Presentation on theme: "DISEASE MANAGEMENT PROGRAMS FOR COPD: WHY HOSPITALS AND"— Presentation transcript:
1 DISEASE MANAGEMENT PROGRAMS FOR COPD: WHY HOSPITALS AND HOMECARE PROVIDERSMUST WORK TOGETHERPresented byKenneth A. Wyka, MS, RRT, AE-C, FAARC27TH Annual Respiratory Care ConferenceLas Vegas, NevadaSeptember 13, 2012
2 DISCLOSURE Other than being employed by Anthem Health Services in NY, I have no obligation to orfinancial arrangement with any manufacturer,organization or related products/servicesmentioned in this presentationKenneth A. WykaSeptember 13, 2012
3 Greetings from Lake George, NY… Queen of American lakes
4 PROGRAM OBJECTIVES At the end of this session, you will be able to: Define the term “disease management” and identify key elements of a disease management program for patients with COPDExplain how a disease management program can be effectively implemented and managedDescribe 2 ways hospitals and home care providers can work together to reduce COPD readmissionsList at least 2 problems or pitfalls that may be deter these strategic initiatives
5 PROBLEMS IN HEALTHCARE Aging populationInability to sustain current method of providing healthcare to those in needRising costsDecreasing numbers of healthcare providersMalpractice claimsLack of preventive careSocietal attitudesHospital readmission rates
6 THE GOVERNMENT ANSWER THE PATIENT PROTECTION AND These problems will be addressed with the passage ofHR 3962 – Affordable Health Care for America Act that wassigned into law in March 23, 2010 as:THE PATIENT PROTECTION ANDAFFORDABLE CARE ACT (APACA)aka “Obamacare”There are 10 titles (with amendments) to this law that willcover various aspects of health care delivery in the U.S.
7 THE PATIENT PROTECTION AND AFFORDABLE CARE ACT (APACA) Title I Quality, Affordable Health Care for All AmericansTitle II The Role of Public ProgramsTitle III Improving the Quality and Efficiency of Health CareTitle IV Prevention of Chronic Disease & Improving Public HealthTitle V Health Care WorkforceTitle VI Transparency and Program IntegrityTitle VII Improving Access to Innovative Medical TherapiesTitle VIII - Community Living Assistance Services and Supports ActTitle IX Revenue ProvisionsTitle X Reauthorization of Indian Health Care Improvement ActHealthCare.gov 2012
8 HOSPITAL READMISSION RATES The new law (APACA) mandates improving readmission rates for Medicare patientsBeginning in FY 2013, PPS hospitals with higher than expected readmission rates will be penalized with reduced paymentsInitially, the diseases will include pneumonia, myocardial infarction and heart failure with COPD being added in FY 2014CMS will monitor readmission rates
9 READMISSION RATES – cont’d Readmission rate refers to patients who are readmitted to the same facility after being previously discharged from that facility for the same medical conditionMedicare will be using a 30 day time frameHospitals will need to address this issue in order to maintain financial stabilityQuestion: Weren’t diagnostic related groups (DRGs)supposed to have addressed all of thisback in the 1980s?
10 CALCULATING READMISSION RATE Determine the readmission rate window (Medicare: 30 day window averaged over 3 year periods)Count number of patients readmittedDivide the number of patients who were readmitted by the total number of patients that were seen and treatedExample: 3 patients were readmitted to a hospital that saw 100 patients over a 30 day period. Using the 30 day period, simply divide 3 by 100 = 3%Hospital Episode Statistics: Readmission Rates and HES, 2012
12 HOSPITAL READMISSION RATES FOR MEDICARE PATIENTS 2011 – Most recent statistics (July 2008-June 2011)30 day readmission rate for MI = 20% (19.7)30 day readmission rate for CHF = 25% (24.7)30 day readmission rate for pneumonia = 19% (18.5)And30 day readmission rate for COPD = 23%Cost = $18 billion annually to MedicareCenters for Medicare and Medicaid Services (CMS), 2011
13 CHRONIC DISEASE PATIENTS CHF readmission = 25%COPD readmission = 23%Length of stay 6 days or longer90% were unplanned40% to 75% deemed preventableJencks SF, Williams MV, Coleman EA. Rehospitalizations among patientsin the Medicare fee-for-service program. N Engl J Med. 2009;360:40 – 75% preventable if existing standards of care were implemented.
14 REIMBURSEMENT PENALTIES APACA implements reimbursement penalties for hospital readmissions within 30 daysFY 2013 – up to 1% of ALL Medicare billingFY 2014 – up to 2% of ALL Medicare billingFY 2015 – up to 3% of ALL Medicare billing
15 FOCUS IS ON FREQUENT FLYERS 2013 Diagnoses: CHF, Acute MI and pneumonia2014 and beyond: COPD, CABG, percutaneous coronary interventions and vascular procedures
16 THE VICIOUS CYCLE“FREQUENT FLYERS”HOSPITALEXACERBATIONSHOME
17 CONTINUUM OF CAREPatients going from hospital to home
18 PATIENTS NEEDING HOME CARE ON DISCHARGE FROM HOSPITAL 70% increase (2.3 million to 4 million)from 1997 to 2008Discharges not needing additional caregrew 8% (from 27 million to 29 million) in this time frameAgency for Healthcare Research and Quality (AHRQ)
19 What 7 letter word has hundreds of letters in it? BRAIN TEASER # 1What 7 letter word has hundreds of letters in it?
21 “CLINICAL GAP”There is a clinical gap in the transition of patients from hospital to homePayors don’t recognize the value of RT servicesUnable to identify and measure value since services have been bundled with equipment reimbursementNo mechanisms to reimburse RT visits in the home (Medicare)
22 THE ANSWER…DISEASE MANAGEMENT Chronic diseases account for 75% of costsAcute care versus chronic care:●Multidisciplinary processes●Effective communication and collaboration●Carefully designed, evidence-basedapproachesCommittee on Quality of Health Care in America, Institute of Medicine(2001). Crossing the Quality Chasm: A New Health System for the 21stCentury. Washington, DC: National Academies Press
23 COPD & ASTHMA STATISTICS ● Approximately 3 million deaths/year● 4th leading cause of death (3rd by 2020)● Cost (US) $40-50 billion/yearAsthma● 34 million in US; 300 million worldwide●2 50,000 deaths/yr (world)● 217,000 ED visits/10.5 million physician officevisits every year
24 HEART FAILURE STATISTICS CHF● Most common discharge diagnosis in patients> 65 years old● Average hospital stay = 9 days● 5 year mortality rate = 50%● Annual cost = $10 billion for diagnosis andtreatment● Up to 40% are readmitted within 30 days ofdischarge (average is 25%)
25 HOW CAN THE PROBLEM OF READMISSION BE EFFECTIVELY ADDRESSED?
26 DISEASE MANAGEMENT According to the Disease Management Association of America (DMAA), diseasemanagement is “a system of coordinatedhealthcare interventions and communications forpopulations with conditions in which patient self-care efforts are significant”It also supports the practitioner/patientrelationship and plan of care
27 GOAL Disease management programs empower patients to better understand their condition andto take active roles in their overall careThe goal of a disease management program forpatients with COPD is to provide the highest level ofhome care to patients with this condition and toimprove their quality of life
28 OBJECTIVES Patients in disease management programs for COPD will be able to:improve their quality of lifeexperience fewer exacerbationshave fewer emergency room visits and/or hospitalizationshave reduced expenditures for medical carelead more active and productive lifestyles
29 DISCHARGE PLANNING Begins on 1st day of hospital admission Coordinating continuum of careDischarge instructionsScreen for risk factors, engage self-management skills and set goalsDeploy home follow-up protocolsAs the saying goes your should start plans for D/C on admission.Coordinating care has many facets from in-hospital visits to pt from home care agency prior to D/C to setting MD f/u appt before going home.Discharge instructions need improvement: larger print, lower grade reading level, take into account functional limitations.Home f/u includes RT’s or RN’s to make post D/C visits
30 DISCHARGE PLANNING – cont’d Implement disease specific programsDevelop action planMonitor progressCommunicate patient progress/failure back to physician/payor to review and adjust care planPrograms should measure risk of readmit.Action plan to address and minimize the risks.
31 What is the only word in the English language that ends in BRAIN TEASER # 2What is the only word in the English language that ends inMT?
34 DISEASE MANAGEMENT PROGRAMS Hospital Inpatient ProgramHospital / Home Care ProgramRespiratory Home Care Company ProgramLet’s look at a few programs that have been implemented.Hospital Home Care program or as I like to call it the “Hybrid” program
36 HOSPITAL INPATIENT PROGRAMS St. Luke’s Hospital, Cedar Rapids, IACrouse Lung Partners, Syracuse NY
37 TRANSITION HOME for PATIENTS with HEART FAILURE at ST. LUKE’S HOSPITAL COMPONENTS INCLUDE:● Enhanced assessment of post-discharge needs at admission● Patient and caregiver education● Patient-centered communication with caregivers at hand-offs● Standardized process for post-acute carefollow-up
38 ENHANCED ADMISSION ASSESSMENT Estimate discharge dateDesignate an accountable clinicianAssess discharge needsReconciling medicationsPosting discharge dateWorking with other organizationsProviding patient-friendly discharge instructionsAccountable clinician is primary nurse, case mngr or MD accountable for effective D/C of pt.Discharge needs could incl. volume status, med’s and dietary restrictions, recommended activity level, and referral to home care and/or disease mngmnt program.Discharge date is posted on white board in room to focus pt, caregivers and family to focus on.Representatives from the home care agency, nursing agency or setting other than home are contacted to inform of expected D/C and arrange for effective hand-off.
39 EDUCATION FOR PATIENTS AND CAREGIVERS Enhanced teaching and learning process to include:● Communication strategies● Teach-back methodology● Return demonstration● Small segments of critical material repeatedfrequently● Outpatient classesTeach back- pt asked to repeat back new information to confirm understanding and gaps in understanding are identified and retaught.Perform what was taught – weigh themselves and record it.Info broken down into small learnable sections, no more than 4 points at a time, only essential info, additional info can be given after D/C, pt retaughtInfo each day to improve recall and new content added in comprehension is strong. Written material is provided to reinforce messages and used in homeas reference.Classes held every other month, 3 to 4 hours, is highly interactive and meant to emphasize material at a time when pt out of the hospital and is feeling better .
40 PATIENT-CENTERED HAND-OFF COMMUNICATION AND POST-ACUTE CARE FOLLOW-UP Ensure clinicians receiving patient at dischargeare provided complete information to include:● functional and cognitive status● family resources● care needs: medication regimen, self-careneeds and durable medical equipment (DME)● scheduled follow-up visit at 5 to 7 days postdischarge with MD prior to leaving hospital
41 CROUSE LUNG PARTNERS PRIMARY RESPIRATORY CARE Primary Care Model for RespiratoryCare Inpatient Disease ManagementThe primary respiratory therapist provides for all the respiratory care and education needs of their patients and follows them through-out their hospitalization and any readmissions
42 CROUSE LUNG PARTNERS PROCESS Primary RT tailors evidence-based protocols to meet individual patient needsRT Department uses protocols consistent with GOLD and ATS COPD guidelinesMD order initiates process allowing primary RT to assess and treat the patient following protocols
43 PROCESS – cont’d Transition process facilitates discharge to home “Lung Partners” office-based RT performshome follow-up
44 PROTOCOLS Short and Long Acting Bronchodilators Inhaled Corticosteroids (ICS)Breathing RetrainingBronchopulmonary HygieneMedical Errors Reduction using Respiratory Care protocolsCOPD EducationNIPPVOxygen therapyOSA
45 OTHER GUIDELINES/PROCEDURES Intravenous to oral therapy conversion programMDI and nebulizer medication administration guidelinesAerosol therapy patient self administration policy and procedureTracheostomy pathway
46 LUNG PARTNERS CARE TRANSITIONS Inclusion Criteria● Primary or secondary diagnosis of COPD● Patient is community dwelling● Patient has working phone● Language concerns● No documentation of dementia or has competent caregiver● Willing to be coached at home● Does not meet Hospice criteria at this time
48 ELEMENTS – cont’d Medication and devices use with education Oxygen managementPulmonary function testingTobacco CessationTransition to home planningFollow-up visit at home by Transition Coach
49 HOSPITAL / HOME CARE PROGRAM Pittsburgh Regional Health Initiative(Regional Consortium of Medical, Business and Civic Leaders)
50 PRHI PROGRAM DEVELOPMENT In order to reduce hospital readmission ratesfor people with chronic diseases (COPD), it is critical to provide focused patient education and an assessment of the patient in their home setting in the days following hospital discharge
51 PRHI CRITICAL ELEMENTS OF REDUCING READMISSIONS Nurse or RT Care Manager Home VisitsPatient EngagementPatient Education MaterialPatient Action Plan
52 CARE MANAGERS ROLE Identify patients for post discharge visits Educate patients/care-givers after dischargeAssist with finding resources: Rx’s, DME, group therapy, educationVisit patients at home within hours of dischargeArrange for and encourage pt’s to keep MD appt. one week post dischargeMonitor patient progress
53 PATIENT ENGAGEMENT AND EDUCATION Establish relationship with patientAll patient care staff responsible for Dx related education using relevant materialsImplement Patient Action Plan: tool to help patient understand and manage their conditionPost-discharge home visit made 2-3 days after discharge
54 HOME ASSESSMENT Assesses: ● Ability of patient to cope in home regimen environment● Reassessment of inhaler technique● Understanding of recommended treatmentregimen● Need for long-term oxygen therapyand/or home nebulizer
55 BRAIN TEASER # 3Name 3 consecutive days without using the words Wednesday, Friday or Sunday.
57 HOME CARE COMPANY DISEASE MANAGEMENT Klingensmith HealthCare, Ford City, PAAnthem Health Services, Albany, NY
58 KLINGENSMITH HEALTHCARE Klingensmith Clinical Care – newly created entity in February 2011Services include: physical and occupational therapy, speech pathology, nursing care, health care aide and respiratory disease management
59 KLINGENSMITH – cont’d Developed assessment & treatment software tailored to COPD patientWhole patient management modelPrimary RT assigned to patient to assureconsistency of care and improvedassessmentUse of Smart DoseTM oxygen system
60 ANTHEM HEALTH SERVICES Value added servicesDisease Management in conjunction with DME orderEnrollment at time of hospital dischargeClinical progress reports sent to prescribing healthcare provider
61 CARE PLUSTM DISEASE MANAGEMENT PROGRAMS Sleep ApneaSyndromesCOPDRestrictive LungDiseasesCHF
62 ENROLLMENTPatient’s with COPD diagnosis can be enrolled in program once provider’s Rx is received at time of hospital dischargePatient’s may be enrolled at time of set-up for home oxygen, aerosol therapy or any other home care equipmentPatient’s may be enrolled at time of RT follow-up if deemed appropriate on assessment
64 GOALS OF DISEASE MANAGEMENT Relieve symptomsPrevent disease progressionImprove exercise toleranceImprove health statusPrevent and treat complicationsPrevent and treat exacerbationsReduce mortality
65 PATIENT CARE PLANEducation on identifying and avoiding triggers, nutrition & hydration, infection control through personal hygiene and immunizationsSmoking cessationCompliance with medications (oral and inhaled) and long-term oxygen therapy (LTOT)Exercise and activities of daily living (ADLs)Disease management and pulmonary rehabilitation
66 STANDING ORDERS Screening and assessment by licensed RT Pulse oximetry (including overnight)Follow-up home care visits (up to 4) by RT once patient is on program
68 WHAT THESE PROGRAMS ALL HAVE IN COMMON Patient self-empowerment toolsPrimary clinicians assigned for continuity of carePost-discharge care plan implementationResults show decrease in hospital readmission rates
69 CONTINUITY OF CARESeamless care from hospital to home
70 WHAT WE KNOWDisease Management programs produce favorable patient outcomesPatient management strategies are essential to good patient carePatient compliance with prescribed therapy is essentialHome care and hospitals need to work together to achieve these goals
71 PROBLEMS & PITFALLS Personnel resources (hospital and home care) Program availability and viabilityReimbursement (who pays?)Impact of National Competitive Bidding Initiative (NCBI) on home care providersLegal issues/ramifications
72 PROBLEMS & PITFALLS – cont’d Attitudes – ↑ some readmissions results in a ↓ mortality rate, and conversely, certain patients who are not readmitted have lower survival rates (↑mortality rate)Cleveland Clinic, New England Journal of Medicine, 2010According to Medicare (2012), some hospitals with high 30 day readmission rates have lower 30 day mortality ratesResearch and patient studies are needed
73 SUMMARYFederal and state laws will always affect delivery of health careDisease management programs workScientific data is needed to validate benefit of home care disease management programsHospitals and home care providers must work together in this changing environment