The impact of pulmonary diseases on other chronic conditions is often misunderstood and commonly underreported. More than half the Americans with Chronic Obstructive Pulmonary Disease (COPD) have not been diagnosed, and these conditions often intersect with other polychronic ailments. This intersectionality was highlighted in the most recent GOLD report, emphasizing the importance of recognizing and addressing co-morbidities such as cardiovascular disease, anemia, renal failure, depression, and sarcopenia; in particular, studies suggest that up to 60% of individuals with COPD have coexisting cardiovascular conditions.
According to the National Center for Health Statistics, respiratory symptoms, especially dyspnea, are a leading reason Americans seek acute care. In many care settings, these presentations are coded under COPD-related diagnoses. However, dyspnea represents a shared final common pathway for a range of underlying polychronic conditions, including heart failure, volume overload from renal dysfunction, anemia, and obstructive lung diseases such as COPD. As a result, patients may carry pulmonary diagnoses that incompletely capture the myriad drivers behind their disabling symptoms. Longitudinal evaluation and treatment performed well in advance of symptom onset can distinguish between these comorbidities and may help reduce symptom severity and mitigate avoidable emergency department utilization. Making diagnoses earlier and instituting treatment at home can prevent the need for acute care for many patients.
As Chief Pulmonologist at Monogram Health, I see the interactions between pulmonary and other polychronic conditions every day. The interplay between chronically dysfunctional organ systems is so profound that a siloed, fragmented approach to healthcare makes it impossible to focus on what matters most: the patient’s overall health, personal goals, and the social determinants of health that impact them. In other words, a siloed approach to sub-specialty care misses seeing the patient as a whole person.
Disrupting the Status Quo with a New Approach
At Monogram Health, our model is designed around early engagement and interdisciplinary management of clinically complex patients. In conventional care pathways, pulmonologists are often engaged after patients have already experienced significant disease progression or repeated acute events, and after long wait times for a pulmonary appointment. Within Monogram’s longitudinal, home-based care model, pulmonary expertise is incorporated earlier, allowing care teams to focus on stabilizing symptoms, clarifying diagnoses, and addressing modifiable drivers of risk.
A typical in-home visit to a patient dealing with pulmonary conditions is built around Monogram’s comprehensive, in-home clinical assessment: Nurses and nurse practitioners trained in polychronic care spend extended time, often an hour or more, evaluating and treating patients in their homes. This setting enables a depth of assessment that is difficult to replicate in traditional outpatient environments.
This assessment includes medication optimization, one of the most beneficial aspects of Monogram’s high-touch, in-home approach due to the rise of polypharmacy, especially among geriatric, polychronic patients. In the home, Monogram clinicians can see what medications the patient is actually taking and how they are taking them, as opposed to trying to reconcile medication lists from the Primary Care Physician, various sub-specialists, and/or a recent discharge. This is particularly important given Monogram patients take an average of more than 12 medications daily. Moreover, the most common cause of inadequate treatment response for pulmonary conditions is problems with inhaler technique or adherence. As appropriate, Monogram clinicians prescribe maintenance treatments such as long-acting bronchodilator inhalers and rescue medications.
Unsurprisingly, many patients with polychronic conditions impacting multiple organ systems are active smokers. As such, smoking cessation is one of the most impactful, yet underutilized, interventions in the community. At Monogram, smoking cessation is treated as a longitudinal, medication-assisted clinical process rather than a brief counseling encounter. Our clinicians have the time and training to assess readiness, provide repeated motivational support, initiate and titrate combination pharmacotherapy including nicotine replacement with bupropion or varenicline, and manage side effects over time. This level of engagement is rarely possible in traditional care settings. For patients with COPD and other chronic conditions, successful smoking cessation meaningfully slows disease progression, reduces exacerbations, and improves overall physiologic reserve—benefits that compound across organ systems and comorbidities.
Once in-home, our nurses and nurse practitioners often identify challenges with living circumstances and other social determinants of health (SDoH). We’re able to bring in Monogram’s full-time employed social workers to seek out resources on the patient’s behalf. Poor housing conditions such as dust, mold, and temperature instability can increase airway irritation and trigger exacerbations, while financial barriers and pharmacy access issues can limit adherence to critical medications like inhalers, nebulizers, and steroids. Monogram is able to close these gaps in care.
Patients often misunderstand or outright disbelieve the labels that providers have given them over the years. It is more often that we hear a patient say, “They keep saying I have COPD, but I don’t understand what that means,” or “Is this the right diagnosis if my inhalers aren’t making me feel better?” At Monogram, we provide personalized, patient-centered education: being in-home allows us to teach the patient using their own inhalers and DME. We help patients understand how their conditions affect their bodies, explaining their various medical problems and go even further to teach infection prevention, breathing mechanics, the purposes of all medications, and early warning signs of deterioration. This gives patients an understanding of their disease that they’ve often lacked, building trust and adherence to treatment.
One of the biggest benefits of being in-home with patients is the ability to perform point-of-care spirometry. Spirometry provides objective data about a patient’s lung function and helps determine whether or how much a pulmonary condition is driving their symptoms. Unfortunately, despite recommendations to the contrary, many patients who meet criteria for spirometry don’t have access in the community, including patients with suspected COPD and those at high risk for obstructive lung disease. The lack of community testing leads to some patients being mislabeled as having COPD when they do not, and for others, the diagnosis isn’t recognized at all. Performing spirometry in the home allows us to engage the patient in the diagnostic process, addressing doubts about their condition; we can make new diagnoses of COPD in high-risk patients and change the trajectory of their remaining years; we may clarify the burden of heart versus lung disease in polychronic patients; and, when present, we can grade the severity of COPD, all of which helps us stratify pulmonary risk for targeted early intervention.
Before the conclusion of any visit, thepatient receives a personalized action plan with clear instructions for managing the onset of respiratory symptoms using the resources they have – and that we provide for them – at home. Patients also have 24/7 access to “Monogram Health FIRST – Urgent Care at Home,” ensuring continuity of care and real-time support if their conditions worsen. These calls are staffed by nurses, nurse practitioners, and physicians and routed to a pulmonary specialist within 24 hours.
Specialty Coordination
Monogram’s success in treating pulmonary conditions is rooted in tightly integrated, multispecialty teams of employed physicians and nurse practitioners who treat clinically complex patients holistically. In traditional systems, specialists come in and treat a specific organ or condition in isolation. At Monogram, sub-specialty clinicians communicate in real-time, often bringing in our colleagues to consult during an appointment, not just through chart documentation or EMR inboxes. This coordination is vital for pulmonary conditions because these conditions often impact each other:
- Cardiology: In-home spirometry and standardized COPD assessment tools help distinguish pulmonary disease from cardiovascular causes of symptoms. In a recent case, a patient diagnosed with COPD and requiring three-to-four liters of oxygen was found, through spirometry testing, not to have COPD at all. His symptoms were driven predominantly by heart failure superimposed on renal disease. Monogram’s pulmonary and cardiac clinicians met on the spot while the nursing practitioner was still in the patient’s home to create an updated, personalized treatment plan.
- Nephrology: Understanding, diagnosing, and treating kidney disease can prevent downstream complications, such as fluid overload, which often precipitates a respiratory crisis. For example, the combined burden of fluid imbalance and reduced respiratory reserve substantially accelerates respiratory decline after a missed dialysis session.
- Palliative Care: Patients living with chronic pulmonary diseases face a heightened risk of acute clinical decompensation; moreover, each such event tends to worsen the patient’s baseline functional status and quality of life. Monogram’s pulmonary programs emphasize palliative care engagement from our initial evaluation. In-home clinicians set up a foundation and expectations that pulmonary clinicians build on. With extended in-home visits, Monogram clinicians go beyond checking the boxes of determining a healthcare proxy and documenting existing code status. The patient, and when possible, family members, are engaged in discussing the patient’s goals of care as well as personal goals. For patients with the most prevalent or expected needs, Monogram’s palliative care physicians meet directly with the patient and work closely with pulmonary and other sub-specialists. In every case, palliative care, like everything else at Monogram, is built on relationships. Trust is built over extended in-home visits, always meeting the patient where they are.
- Endocrinology, Psychiatry, and more: The recognition and treatment of all co-morbid conditions is essential to the management of pulmonary disease. Uncontrolled diabetes paired with systemic corticosteroids used for acute exacerbation of COPD increases the risk for pneumonia. Anxiety and depression exacerbate the symptoms of dyspnea and progressive disability common in severe COPD. Anemia, an independent cause of dyspnea, can compound pulmonary symptoms. Anemia is associated with a worsening quality of life, airflow obstruction, and increased risk of severe exacerbations, with a higher mortality in patients with COPD.
Structure, Process, and Outcomes
Monogram has invested time and resources in in-home clinicians, paired with sub-specialist training and support, to further improve patient experience and outcomes.
- Structure: Our pulmonary team performs hundreds of asynchronous e-consults, co-visits with in-home clinicians, and robust didactics, including CME eligible Grand Rounds, and 1:1 training sessions with in-home Advanced Practice Providers (APPs). If fact, over 95% of visits between a pulmonary clinician and a patient are moderated by an in-home APP, providing clinical care and sub-specialty training simultaneously with a framework for graduated autonomy. In 2025, Monogram sub-specialists provided weekly company-wide Grand Rounds with over 50 hours of teaching. Since September, these Grand Rounds have been CME eligible through Monogram’s partnership with UT Health Houston.
- Process: We perform symptom scoring with every patient who has COPD or another pulmonary condition, allowing us to track trends over time. When scores improve, we can demonstrate progress; when they do not, we proactively intervene. The Chronic Airways Assessment Test (CAAT aka CAT) has been performed over 52,000 times on over 15,000 distinct patients in the past year with 39% positive scores (over 10). We have obtained clinically actionable quality results from in-home spirometry for over 2,700 Monogram patients since launching the program in the past year.
- Outcomes: Patients with COPD enrolled in Monogram’s program have 13% fewer ER visits per thousand, 13% fewer admissions per thousand, and about 14% fewer readmissions per thousand compared to a non-enrolled comparison population. The effect is only stronger if you consider patients with COPD and heart failure, CVD, Diabetes, and CKD stage 4 or higher, including ESRD: 24% fewer ER visits per thousand, 20% fewer admits per thousand, and 23% fewer readmissions per thousand.
This holistic, personalized, patient-driven, patient-centered care delivered is extremely difficult to deliver at a population level through traditional brick-and-mortar systems. Even in Boston, MA – where I live and where it feels like there is a hospital on every street corner – care is fragmented and access is challenging. Patients struggle to convey results between doctors and health systems and often lack timely access to sub-specialist care. But at Monogram, patients experience concierge-level treatment and care delivered to their homes based on their medical need rather than what they can afford or access on their own. Monogram’s care is accessible, equitable, interconnected, and uninterrupted, and the results are plain to see – especially to the patients we serve.
The post Reinventing Pulmonary Care for Medically Complex Patients in America appeared first on Becker's Hospital Review | Healthcare News & Analysis.
Source: Read Original Article
