COPD Outreach Program

Transcription

1 COPD Outreach Prgram Wendy Laframbise, Advanced Practice Nurse Certified Respiratry Educatr COPD Outreach Prgram March, 2015

2 Disclaimer: The Canadian Fundatin fr Healthcare Imprvement (CFHI), in partnership with Behringer-Ingelheim (Canada) Ltd. (BICL), is prviding seed funding as well as participatin in a unique 12-mnth, pan-canadian all teach, all learn quality imprvement cllabrative

3 Backgrund Chrnic bstructive pulmnary disease (COPD) is caused primarily by smking and affects apprximately 750,000 Canadians 1 In the Champlain LHIN regin an estimated 23,561 individuals have a COPD diagnsis 2 Studies demnstrate that patients enrlled in a respiratry utreach service cmprising early discharge care, educatin, telephne supprt and rapid-access t respiratry utpatient clinics, experience fewer emergency department presentatins and hspital readmissins fr acute exacerbatins f COPD than prir t enrlment 3 1 (O Dnnell et al., 2008) 2 (CIHI, ) 3 (Lawlr et al., 2009)

4 PROBLEM COPD Outreach Prgram Patients with Chrnic Obstructive Pulmnary Disease (COPD) have a high rate f readmissin t The Ottawa Hspital (TOH) within 30 days f discharge. OUTCOME MEASURE Reduce 30-day readmissin rate by 25% PROCESS MEASURES 80% f patients wh smke, will receive smking cessatin cunseling 80% f patients will receive self-management educatin, including an AP 80% f patients will receive a fllw-up appintment with their Primary Care Prvider 25% f patients will be referred t a PR Prgram (natinal average 1.2% patients with COPD have access t PR)

5 Prgram Criteria Have a cnfirmed r pending single pulmnary diagnsis f COPD (by spirmetry) Live within 25 km frm TOH and are cmmunity dwelling (e.g., nt LTC, RH) Are willing t be referred AND Have at least ONE f the fllwing: Mderate t severe COPD (Medical Research Cuncil (MRC) 3-5): Chrnic respiratry failure (PaCO2 greater than 45 mmhg r PaO2 less than 55 mmhg) Clinical signs f right sided heart failure Admissin t ICU due t acute exacerbatin f chrnic bstructive pulmnary disease (AECOPD) in the past year Admissin t hspital with AECOPD mre than nce in the past year (this admissin and at least ne ther) Fur r mre Emergency Department visits fr AECOPD in the past year (with r withut in-patient admissin)

6 Enrllment prcess Referral Criteria Recruit Self-referral via admissin reprts Physician Referral (Respirlgy, Medicine) by page, fax, vic r Assess Inf line # t patient On-line dcumentatin t PCP, Cmmunity Respirlgist and Attending Referral t RT/CRE Referral t CCAC RRN hur phne fllw-up by APN/CRE r RN (COPD Educatr) Hme visit by CCAC RRN (24-48 hur) Hme visit by APN/CRE Phne fllw-up mnthly x 3 mnths and at 12 mnths

7 Pulmnary Rehabilitatin Patients enrlled in the COPD Outreach Prgram represent the mderate t very severe COPD ppulatin with multiple c mrbidities. Subsequently, these patients ften require an inpatient PR prgram, surrunded by the supprt and expertise f an interdisciplinary team in a structured envirnment. Infrm patients abut PR ptins in the Champlain LHIN Assess apprpriateness f referral t varius prgrams Facilitate referral prcess as apprpriate Refused/Nt Interested 49% Palliative Care 9% TRC 30% SWCHC 3% Lung Assciatin 9%

8 Effectiveness and Efficiency Effectiveness Certified Respiratry Educatr essential t ptimize delivery f self-management educatin including medicatin review Experience in Pulmnary Rehabilitatin and knwledge abut cmmunity resurces Prevented up t 6 ED visits (Dr. Burbeau Mntreal CHEST Clinic) PR within ne mnth f an acute exacerbatin cllabratin with TOHRC t facilitate this gal Engage patients mtivated t learn and self-manage Efficiencies Leverage the expertise f key internal and external stakehlders Leaders lcally, prvincially and natinally- leader in CFHI cllabrative greatest results with least amunt f resurces (1.0 FTE APN FTE RN) demnstrating effectiveness and efficiency Quality Imprvement Initiative (REB Research) Better patient experience, better quality at less cst, healthier ppulatins

9 Five year plan Develp and Implement a COPD Outreach Prgram Develp best practice clinical pathway Build capacity fr best practice in hspital COPD care in Emergency Department; Medicine units, and in cmmunity settings thrugh knwledge transfer Develp a COPD Educatr Prgram

10 First Quarter Results 38 patients enrlled and 28 patients have reached the 30-day threshld COPD-related healthcare utilizatin Patients that were discharged frm ED, revisited ED within 30 days Patients that were discharged frm ED, were admitted within 30 days Patients that were discharged frm acute care, were readmitted within 30 days Pre-prgram (%) (n=28) *3.57 Pst-prgram (%) (n=28) * Patient readmitted within 24 hurs - did nt have pprtunity t receive fllw-up phne call r hme visit frm COPD Outreach Team ( day COPD-related readmissin rate was 10.1%)

11 References Canadian Institute fr Health Infrmatin (CIHI) ( ). Criner, G.J., et al. (2014). Preventin f Acute Exacerbatin f Chrnic Obstructive Pulmnary Disease: American Cllege f Chest Physicians and Canadian Thracic Sciety Guideline. CHEST. Lawlr, et al. (2009). Early discharge care with nging fllw-up supprt may reduce hspital readmissins in COPD. Internatinal Jurnal f COPD. 2009: O Dnnell et al. (2008). Canadian Thracic Sciety recmmendatins fr management f chrnic bstructive pulmnary disease 2008 update highlights fr primary care. Canadian Respiratry Jurnal