TACKLING COPD READMISSIONS Wendy Presley RN
WHY START WITH COPD? HIGH VOLUME PROBLEM PRONE COSTLY And you just can t resist a challenge
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
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 2009. Nat Vital Stat Rep. 2012; 60(3): 1-117 3Office 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, 2010-2011.
PLAN
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
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.
GATHER THE PLAYERS
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
Committee and Sub-committee Meetings
GOLD STANDARDS Global Initiative for Chronic Obstructive Lung Disease DO
Smoking Cessation Patient education Early Patient ID
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
EARLY PATIENT IDENTIFICATION Over 40 y/o Current or previous smoker Do Lung Function Questionnaire annually If score 18 or less, perform office spirometry
EMR template for COPD management
COPD ACTION PLANS
SPACERS DISPENSE SPACERS AT OUTPATIENT VISITS USE 94664 TO CHARGE ONLY RECOUP ABOUT ½ THE COST
SMOKING CESSATION CLASSES
COPD exacerbation patient is admitted.
ADMISSION ORDER SETS
Respiratory Therapy Initiating more smoking cessation conversations Instructing on inhaler technique General COPD teaching
Patient all better- going home. Encourage home care services Follow-up phone contact within 1-2 days
Smoking Cessation Patient education Early Patient ID Better Choices
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 2014 2014 Jul-Sep 2014 Oct-Dec 2014 Jan-Mar 2015 Total Discharges- ALL CAUSE 919 973 928 966 941 933 841 886 858 916 916 850 842 HospVolume Total D/C COPD ALL Cases (Prim&Second) 302 342 283 323 272 311 236 274 308 316 333 249 278 % 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) 95 87 64 92 92 66 58 71 76 75 70 75 86 HospLOS COPD ALOS- Balancing Measure 3.649 3.545 3.595 3.388 3.972 4.65 3.03 2.128 2.86 2.564 2.4 2.93 2.946 COPD Cases Mortality inpt 5 2 4 4 7 5 6 4 7 4 5 1 8 Hospital Disposition COPD Cases d/c to Home Care (VNA) 42 48 44 63 67 66 44 52 55 52 43 40 70 COPD Cases D/C to Home 173 224 178 199 132 175 145 175 151 188 215 146 138
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 67 81 88 83 78 75 67 78 88 88 79 53 59 COPD Cases Readmit w/i 30 days inpt 39 37 34 39 31 49 33 39 56 50 45 25 22 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 31 24 25 33 23 40 28 27 33 39 33 21 16 COPD D/C Home Care 1st admission 6 6 4 4 5 7 5 9 8 18 6 2 6
Sep-13 Nov-13 Mar-14 Jun-14 Aug-14 Jan-15 Mar-15 Apr-15 # Active COPD patients in PPS 1794 1810 1838 1836 1843 1775 1784 1804 # COPD seen since 10/13 (Launch) na 524 1324 1465 1606 1642 1655 1673 # 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) 71 88 97 105 Total # Using GOLD Group A 20 24 115 140 166 173 182 Total # Using GOLD Group B 59 80 239 276 330 346 366 Total # Using GOLD Group C 4 181 38 43 51 53 55 Total # Using GOLD Group D 42 23 142 159 190 197 207 Total # Using Any GOLD Group 125 108 534 618 737 769 810 COPD Screening 2441 3515 4046 4714 4901 5088
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
Where are we now? Subcommittees are regrouping Some of our ideas going forward
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
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
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.
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