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

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
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 PATIENT PROTECTION AND
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)
supposed to have addressed all of this
back 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 readmitted
Divide the number of patients who were readmitted by the total number of patients that were seen and treated
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
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:
40 – 75% preventable if existing standards of care were implemented.

14. 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”
HOSPITAL
EXACERBATIONS
HOME

17. CONTINUUM OF CARE
Patients 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 2008
Discharges not needing additional care
grew 8% (from 27 million to 29 million) in this time frame
Agency for Healthcare Research and Quality (AHRQ)

19. What 7 letter word has hundreds of letters in it?
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
Committee on Quality of Health Care in America, Institute of Medicine
(2001). Crossing the Quality Chasm: A New Health System for the 21st
Century. 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/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

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 and
treatment
● Up to 40% are readmitted within 30 days of
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 1st 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
As 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 programs
Develop action plan
Monitor progress
Communicate patient progress/failure back to physician/payor to review and adjust care plan
Programs 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 # 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
Let’s look at a few programs that have been implemented.
Hospital Home Care program or as I like to call it the “Hybrid” 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

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
Accountable 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 repeated
frequently
● Outpatient classes
Teach 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 retaught
Info each day to improve recall and new content added in comprehension is strong. Written material is provided to reinforce messages and used in home
as 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 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)
● scheduled follow-up visit at 5 to 7 days post
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

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
“Lung Partners” office-based RT performs
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 regimen
environment
● Reassessment of inhaler technique
● Understanding of recommended treatment
regimen
● Need for long-term oxygen therapy
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
Whole patient management model
Primary RT assigned to patient to assure
consistency of care and improved
assessment
Use of Smart DoseTM 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 PLUSTM DISEASE MANAGEMENT PROGRAMS
Sleep Apnea
Syndromes
COPD
Restrictive Lung
Diseases
CHF

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. CONTINUITY OF CARE
Seamless care from hospital to home

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
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?