PURPOSE: Chronic Diseases such as COPD and heart failure (HF) have been identified as the first and third most expensive diagnoses to manage in the US. Medication adherence is a causative factor in frequent exacerbations requiring hospitalization in COPD and HF. The purpose of this study was to evaluate outcomes over time of a Medical Home Program (MHP) with protocols focused on teaching medication and symptom management and monitored exercise conditioning in the treatment of pts with COPD or HF or combined disease.
METHODS: The study was designed as a prospective case-control study. Enrollment occurred immediately post a disease related hospitalization. Patients provided informed consent allowing review of medical records for 5 years. Data analysis included comparison of functional capacity, quality of life and disease related hospitalizations one year prior to the program and up to two years after the program. MHP included a HF and or COPD specific clinic and a 12 week comprehensive HF and or COPD management and exercise program Medications for MHP Pts were optimized per evidence-based recommendations. Pts received education in the proper use of medications and management of side effects, appropriate diet targeting sodium balance, use of breathing techniques and bronchial hygiene.
RESULTS: Disease related hospitalization days for the combined population were evaluated for 12 months prior to enrollment and 24 months post enrollment. Pre enrollment data reported 9.62 hospital days per patient per year and post enrollment data reported 2.85 hospital days per patient per year two years following enrollment.
CONCLUSION: 1. All Patients participating in MHP demonstrated long-term improvement in functional capacity.2. Patients demonstrated a significant reduction in disease related hospital days two years following MH.
CLINICAL IMPLICATIONS: Data from this study suggests that MHP for COPD and HF could improve pt. functional capacity and reduce cost of management of these diagnoses.
DISCLOSURE: Linda Houston-Feenstra, No Financial Disclosure Information; No Product/Research Disclosure Information