Slide 2. Slide 3 Respiratory Therapists Making a Difference. Disclosure. Improving Care Transition for COPD Patients: A New Priority

Transcription

1 Slide 1 3rd Annual UCSF Respiratory Care Symposium NOVELTIES IN RESPIRATORY CARE 2017: TOOLS TO ENHANCE PATIENT OUTCOMES October 28, 2017 San Francisco CA Improving Care Transition for COPD Patients: A New Priority Patrick J. Dunne, MEd, RRT, FAARC Fullerton, CA pjdunne@sbcglobal.net Slide 2 Disclosure Professional relationship with Monaghan Medical Corporation Career-long member/supporter of AARC State affiliates Slide 3 Respiratory Therapists Making a Difference

2 Slide 4 Objectives Describe the concept and impact of the Triple Aim on health care reform efforts; Review the causes of recidivism in COPD patients, and the key elements of effective care transition; Describe steps that can help promote sustained adherence with aerosolized controller medications, and State the benefits of tracking the health care status of chronically ill patient populations. Slide 5 The Triple Aim Institute for Healthcare Improvement; 2007; Cambridge, MA The simultaneous pursuit of: Improving patient experience of care Improving health of populations Reducing per capita cost of health care Slide 6 The Triple Aim Institute for Healthcare Improvement; 2007; Cambridge, MA BETTER CARE BETTER HEALTH LOWER PER CAPITA COSTS! Improve experience of care: * Patient-centered * Safe * Efficient * Effective * Timely * Equitable Improve health of populations: Long-term Address upstream causes of much ill health (poor nutrition, unwise lifestyle choices, economic disparity, etc.) Short-term Focus on high-risk patient populations Lower per capita cost of care: Reduce waste, inefficiencies, needless hassles NOT by withholding needed and necessary care

3 Slide 7 Government Changes in Health Care Newly Emerging Environment of Care TRADITIONAL EMPHASIS Acute care In-patient Treat symptoms Individual patient Billable procedures Fee-for-service NEWER EMPHASIS Chronic care Out-patient Manage disease At-risk populations Outcomes of care Pay-for-performance Fee-for-service = volume driven Pay-for-performance = value driven Slide 8 Now, About COPD.... Definition: A progressive, inflammatory chronic disease characterized by: Increasing airflow obstruction, Destruction of pulmonary gas exchange areas, and Clinically relevant extra-pulmonary effects secondary to systemic inflammation Prevalence increasing 3 rd Leading cause of death (120,000/year) Since 2000, mortality greater in women 4 th Leading cause of recidivism (EXPENSIVE $$$$) Cost of hospital stay greater than reimbursement Primary cause: Long-term exposure to noxious inhalants A largely preventable disease Slide 9 COPD is a Multisystem Disease Lung Cancer Pulmonary Hypertension Anemia Diabetes Metabolic Syndrome Cachexia Mental/Behavioral Health Issues Cardiovascular Disease Peripheral Muscle Wasting/Dysfunction Osteoporosis Mal-nutrition GI Complications Adapted from Kao C, Hanania NA. Atlas of COPD

4 Slide 10 Hospital Readmissions Primary Contributing Factors for COPD Poorly coordinated transition of care Patients not prepared for continuing self-care responsibilities Gaps in knowledge of disease & progression Unaware of impact of non-adherence, repeat exacerbations Unaware of early warning signs/symptoms of relapse 3 of 4 re-admitted patients no MD visit after discharge Ideally seen within 5-7 days of discharge Low use of evidence-based medical practice (GOLD Guidelines) Sub-optimal prescribing of controller medications Delivery device incongruence Continued access issues Slide 11 Impact of of Chronic Conditions Life-long condition Account for 70% of all deaths in the US (1.7mm/yr.) Not curable BUT controllable Many patients have multiple conditions Chronic conditions overly expensive ⅔ of $3.2 trillion annual expenditures Many suffer frequent exacerbations Baby-Boomer generation million/year turn 65 High prevalence of chronic disease Slide 12 Chronic Disease Management A New Priority A Necessary Pivot Coordinated approach to chronic medical care Slow disease progression, minimize complications Improve health outcomes, quality of life Better utilization of health care services Best chronic care: Patient-centric Evidence-based Multi-disciplinary Utilizes care-teams Follows the patient regardless of care setting

5 Slide 13 COPD Care Transition Plan Essential Elements (Coleman EA. Formalized Care Plan Patient centric Comprehendible Shared Red Flag Warnings Increased cough, dyspnea, mucus Whom to call & when Medication Reconciliation Maintenance meds Appropriate delivery device Continued access Follow-up Appointments Primary care, specialist Pulmonary rehab Spirometry, immunizations Tobacco counseling Daily Activity Plan Medication adherence ADLs and ambulation as tolerated 30 mins/day 5 days a week Ensuring Follow-through Directly or via surrogate Ongoing monitoring Telehealth; Patient registry Slide 14 COPD Care Transition Plan Essential Elements (Coleman EA. Formalized Care Plan Patient centric Comprehendible Shared Red Flag Warnings Increased cough, dyspnea, mucus Whom to call & when Medication Reconciliation Maintenance meds Appropriate delivery device Continued access Follow-up Appointments Primary care, specialist Pulmonary rehab Spirometry, immunizations Tobacco counseling Daily Activity Plan Medication adherence ADLs and ambulation as tolerated 30 mins/day 5 days a week Ensuring Follow-through Directly or via surrogate Ongoing monitoring Telehealth; Patient registry Slide 15 Medication Reconciliation Ensuring Symptom Control PAC Joint Commission Helps avoid medication errors Omission, duplication, dosing mistakes, drug interactions To be done at every care transition New medications are ordered Existing orders are rewritten Caveats: Not a straightforward process Patient input can be incomplete Comorbidities adds further complexity Traditionally 3 disciplines (MDs, RNs, PharmDs) Roles/responsibilities vary Evidence supports RTs best at respiratory meds!

6 Slide 16 Device Selection & Outcomes of Aerosol Therapy Dolovich M, et al. Chest 2005 = = RESULTS: Each of the delivery devices provided similar outcomes in patients using the correct technique for inhalation. CONCLUSIONS: Devices used for the delivery of bronchodilators and steroids can be equally efficacious Slide 17 Ideal Particle Size Optimal airway deposition; Best clinical effect Slide 18 Medication Nebulizers Not all jet-nebulizers are created equal! Conventional T-Piece Breath enhanced Breath actuated Respirable dose a function of nebulizer design and operation Higher respirable dose improves drug delivery efficiency Low cost, generic T-piece nebulizers have low respirable dose

7 Slide 19 Performance Comparison of Nebulizer Designs* Higher Respirable Dose = Optimum Drug Delivery CONVENTIONAL T-PIECE BREATH ENHANCED BREATH ACTUATED Aerosol generated continuously Inhalation & exhalation co-mingled Most ambient loss; caregiver exposure Aerosol generated continuously Inhalation & exhalation co-mingled Less ambient loss; caregiver exposure Aerosol generated during inhalation only No co-mingling inhalation & exhalation Least ambient loss; caregiver exposure Respirable dose 10-15% Respirable dose 15-20% Respirable dose 30% Least efficient drug delivery Enhanced drug delivery 2½ times more drug delivery * Rau J, et al. Respir Care, February 2004 Slide 20 COPD Exacerbation Inpatient Care The goal for treatment of COPD exacerbations is to minimize the negative impact of the current exacerbation and to prevent subsequent events. Short-acting inhaled beta 2-agonists (SABAs), with or without short-acting anticholinergics, are recommended as the initial bronchodilators to treat an acute exacerbation. Maintenance therapy with long-acting bronchodilators (LABAs) should be initiated as soon as possible before hospital discharge Global Initiative for Chronic Obstructive Lung Disease ( Slide 21 Bronchodilator Assessment Score When SABA use Q4H, convert to LABA, with SABA to Q4H/prn Bronchodilator Therapy Assessment Score SCORE Normal/Clear End Expiratory Pronounced Inspiratory & Absent or Breath sounds Wheeze Expiratory Expiratory Near Absent Wheeze Wheeze Dyspnea (SOB) None Slight Mild Moderate Severe TOTAL SCORE: Total Score SABA SABA SABA and Every 2 hours; if on Every 1 hour up to Q4 hours PRN for increased Q4 hours PRN for increased Anticholinergic every continuous, then 3 treatments, then Frequency shortness of shortness of 4 hours; consider starting wean SABA by 5 mg/hr as tolerated start continuous SABA and breath; continue breath; long-acting down Anticholinergic long-acting start long-acting bronchodilators to 5 mg/hr bronchodilators bronchodilators

8 Slide 22 COPD Care Transition Plan Medication Reconciliation Post-hospital pharmacotherapy Proper maintenance meds (SABA, LABA, LAMA, ICS, LTOT, NIV) Appropriate delivery devices (DPI, pmdi/vhc; Home nebulizer) Routine maintenance, troubleshooting, Infection control Achieving sustained adherence Complete patient buy-in Able to use prescribed delivery device(s) Periodic reinforcement / re-training Mindful of advantages; Aware of consequences Continued access to maintenance meds Slide 23 COPD Care Transition Plan Medication Reconciliation Medicare Drug Coverage Post acute care Part B - - Physician services; DME Benefit ($104.90/month) Medicare pays 80%; Co-insurance 20% Home compressor/nebulizer, respiratory solutions (J-Code) Home care pharmacy supplies maintenance meds o Minimal out-of-pocket expenses Part D - - Prescription Drug Plan ($35.00 $60.00/month) May be annual deductible Patient (25%) & plan (75%) pay Total drug costs = $3,700 Enters coverage gap o Private pay until Total out-of-pocket costs = $4,950 o Donut hole = No prescription refills = Non-adherence All inhalers covered under Part D Slide 24 Inhaler Misuse in COPD Patients Important Considerations Age-related physical/mental deterioration Visual, hearing, tactile, memory Add disease-related limitations Inability to alter breathing pattern Actuation/inhalation coordination issues Diminished PIFR capability due to low FEV 1

9 Slide 25 Physical Ability to Use a DPI Poor Use = Non-delivery of Medication Value of assessing peak inspiratory flow rate Not demanding but insightful maneuver Ability to generate PIFR L/min PIFR 30L/min candidate for nebulizer Slide 26 Role of Nebulized Therapy in COPD Dhand R, et al. COPD; Feb 2012 Recommendation: Many patients, especially elderly patients with COPD, are unable to use their pmdis and DPIs in an optimal manner. For such patients, nebulizers should be employed on a domiciliary basis... Nebulizers are more forgiving to poor inhalation technique, especially Poor coordination with pmdis, and The requirement to generate adequate peak inspiratory flows with DPIs. Slide 27 Nebulized Therapy at Home Enabling Sustained Medication Adherence Inconvenience, IC issues addressed Ease of use; simple technique Effective, reliable drug delivery Use not limited by disease severity or mental acuity Device and unit dose meds covered under Medicare Part B

10 Slide 28 Secretion Retention with COPD Exacerbation Contributes to Airflow Obstruction; WOB Non-pharmacologic airway clearance therapy (ACT) Secretion retention, ineffective cough problematic CPT uncomfortable for COPD patients Proven alternate ACT techniques for CF ACBT, AD, HFCWO, IPV, OPEP Which to consider for COPD? OPEP Rx a viable regimen Inexpensive, non-invasive Alone or in combo with SVN Slide 29 Home Cleaning/Sterilizing Options AeroEclipse Reusable; Aerobika Infection Control Options Dishwasher safe Immersible in boiling water Microwave sterilizer Slide 30 Expanded Role for RTs in COPD Care At The Very Least Begin to plan for discharge at admission Disease management activities Nature of COPD Importance of symptom control Consequences of repeat exacerbations Smoking cessation; Daily activity level Medication reconciliation Proper use of SABAs, LABAs, LAMAs, LTOT & NIV o SABAs prn only Selection/training in delivery devices o Compressor-nebulizer versus inhalers Consequences of non-adherence

11 Slide 31 Expanded Role for RTs in COPD Care At The Very Least Schedule post-discharge follow-up visits Primary care physician/clinic (within 7 days!) Additional appointments as needed Pulmonary Rehab, Tobacco Cessation, PFT, PSG Provide action plan for the unexpected Seek immediate care with: Increasing cough Increasing dyspnea (especially if refractory to SABAs) Changes in sputum volume, consistency, color Become active/visible in hospital-wide readmission reduction and transition care programs Slide 32 Tracking High-risk Populations Looking Collectively vs. Individually Over Time Develop a local patient registry by disease Establish baseline data set; Update accordingly Enables identification of recurrent gaps Those that can be directly addressed Those that require external resources Those that require an innovative intervention Generates data to support new initiatives Demonstrates awareness of the Triple Aim Especially reducing costs of care Facilitates redesign of traditional RT inpatient role Establishes foundation for community outreach programs Slide 33 Respiratory Therapists Making a Difference

12 Slide 34 3rd Annual UCSF Respiratory Care Symposium NOVELTIES IN RESPIRATORY CARE 2017: TOOLS TO ENHANCE PATIENT OUTCOMES October 28, 2017 San Francisco CA Improving Care Transition for COPD Patients: A New Priority Patrick J. Dunne, MEd, RRT, FAARC Fullerton, CA pjdunne@sbcglobal.net