COPD Chronic Care Management mHealth Program


Sharp HealthCare

Project Summary

COPD chronic care management of under-funded (Medi-Cal, CMS), unfunded (self-pay) and unassigned (Medicare FFS) patients utilizing mHealth technology


Cardiocom Commander Flex

Targeted Locations

San Diego, California


San Diego Beacon Community


12-Month Goals


  • Reduce 30-day readmit rates by 30% during grant period
  • Reduce direct costs associated with readmissions by 30%


Older Adult Population

1st year: 120-180 patients with COPD, Medi-Cal/County Medical Services, unfunded and Medicare fee-for-service

Setting/Provider Type

Patient homes and Sharp HealthCare clinicians


Pre- and post-intervention evaluation.
Outcome measures:  Medical service use (e.g., total admissions, readmissions); cost of medical care (hospital costs, medical group costs, system costs); caregiver burden; clinical measures; patient behaviors (e.g. compliance using remote monitoring equipment; medication adherence, primary/specialty physician follow up, drugs); and mortality.

Replication, Dissemination Plan

Knowledge management, specifically sharing best practices and lessons learned with other organizations, is a cultural norm at Sharp HealthCare. Dissemination of project findings to the San Diego Beacon Community will also occur.

Sustainability Plan

Financial savings (cost avoidance) of the technology are significantly greater than the cost to implement and maintain the program, future funding to support the sustainability of this program will be incorporated into the budgeting process for the operational area supporting the program.  This will be treated as an expense (i.e., home care, disease case management, transitions, etc.) to care for chronic care patients in an effort to keep them out of the acute care setting.

Sharp HealthCare Technology Intervention

This project  is using the Cardiocom Commander Flex, web-enabled data portal and a personal health coach to reach at least 120 – 180 patients with COPD.  The technology employed monitors daily oxygen saturation along symptoms. Information is automatically sent over a cellular network to data portal for analysis by the chronic care RN project coordinator. The technology, in conjunction with a Chronic Care RN Project Coordinator, is used in conjunction with a transitional care model that enables the patient to be successful in their transition from hospital to home. While the technology is integral to patient care, a patient dealing with a chronic condition, especially post-hospital discharge, there is a greater likelihood of success in compliance with discharge instructions if the patient has a person to whom they are accountable.  The Sharp program includes a dedicated hospital-affiliated clinician to address the critical social factors and health care issues (i.e., depression, medication reconciliation, activities of daily living) that influence poor compliance that in turn can lead to a readmission. The use of a portable device that allows two-way communication also contributes to patients being more compliant with their discharge instructions.

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