Denise McKinnon’s day at Duke University Hospital typically begins with a review of a systems list to see which patients with chronic obstructive pulmonary disease have been admitted.

As a COPD navigator, McKinnon serves as a patient advocate for those with the disease. She oversees patient care and provides education on managing the illness with the goal of improving overall quality of life and reducing hospital readmissions.

“The first order of business is to locate the patient, and then to do a chart review to see how their disease is managed prior to the admission to ensure that they’re stable enough for a visit,” McKinnon says. ““You don’t want to go see them while they’re in the ICU or in acute phase, because our goal is to teach the patient how to manage their disease prior to discharge.”

Better Disease Management

COPD is the third-leading cause of hospital readmissions in the United States, but what exactly is it?

“Chronic obstruction pulmonary disease is a persistent long-term condition in which there is decreased airflow in and out of the lungs,” McKinnon explains.

A 37-year veteran at Duke, McKinnon became the hospital’s first COPD navigator five years ago. The position is an emerging one across the country as institutions aim to not only provide better treatment, but the education and resources to help patients manage their diseases on their own and prevent more hospital visits. The job goes beyond the treatment provided in hospitals by pulmonologists, respiratory therapists, and nurses – their work empowers patients to improve their own quality of life.

“Our medical director always put great emphasis on COPD management. In addition, before we had this particular role many years ago, I took care of many COPD patients when I first came to Duke under his direction. Our role was much different back then. We concentrated more on delivering care,” McKinnon says.

Over the years the patients were admitted to areas outside the pulmonary floor. It was easier to have one navigator find those patients and contact their providers. The catalyst for the role wasn’t so much readmission rates – they were already pretty good – but “improving the quality of care for the COPD patients,” McKinnon added. “We knew that if we did that, then we would inadvertently drop the readmissions at some point.”

The Importance of Facetime

Back to her day-to-day work: If she determines a patient is well enough for a visit, she’ll go speak to them.

“We do a face-to-face interview, which is extremely important in this process,” McKinnon said. “You may learn things about the patient’s disease management that they may not have communicated to the other healthcare workers. “I have the ability to establish a rapport with patients.”

Next comes applying GOLD guidelines (the Global Initiative for Chronic Obstructive Lung Disease):

  • Assess medication regimens using the GOLD standards and patients’ understanding of delivery devices.
  • Assess for oxygen requirements.
  • Assess for sleep-disordered breathing by using a STOP questionnaire for patients whom we suspect may have OSA and make recommendations to providers for a sleep study.
  • Look for Co2 retention and evaluate the need for BIPAP/NIV.
  • Provide smoking cessation for patients who are amenable to this service.
  • We highly recommend pulmonary rehab to deconditioned patients.
  • When anxiety or depression is a problem, we recommend stress management and communicate this to the covering provider.

COVID-19’s Impact

The lengthy list of duties McKinnon discussed are all currently being done inpatient due to the COVID-19 pandemic. Previously, she’d arrange follow-up appointments at her patients’ clinics.

In addition to forcing all job functions to be done inside the hospital, the coronavirus has led to concerns over patient safety.

“They already have a compromised respiratory system. Every fall, we see COPD patients who develop respiratory viruses,” McKinnon said.

Patients who come to the ER receive a COPD action plan. A green light means they’re doing well, while yellow signals they are “in the cautionary.” In the yellow phase, McKinnon encourages patients to contact their individual providers to avoid a hospital admission.

‘Thank You for That’

Certain success stories – resulting in patients that don’t need to be readmitted – remain fresh in McKinnon’s mind.

“I did smoking counseling on one particular guy. I got an email from his sister and she said, ‘After you left my brother’s room, he went home and he never smoked again. We want to thank you for that,’” she recalled. “And I had a lady who lives in the coast, I went in to do her education. She also sent me an email thanking me for educating her on how she could respond to her disease, specifically the action plan. She now knew when she was getting in what we call the ‘yellow zone,’ and instead of getting sick enough to come here for an admission, she would call her pulmonologist. He was able to prescribe medication to prevent an admission. We’ve seen a lot of those kind of things and it’s really exciting.”

McKinnon believes it’s important for respiratory therapists be aware of the potential to move into disease management roles.

“This is the time for respiratory therapists to get on board with the disease management roles whether it be trach navigator or COPD navigator,” she said. “After you have been a therapist for a while, you’ve been working in this capacity, you can apply for your case management certification.”