Managing Chronic Obstructive Pulmonary Disease (COPD) Learning Collaborative

Size: px

Start display at page:

Download "Managing Chronic Obstructive Pulmonary Disease (COPD) Learning Collaborative"

Darren Sims
5 years ago
Views:

Managing Chronic Obstructive Pulmonary Disease (COPD) Learning Collaborative 1 Sponsored by AMGA and Boehringer Ingelheim Pharmaceuticals, Inc.

1 Managing Chronic Obstructive Pulmonary Disease (COPD) Learning Collaborative 1 Sponsored by AMGA and Boehringer Ingelheim Pharmaceuticals, Inc. November 2-4, 2011 San Antonio, TX DuPage Medical Group COPD Collaborative Final Report Kamila Zlotnicki, MHA; Project Manager Value Driven Health Care Susan Becker, RN, MBA; Quality Manager Value Driven Health Care

2 2 Presentation Agenda DuPage Medical Group (DMG) Vital Statistics and QEA DMG and COPD What we have done thus far: Tools and processes in place for the care of our COPD patients COPD Collaborative Results Challenges and Solutions Future Steps Lessons Learned Questions for the Group

3 3 DuPage Medical Group Vital Statistics and QEA

4 4 DuPage Medical Group Independent multi-specialty group in the western suburbs of Chicago Established in 1999 (from groups practicing since the 60s) 333 Physicians; 2500 employees ~$375 million Revenue 40 Specialties; 45+ Sites 350,000 active patients; Serve 1/3 of DuPage County (Locations in 4 counties DuPage, Will, Kane and Cook) Dedicated to a full range of Ancillary services including Imaging, Infusion Therapy and the Cancer Center (currently under construction) Dominant physician group at 3 area hospitals; committed to growing our footprint in the Hinsdale and LaGrange area Partnership with Edward Hospital to improve quality, efficiency and access in the region

5 5 Quality Efficiency Access DMG s transformation to adapt and lead the changing health care environment by delivering physiciandirected, market-competitive health care services focused on excellence in: Patient outcomes Patient experience Business processes Patient access

6 6 DMG and COPD What we have done thus far: Tools and processes in place for the care of our COPD patients

7 7 DMG and COPD Vision: Goal: To improve the outcomes of COPD in our patient population Improve the care provided to our COPD patients, to decrease hospitalizations and improve patient outcomes

8 8 Collaborative Team Composition Pulmonary R. Nemivant, MD M. McCormick, BA.RRT, MBA S. Stakenas, APN K. Warren, APN Internal Medicine R. King, MD Value Driven Health Care K. Ramachandran K. Zlotnicki, MHA S. Becker, RN, MBA Information Technology D. Pickering K. LeClair Family Practice

9 9 COPD Pathway Released January 2010 Site by site roll out of the pathway On-site education of functionality COPD Pathway is triggered by the use of the Problem List Includes COPD-specific SmartSets, flowsheet, dyspnea scale, patient education and guidelines

10 10 COPD on Problem List Epic - COPD Tools

11 11 COPD Pathway Epic - COPD Tools

12 12 COPD SmartSet Epic - COPD Tools

13 13 Epic - COPD Tools COPD Flowsheet

14 14 Epic - COPD Tools COPD Flowsheet report over time

15 Epic - COPD Tools 15

16 16 Patient Instructions Epic - COPD Tools

17 17 Spirometry Spirometry results are not integrated with Epic Worked with respiratory team to develop a process to routinely enter results into Epic following procedure Manually enter results for procedures previously done

18 18 Post Hospital Patient Outreach Developed process for post-hospitalization follow-up of COPD patients Most hospitalized COPD patients are contacted upon discharge by a DMG Case Manager Assure understanding of follow-up instructions Arrange any follow-up appointments

19 Phytel Outreach Calls Utilizing automated outreach calls to our COPD patients Following 5 month pilot, rolled out to all Primary Care sites in June 2011 COPD protocol for outreach:

19 19 Phytel Outreach Calls Utilizing automated outreach calls to our COPD patients Following 5 month pilot, rolled out to all Primary Care sites in June 2011 COPD protocol for outreach: Identify patients years old with a COPD diagnosis who have not had a chronic condition visitrelated charge in the previous 6 months and do not have a visit scheduled in the next 2 months

20 Total Number of Patients 20 Outreach Call Data % Time in Days to Appointment Scheduled % % 13% Days from Outreach to Appointment Scheduled

21 COPD Collaborative Results 21

22 COPD Initiative Data DuPage Medical Group COPD on Problem List Total Number of Active Patients w/copd on Problem List Oct 2009 - Oct 2011 Number of Active Patients w/copd added to Problem List

22 22 COPD Initiative Data DuPage Medical Group COPD on Problem List Total Number of Active Patients w/copd on Problem List Oct Oct 2011 Number of Active Patients w/copd added to Problem List betw. Jan 2011 Oct 2011 All Patients with COPD Count % Count % Patient Total - All patients with diagnosis of COPD 4, Patients with spirometry evaluation results documented 1,910 44% % Patients who have an FEV1/FVC less than 70% and have symptoms who were prescribed an inhaled bronchodilator during the past 12 months Count % Count % Patient Total - All patients with FEV1/FVC < 70% 1,076 56% % Patients with documented symptoms % % Patients prescribed an inhaled bronchodilator (short-acting or long-acting) % %

23 23 COPD Collaborative Results n=1,910 n=320 n=890

24 Challenges and Solutions 24

25 25 Challenges and Solutions DMG is not part of an integrated health system so we were unable to utilize hospital-ready data Utilizing our claims data was difficult as the information was incomplete Developed partnership with our hospitals to get data on ER visits and hospital admissions

26 Challenges and Solutions Past data on spirometries was not easily accessible within Epic, nor was it on the COPD flowsheet Manually went back and input the

26 26 Challenges and Solutions Past data on spirometries was not easily accessible within Epic, nor was it on the COPD flowsheet Manually went back and input the historical spirometry results onto the flowsheet Redesigned the workflow so spirometry results are captured on the flowsheet Keeping the momentum we have gained

27 Future Steps 27

28 Future Steps Initiation of the Pulmonary Dashboard Continue work on Medical Home for COPD patient population Continue to improve and enhance COPD Pathway Develop

28 28 Future Steps Initiation of the Pulmonary Dashboard Continue work on Medical Home for COPD patient population Continue to improve and enhance COPD Pathway Develop patient screening / survey for use in MyChart to capture QoL information Develop COPD Action Plan for patients Continue physician and staff education regarding COPD management

29 29 Dashboards Pulmonary Dashboard PFT performed AAP completed ACT completed Bronchodilator prescribed Smoking status recorded and smoking cessation given Pneumovax administered COPD hospitalizations COPD re-hospitalizations within 30 days of discharge

30 30 Dashboards Adult PCP Bailey, Miranda Grey, Meredith Burke, Preston O Malley, George Shepherd, Derek Yang, Cristina

31 31 Dashboards Pediatric Bailey, Miranda Burke, Preston Grey, Meredith O Malley, George Shepherd, Derek

32 Lessons Learned 32

33 33 Lessons Learned Continuing education Redesigning workflows and putting tools into place does not guarantee they will be used Important to keep the pathways top of mind Ongoing education on usage and pathway updates Education on spirometry and diagnostic symptoms of COPD

34 34 Questions for the Group What strategies are your organizations using to keep COPD patients out of the hospital? How successful have these interventions been?

35 Thank You 35

Managing COPD Learning Collaborative

Managing COPD Learning Collaborative November 2-4, 2011 San Antonio, TX Sponsored by AMGA and Boehringer Ingelheim Pharmaceuticals, Inc. Geisinger Health System Carolyn C. Houk, MD FACP Paul Simonelli,