A hospital to home program for patients with COPD


Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease that causes airflow blockage and breathing-related problems. It is the third leading cause of death in the U.S., behind heart disease and cancer.

One of five patients admitted to the hospital with COPD is readmitted within 30 days, and up to half of these readmissions may be preventable. Drivers of readmission are complex and multifactorial. Approximately 80 percent of COPD patients have at least one comorbidity, and 50 percent have four or more. Additionally, many patients with COPD are frail, debilitated, and have high anxiety and depression levels that complicate management.

In 2017, more than 3,000 patients with COPD were admitted to downtown Penn Medicine hospitals over 5,000 times – 20% of whom were readmitted within 30 days.


BreatheBetterTogether (BBT) is a hospital to home transition program for patients with COPD that facilitates the development and implementation of personalized home-based interventions.

The program leverages a customized Agent dashboard to identify high-risk hospitalized patients with COPD. This technology enables respiratory therapists to engage with patients early in their hospitalization to establish a trusting relationship and conduct self-management training.  

Before discharge, patients are enrolled in a remote-monitoring program powered by Way to Health to detect early symptoms of clinical decline in the outpatient setting. BBT patients receive a daily text message asking them if they feel better, worse, or the same. If a patient responds that they feel worse, the BBT team is immediately alerted. The inpatient respiratory therapist who cared for the patient during their hospitalization conducts an evaluation by phone, provides guidance and reassurance, and, if necessary, rapidly escalates unresolved issues to the on-call pulmonologist.

For patients whose needs cannot be met over the phone, a Penn Cavalry visit is triggered. Cavalry visits entail an experienced Penn Care at Home nurse making a timely acute care visit to the patient's home. After evaluating the patient, the nurse contacts the on-call pulmonologist to coordinate interventions to prevent rehospitalization, such as administering IV corticosteroids, antibiotics, and/or diuretics. If a patient is deemed too ill to treat at home, the nurse contacts emergency medical services and waits with the patient until they arrive for transport to the hospital.


BBT improves patient outcomes and reduces readmission rates by alerting care teams to patient issues early - when they can potentially be resolved with home-based interventions.

In the initial pilot phase with more than 150 high-risk COPD patients at the Hospital of the University of Pennsylvania (HUP), the introduction of BBT led to a 32 percent reduction in 30-day readmissions, and Penn Cavalry prevented 82 percent of readmissions. Together, these programs result in cost savings to the health system of approximately $10,000 per patient.  

BBT is the standard of care at HUP, Pennsylvania Hospital, Penn Presbyterian Medical Center, and Lancaster General Health.


Patients with COPD are at increased risk of severe illness from COVID-19. The BBT program enables more COPD patients to be managed at home rather than in hospital settings, thereby decreasing the risk of exposure for this vulnerable population. Additionally, the BBT logic was used as a blueprint to create COVID Watch, a program launched at the start of the pandemic. COVID Watch enables patients who are confirmed or likely to have COVID-19 but not sick enough to need hospitalization to be monitored at home.

Phase 3: How we work

Vivek Ahya, MD
Michael Sims, MD, MSCE
Colleen Cain, RRT

Innovation leads

Mike Begley, MA
Matt Van Der Tuyn, MA
David Asch, MD, MBA


Innovation Accelerator Program
Independence Blue Cross

Innovation Methods

Frequently, our work involves reimagining processes to achieve better results.
The concept of deletion is about isolating part of a process that is problematic and solving for its absence. Imagine solving for airport security without the security line or collecting tolls without tollbooths.
With this technique, you're not allowed to improve the flawed part of a process. You must delete it and then, making sure you understand what essential benefits it provided, if any, introduce alternative approaches.

To kick start brainstorming a different way of caring for vulnerable COPD patients, the team asked the question, "How would we care for COPD patients having an exacerbation if hospital care wasn't an option?"

The concierge
A concierge provides hands-on, efficient, and proactive services for customers.
Similar to the concept of walking in someone's shoes, a concierge walks alongside someone and helps them get things done.
Acting as a concierge or high-touch helper for a small sample of people will enable you to get deep into the reality of their journey and learn about the barriers they face, because like a real concierge, you'll help them navigate those barriers. You can also test solutions in real time as you explore the problem space in context.
The concierge
To understand the root causes of clinical decline for patients with COPD, we started conducting daily check-ins via text message with a small number of patients. This was introduced as a concierge service to patients.
While this started as an approach to learn what happens when patients are at home, it ended up becoming the foundation of the BBT intervention.
High fidelity learning can come from low fidelity deployment.
Mini-pilots will allow you to learn by doing, usually by deploying a fake back end. You might try a new intervention with ten patients over two days in one clinic, using manual processes for what might ultimately be automated.
Running a "pop-up" novel clinic or offering a different path to a handful of patients will enable you to learn what works and what doesn't more quickly. And, limiting the scope can help you gain buy-in from stakeholders to get your solution out into the world with users and test safely.

To determine the efficacy of the same-day acute care visit model, the team launched a 20-day pilot leveraging existing ride-sharing services and borrowed medical supply backpacks from the helicopter-based trauma team.

Rapidly deploying the service enabled the team to validate that seemingly inevitable admissions could be prevented at a very low cost.


Pitch Day 2018