at what more we can be doing from a telemedicine perspective, and how we can leverage innovation that meets our patients where they are, especially when sometimes they don't have great access to technology.”

In the meantime, everyone is determined to keep up the program’s great results. “It’s not a single person or process,” says Dr. Sungurlu of their success in reducing COPD readmissions. “It's the fact that we have so many people working together from every angle, because each patient is different, and their barriers to care are different.”

Dr. Kohn shares, “I was drawn to the TCE team because for me, it’s one of the clearest examples of enacting the mission of Montefiore—providing high-level academic care to the underserved population of the Bronx. It’s extremely fulfilling to know we’re helping a high-risk population of people with complex chronic diseases like COPD.”

“It's honestly amazing the amount of resources that have been put into this,” adds Dr. Sungurlu. “It’s something I'm pretty proud to be involved in.”