TABLE 2.

Select COPD Programs and Initiatives by Site, as Described by Interviewees

Readmission Group	Site	COPD Programs and Initiatives
Low	A	Designated COPD nurse (in charge of triaging patient calls; postdischarge follow-ups to assist with appointment scheduling, referrals, and need assessment; and follow-ups with frequent exacerbators) Monitoring pulmonary rehabilitation referrals Telehealth pulmonology rehabilitation (weekly 30-minute calls to discuss progress, barriers, and solutions; used as an alternative or supplement to outpatient rehabilitation) COPD discharge bundles (pulmonary rehabilitation referral, vaccinations, inhaler education, postdischarge action plan) Involving primary care team members in COPD care management Robust use of electronic consultations (e-consults) between providers Subspecialty urgent care clinic Multidisciplinary lung cancer and lung disease programs
	B	Involving outpatient pulmonary team during hospitalization Daily inpatient discharge rounds to assess patients’ postdischarge needs COPD patient education COPD coordinator to schedule appointments and arrange home-based care COPD telehealth (patients calling VAMC-based providers from CBOCs) Inpatient and outpatient smoking cessation programs Pulmonary rehabilitation referrals
	C	Inpatient self-management education Inpatient and outpatient smoking cessation counseling Multidisciplinary COPD postdischarge clinic Non-condition-specific readmission reduction clinic
High	D	Case management (postdischarge follow-up and in-person/telehealth appointment to discuss medication, symptom management, and action plan) Predischarge patient education Standardized COPD order set embedded in EHR (to facilitate medication prescriptions)
	E	Early palliative care consult Hospital interdisciplinary huddles to discuss patient needs Early-stage quality improvement project to create a readmission-reduction interdisciplinary team
	F	Postdischarge nurse follow-up Inpatient and outpatient smoking cessation programs Telehealth services (for monitoring COPD symptoms) Pulmonary rehabilitation Interdisciplinary huddles on readmission reduction for chronic conditions

CBOC indicates community-based outpatient cLiniC; COPD, chronic obstructive pulmonary disease; EHR, electronic health record; VAMC, Veterans Affairs medical center.