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Presented by Kenneth A. Wyka, MS, RRT, AE-C, FAARC 27 TH Annual Respiratory Care Conference Las Vegas, Nevada September 13, 2012 DISEASE MANAGEMENT PROGRAMS.

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Presentation on theme: "Presented by Kenneth A. Wyka, MS, RRT, AE-C, FAARC 27 TH Annual Respiratory Care Conference Las Vegas, Nevada September 13, 2012 DISEASE MANAGEMENT PROGRAMS."— Presentation transcript:

1 Presented by Kenneth A. Wyka, MS, RRT, AE-C, FAARC 27 TH Annual Respiratory Care Conference Las Vegas, Nevada September 13, 2012 DISEASE MANAGEMENT PROGRAMS FOR COPD: WHY HOSPITALS AND HOMECARE PROVIDERS MUST WORK TOGETHER

2 DISCLOSURE Other than being employed by Anthem Health Services in NY, I have no obligation to or financial arrangement with any manufacturer, organization or related products/services mentioned in this presentation Kenneth A. Wyka Kenneth A. Wyka September 13, 2012 September 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 COPD  Explain how a disease management program can be effectively implemented and managed  Describe 2 ways hospitals and home care providers can work together to reduce COPD readmissions  List at least 2 problems or pitfalls that may be deter these strategic initiatives

5 PROBLEMS IN HEALTHCARE  Aging population  Inability to sustain current method of providing healthcare to those in need  Rising costs  Decreasing numbers of healthcare providers  Malpractice claims  Lack of preventive care  Societal attitudes  Hospital readmission rates

6 THE GOVERNMENT ANSWER THE GOVERNMENT ANSWER These problems will be addressed with the passage of HR 3962 – Affordable Health Care for America Act that was signed into law in March 23, 2010 as: THE PATIENT PROTECTION AND AFFORDABLE CARE ACT (APACA) aka “Obamacare” There are 10 titles (with amendments) to this law that will cover 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 Americans Title II - The Role of Public Programs Title III - Improving the Quality and Efficiency of Health Care Title IV - Prevention of Chronic Disease & Improving Public Health Title V - Health Care Workforce Title VI - Transparency and Program Integrity Title VII - Improving Access to Innovative Medical Therapies Title VIII - Community Living Assistance Services and Supports Act Title IX - Revenue Provisions Title X - Reauthorization of Indian Health Care Improvement Act HealthCare.gov 2012

8 HOSPITAL READMISSION RATES  The new law (APACA) mandates improving readmission rates for Medicare patients  Beginning in FY 2013, PPS hospitals with higher than expected readmission rates will be penalized with reduced payments  Initially, the diseases will include pneumonia, myocardial infarction and heart failure with COPD being added in FY 2014  CMS 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 condition  Medicare will be using a 30 day time frame  Hospitals will need to address this issue in order to maintain financial stability Question: Weren’t diagnostic related groups (DRGs) Question: Weren’t diagnostic related groups (DRGs) supposed to have addressed all of this supposed to have addressed all of this back in the 1980s? back in the 1980s?

10 CALCULATING READMISSION RATE 1. Determine the readmission rate window (Medicare: 30 day window averaged over 3 year periods) 2. Count number of patients readmitted 3. Divide the number of patients who were readmitted by the total number of patients that were seen and treated 4. Example: 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

11 LET’S START WITH A FEW STATISTICS

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) And And  30 day readmission rate for COPD = 23%  Cost = $18 billion annually to Medicare Centers for Medicare and Medicaid Services (CMS), 2011

13 CHRONIC DISEASE PATIENTS  CHF readmission = 25%  COPD readmission = 23%  Length of stay 6 days or longer  90% were unplanned  40% to 75% deemed preventable Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360:

14 REIMBURSEMENT PENALTIES REIMBURSEMENT PENALTIES  APACA implements reimbursement penalties for hospital readmissions within 30 days  FY 2013 – up to 1% of ALL Medicare billing  FY 2014 – up to 2% of ALL Medicare billing  FY 2015 – up to 3% of ALL Medicare billing

15 FOCUS IS ON FREQUENT FLYERS  2013 Diagnoses: CHF, Acute MI and pneumonia  2014 and beyond: COPD, CABG, percutaneous coronary interventions and vascular procedures

16 THE VICIOUS CYCLE “FREQUENT FLYERS” “FREQUENT FLYERS” HOSPITAL HOME EXACERBATIONS

17 Patients going from hospital to home Patients going from hospital to home CONTINUUM OF CARE CONTINUUM OF CARE

18 PATIENTS NEEDING HOME CARE ON DISCHARGE FROM HOSPITAL  70% increase (2.3 million to 4 million) from 1997 to 2008  Discharges not needing additional care grew 8% (from 27 million to 29 million) in this time frame grew 8% (from 27 million to 29 million) in this time frame Agency for Healthcare Research and Quality (AHRQ) Agency for Healthcare Research and Quality (AHRQ)

19 BRAIN TEASER # 1 What 7 letter word has hundreds of letters in it?

20 MAILBOX

21 “CLINICAL GAP”  There is a clinical gap in the transition of patients from hospital to home  Payors don’t recognize the value of RT services  Unable to identify and measure value since services have been bundled with equipment reimbursement  No mechanisms to reimburse RT visits in the home (Medicare)

22 THE ANSWER…DISEASE MANAGEMENT  Chronic diseases account for 75% of costs  Acute care versus chronic care: ●Multidisciplinary processes ●Effective communication and collaboration ●Carefully designed, evidence-based approaches approaches Committee on Quality of Health Care in America, Institute of Medicine (2001). Crossing the Quality Chasm: A New Health System for the 21 st Century. Washington, DC: National Academies Press

23 COPD & ASTHMA STATISTICS  COPD ● Approximately 3 million deaths/year ● 4 th leading cause of death (3 rd by 2020) ● Cost (US) $40-50 billion/year  Asthma ● 34 million in US; 300 million worldwide ●2 50,000 deaths/yr (world) ● 217,000 ED visits/10.5 million physician office visits every year visits every year

24 HEART FAILURE STATISTICS  CHF ● Most common discharge diagnosis in patients > 65 years old > 65 years old ● Average hospital stay = 9 days ● 5 year mortality rate = 50% ● Annual cost = $10 billion for diagnosis and treatment treatment ● Up to 40% are readmitted within 30 days of discharge (average is 25%) discharge (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), disease management is “a system of coordinated healthcare interventions and communications for populations with conditions in which patient self- care efforts are significant” It also supports the practitioner/patient relationship and plan of care

27 GOAL Disease management programs empower patients to better understand their condition and to take active roles in their overall care The goal of a disease management program for patients with COPD is to provide the highest level of home care to patients with this condition and to improve their quality of life

28 OBJECTIVES Patients in disease management programs for COPD will be able to:  improve their quality of life  experience fewer exacerbations  have fewer emergency room visits and/or hospitalizations  have reduced expenditures for medical care  lead more active and productive lifestyles

29 DISCHARGE PLANNING  Begins on 1 st day of hospital admission  Coordinating continuum of care  Discharge instructions  Screen for risk factors, engage self- management skills and set goals  Deploy home follow-up protocols

30 DISCHARGE PLANNING – cont’d  Implement disease specific programs  Develop action plan  Monitor progress  Communicate patient progress/failure back to physician/payor to review and adjust care plan

31 BRAIN TEASER # 2 What is the only word in the English language that ends in MT?

32 DREAMT

33 IMPLEMENTATION OR “HOW DO WE GET THERE?”

34 DISEASE MANAGEMENT PROGRAMS  Hospital Inpatient Program  Hospital / Home Care Program  Respiratory Home Care Company Program

35 KEY WORD FOR ALL PROGRAMS TRANSITION

36 HOSPITAL INPATIENT PROGRAMS  St. Luke’s Hospital, Cedar Rapids, IA  Crouse 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 care follow-up follow-upwww.innovations.ahrq.gov/content.aspx?id=2006

38 ENHANCED ADMISSION ASSESSMENT  Estimate discharge date  Designate an accountable clinician  Assess discharge needs  Reconciling medications  Posting discharge date  Working with other organizations  Providing patient-friendly discharge instructions

39 EDUCATION FOR PATIENTS AND CAREGIVERS  Enhanced teaching and learning process to include: ● Communication strategies ● Communication strategies ● Teach-back methodology ● Return demonstration ● Small segments of critical material repeated frequently frequently ● Outpatient classes

40 PATIENT-CENTERED HAND-OFF COMMUNICATION AND POST-ACUTE CARE FOLLOW-UP  Ensure clinicians receiving patient at discharge are provided complete information to include: ● functional and cognitive status ● family resources ● care needs: medication regimen, self-care needs and durable medical equipment (DME) needs and durable medical equipment (DME) ● scheduled follow-up visit at 5 to 7 days post discharge with MD prior to leaving hospital discharge with MD prior to leaving hospital

41 CROUSE LUNG PARTNERS PRIMARY RESPIRATORY CARE Primary Care Model for Respiratory Care Inpatient Disease Management The 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 The 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 needs  RT Department uses protocols consistent with GOLD and ATS COPD guidelines  MD order initiates process allowing primary RT to assess and treat the patient following protocols

43 PROCESS – cont’d  Transition process facilitates discharge to home home  “Lung Partners” office-based RT performs home follow-up home follow-up

44 PROTOCOLS  Short and Long Acting Bronchodilators  Inhaled Corticosteroids (ICS)  Breathing Retraining  Bronchopulmonary Hygiene  Medical Errors Reduction using Respiratory Care protocols  COPD Education  NIPPV  Oxygen therapy  OSA

45 OTHER GUIDELINES/PROCEDURES  Intravenous to oral therapy conversion program  MDI and nebulizer medication administration guidelines  Aerosol therapy patient self administration policy and procedure  Tracheostomy 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

47 DISEASE MANAGEMENT ELEMENTS  Anxiety screening  Depression screening  Nutritional screening  QOL assessment  Functional limitation assessment  Mobility assessment  Sleep Disorders assessment  Assess Advance Directives  Develop action plan  Develop self- management tools

48 ELEMENTS – cont’d  Medication and devices use with education  Oxygen management  Pulmonary function testing  Tobacco Cessation  Transition to home planning  Follow-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 rates for 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 Visits  Patient Engagement  Patient Education Material  Patient Action Plan

52 CARE MANAGERS ROLE  Identify patients for post discharge visits  Educate patients/care-givers after discharge  Assist with finding resources: Rx’s, DME, group therapy, education  Visit patients at home within hours of discharge  Arrange for and encourage pt’s to keep MD appt. one week post discharge  Monitor patient progress

53 PATIENT ENGAGEMENT AND EDUCATION  Establish relationship with patient  All patient care staff responsible for Dx related education using relevant materials  Implement Patient Action Plan: tool to help patient understand and manage their condition  Post-discharge home visit made 2-3 days after discharge

54 HOME ASSESSMENT  Assesses: ● Ability of patient to cope in home environment environment ● Reassessment of inhaler technique ● Understanding of recommended treatment regimen regimen ● Need for long-term oxygen therapy and/or home nebulizer and/or home nebulizer

55 BRAIN TEASER # 3 Name 3 consecutive days without using the words Wednesday, Friday or Sunday.

56 Yesterday, Today &Tomorrow

57 HOME CARE COMPANY DISEASE MANAGEMENT Klingensmith HealthCare, Ford City, PA Anthem Health Services, Albany, NY

58 KLINGENSMITH HEALTHCARE  Klingensmith Clinical Care – newly created entity in February 2011  Services 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 patient software tailored to COPD patient  Whole patient management model  Primary RT assigned to patient to assure consistency of care and improved consistency of care and improved assessment assessment  Use of Smart Dose TM oxygen system

60 ANTHEM HEALTH SERVICES  Value added services  Disease Management in conjunction with DME order  Enrollment at time of hospital discharge  Clinical progress reports sent to prescribing healthcare provider

61 CARE PLUS TM DISEASE MANAGEMENT PROGRAMS CARE PLUS TM COPD Restrictive Lung Diseases CHF Sleep Apnea Syndromes

62 ENROLLMENT  Patient’s with COPD diagnosis can be enrolled in program once provider’s Rx is received at time of hospital discharge  Patient’s may be enrolled at time of set-up for home oxygen, aerosol therapy or any other home care equipment  Patient’s may be enrolled at time of RT follow-up if deemed appropriate on assessment

63 Enrollment Rx (new patient)

64 GOALS OF DISEASE MANAGEMENT  Relieve symptoms  Prevent disease progression  Improve exercise tolerance  Improve health status  Prevent and treat complications  Prevent and treat exacerbations  Reduce mortality

65 PATIENT CARE PLAN  Education on identifying and avoiding triggers, nutrition & hydration, infection control through personal hygiene and immunizations  Smoking cessation  Compliance 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

67 STANDING ORDERS – cont’d  Comprehensive patient education: ● Cardiopulmonary A&P ● COPD disease process ● Medications, oxygen & treatment compliance ● Breathing exercises ● ADLs ● Nutrition ● Stress management ● Patient monitoring ● Smoking cessation (as needed)

68 WHAT THESE PROGRAMS ALL HAVE IN COMMON  Patient self-empowerment tools  Primary clinicians assigned for continuity of care  Post-discharge care plan implementation  Results show decrease in hospital readmission rates

69 Seamless care from hospital to home Seamless care from hospital to home CONTINUITY OF CARE

70 WHAT WE KNOW  Disease Management programs produce favorable patient outcomes  Patient management strategies are essential to good patient care  Patient compliance with prescribed therapy is essential  Home care and hospitals need to work together to achieve these goals

71 PROBLEMS & PITFALLS  Personnel resources (hospital and home care)  Program availability and viability  Reimbursement (who pays?)  Impact of National Competitive Bidding Initiative (NCBI) on home care providers  Legal 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, 2010 Cleveland Clinic, New England Journal of Medicine, 2010 According to Medicare (2012), some hospitals with high 30 day readmission rates have lower 30 day mortality rates According to Medicare (2012), some hospitals with high 30 day readmission rates have lower 30 day mortality rates  Research and patient studies are needed

73 SUMMARY  Federal and state laws will always affect delivery of health care  Disease management programs work  Scientific data is needed to validate benefit of home care disease management programs  Hospitals and home care providers must work together in this changing environment

74 Thank you for your attention …

75 ARE THERE ANY QUESTIONS?


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