TACKLING COPD READMISSIONS. Wendy Presley RN

Transcription

1 TACKLING COPD READMISSIONS Wendy Presley RN

2 WHY START WITH COPD? HIGH VOLUME PROBLEM PRONE COSTLY And you just can t resist a challenge

3 Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases GOLD Strategy for Diagnosis, Management and Prevention of COPD

4 In 2010, the US spent $49.9 billion on COPD related health care costs1 COPD is the third leading cause of death in the US2 An estimated 15 million Americans have been diagnosed with COPD1 1 in 15 NH adults or 6.5% have COPD, 3.9 % of adults and 11.7 % of those 6 In NH among those with COPD, 42% are active smokers Hospital readmissions within 30 days are occurring at a present rate of 20% COPD readmissions represent a large percentage of the readmissions 1National Heart, Lung and Blood Institute. Morbidity and Mortality: 2009 Chartbook on Cardiovascular, Lung and Blood Diseases. 2Kochanek KD, Xu J, Murphy SL, Miniño AM, Kung HC. Deaths: final data for Nat Vital Stat Rep. 2012; 60(3): Office of Health Statistics and Data Management (HSDM), Bureau of Public Health Statistics and Informatics (BPHSI), New Hampshire Department of Health and Human Services (DHHS), Division of Public Health Services,

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6 PLAN

7 AIM STATEMENT With a whole system, multi-disciplinary approach to care and using population health management strategies, we seek to identify, develop, and support the implementation of ongoing improvement in the processes, systems and policies that affect the care provided to, and outcomes for, our patients with COPD. These strategies include, but are not limited to: Evidence-based best practice used in conjunction with clinical expertise Development, refinement and use of data to id specific needs and utilizatio Use benchmark data to identify gaps Engage collaborative teams Support patient education and self-management Leverage technology to improve efficiencies

8 CLINICAL AND OPERATIONAL OUTCOME METRICS % OF PATIENTS OVER 18Y/O WITH DX OF COPD WHO HAVE HAD SPIRO % OF COPD PATIENTS WITH fev1 LESS THEN 70% PRESCRIBED AN INHALER % OF PATIENTS READMITTED IN 30 DAYS WITH COPD % OF PATIENTS WITH COPD RECEIVING SMOKING CESSATION COUNSELING HCAHPS SCORES REGARDING DISCHARGE LOS REHOSPITALIZED IN 12 MONTHS.

9 GATHER THE PLAYERS

10 VP of Patient care services VP of Physician practice services QI Leadership in and out patient Head of Pharmacy Head of Respiratory Care Dept Pulmonologist Hospitalist Head of Patient Education Head of Care Management Head of Paramedicine Managers of ED. ICU, Tele Manager of Pulmonary Rehab Representative of Walk-In

11 Committee and Sub-committee Meetings

12 GOLD STANDARDS Global Initiative for Chronic Obstructive Lung Disease DO

13 Smoking Cessation Patient education Early Patient ID

14 STAFF EDUCATION USED BOEHRINGER INGELHEIM FOR SPIROMETRY TRAINING USED GSK FOR GENERAL COPD EDUCATION INCLUDING EXACERBATION SKILLS DAY EDUCATION ON NEW PROCESSES FOR IN AND OUTPT STAFF JOINT BREAKFAST FOR PROVIDERS AND SUPPORT STAFF OUTPATIENT

15 EARLY PATIENT IDENTIFICATION Over 40 y/o Current or previous smoker Do Lung Function Questionnaire annually If score 18 or less, perform office spirometry

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18 EMR template for COPD management

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23 COPD ACTION PLANS

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25 SPACERS DISPENSE SPACERS AT OUTPATIENT VISITS USE TO CHARGE ONLY RECOUP ABOUT ½ THE COST

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27 SMOKING CESSATION CLASSES

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29 COPD exacerbation patient is admitted.

30 ADMISSION ORDER SETS

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33 Respiratory Therapy Initiating more smoking cessation conversations Instructing on inhaler technique General COPD teaching

34 Patient all better- going home. Encourage home care services Follow-up phone contact within 1-2 days

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36 Smoking Cessation Patient education Early Patient ID Better Choices

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38 Aspect Indicator Trend Jan-Mar 2012 Apr-Jun 2012 Jul-Sep 2012 Oct-Dec 2012 Jan-Mar 2013 Apr-Jun 2013 Jul-Sep 2013 Oct-Dec Apr-Jun 2013 Jan-Mar Jul-Sep 2014 Oct-Dec 2014 Jan-Mar 2015 Total Discharges- ALL CAUSE HospVolume Total D/C COPD ALL Cases (Prim&Second) % of all Discharges with COPD Condition 33% 35% 30% 33% 29% 33% 28% 31% 36% 34% 36% 29% 33% Principle Dx COPD inpt SS (ICD-9) HospLOS COPD ALOS- Balancing Measure COPD Cases Mortality inpt Hospital Disposition COPD Cases d/c to Home Care (VNA) COPD Cases D/C to Home

39 ALL Cause Readmit RATE to Acute Care within 30 Days 7.42% 8.45% 9.67% 8.77% 8.49% 8.18% 7.79% 8.94% 10.50% 9.70% 8.87% 5.36% 7.07% ALL Cause Number of Readmissions COPD Cases Readmit w/i 30 days inpt Hospital Readmission % COPD to all Readmissions 58% 46% 39% 47% 40% 65% 49% 50% 64% 57% 57% 47% 37% COPD D/C to home 1st admission COPD D/C Home Care 1st admission

40 Sep-13 Nov-13 Mar-14 Jun-14 Aug-14 Jan-15 Mar-15 Apr-15 # Active COPD patients in PPS # COPD seen since 10/13 (Launch) na # FEV1% exp 670 (37%) 688 (38%) 789 (43%) 860 (47%) 895 (49%) 937 (53%) 968 (54%) 990 (55%) % of pts with COPD who are current smokers PPS Measures # with Doc Pneumovax 1206 (67%) 1220 (67%) 1252 (68%) 1262 (69%) 1266 (69%) 1302 (73%) 1279 (72%) 1278 (71%) # participated in Pulm Rehab 61 (3%) 61 (3%) # of referrals since 10/13 (Launch) Total # Using GOLD Group A Total # Using GOLD Group B Total # Using GOLD Group C Total # Using GOLD Group D Total # Using Any GOLD Group COPD Screening

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42 Chart review of 12 COPD admissions 10/12 patients had a previous dx of COPD 10/12 had oxygen sat doc prior ov 6/12 used the HPI in prior ov 11/12 patients on recommended tx Pts with financial concerns did not seem to have those addressed Inconsistent phone contact post discharge

43 Where are we now? Subcommittees are regrouping Some of our ideas going forward

44 Look at inpt order sets- WHICH ARE MUST HAVES Samples or coupons/cards for inhalers on discharge Nebulized meds-part D vs expensive inhalers on Part B Smoking cessation-? AA approach of ongoing classes

45 Revisit f/u phone calls with support staff-show them the evidence Spacer distribution in all practices Work with PCPs resistant to the use of HPI-demonstrate the +s Motivational interviewing training

46 LESSONS LEARNED Engage providers in short survey before starting a QI initiative. Consider engaging patients in a focus group or survey to better understand barriers. Be realistic about your assets, barriers, patient population. Be a detective, do root cause analysis. Don t assume you know the solutions.

47 RESOURCES Breathenh.org-NH COPD PLAN Global Initiative for COPD Updated 2014 Center for Health Care Quality and Payment Reform- Reducing Hospital Readmissions COPD ConferencesUSA.org-COPD Hospital Readmissions Understanding the Costs CMS.gov-Readmission Reduction Program PRHI Readmission Reduction Guide: A Manual for Preventing Hospitalizations Carolina HealthCare System-COPD Initiative w.presley@fmhospital.com