COPD Reducing Avoidable Readmissions Lisa Price, RRT, Director Respiratory Care

Objectives Understanding why avoiding readmissions is so important Strategies used in preventing avoidable readmissions Success Stories Why Cardiac and Pulmonary Rehab is suited perfectly to help

Reduce Avoidable Readmissions Institute for Healthcare Improvement: US Hospitalizations account for nearly 1/3 of the total $2 trillion spent on health care Cost for people 65 or older is about 17 billion each year (Medicare) Cost for a readmission principle dx COPD is $8,400, with a readmission rate of 7.1 %. Health care cost utilization Project

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Agree or Disagree Healthcare today is fragmented and frustrating to patients, and care providers. How do we fill in the spaces for a smooth transition? Where is the documentation?

So Many Interventions Studied RED- re-engineered Discharge Transitional Care Model Heart Failure Resource Center Home Healthcare Telemedicine Novant Physician Group Practice Demonstration Project Kaiser Permanente Chronic Care Coordination

Reducing Readmission Models Cont. BOOST INTERACT Guided Care Hospital At Home

Care Transition Model Dr. Eric Coleman Support patients and families Increase skills among healthcare providers Enhance ability of health information to exchange across settings System interventions to improve quality and safety Develop Measures Influence health policy at national level Colorado 2000 Dr. Coleman wrote and validated research funded by John Haratford and Robert Wood Johnson foundation Created a checklist when moving from one level to another Includes management session with transition coach who is RN

What Does Evidence Tell Us Improving core discharge planning and transition processes out of the hospital; improving transitions and care coordination at the interfaces between care settings; and enhancing coaching, education, and support for patient self-management help to reduce avoidable readmissions.

Who are our Partners? Home Health Meals on Wheels LTACH Community Centers EMS Transportation Groups- like Uber Health PCPs

Improvement Stories STAAR Initiative- State Action on Avoidable Rehospitalization Initiative 20% improvement 2 years

Improvement Stories cont. University Hospital Cleveland, Ohio That Defining Moment- The transition that takes a patient from the hospital to their home or another care setting marks a pivotal care moment. Zeroing in on what happens…. ​ Kathleen Vidal, RN, MSN, Director of Nursing Practice Development at University Hospitals in Cleveland, Ohio, found one important lesson: identify the key learner in a patient’s family. “You have, say, an elderly man in the hospital and his wife is with him all the time. In the past, you’d just automatically tell his wife everything. But in reality, it’s his daughter who sets up the pills and takes him to the doctor.”

There is not a “Silver Bullet” to fix this

Cardiac and Pulmonary Rehab Perfectly suited for national priority Recurring visits Education /Lifestyle changes Relationship with patient and physicians Well documented ITP Socialization Ask a million questions, what is important to patient, interventions, assess reassess

Phase II and III Med reconciliation Assessment/Re-assessment Creating life long health changes Improve functional capacity Reduce avoidable risk factors Improvement in depression Improvement in dyspnea Improvement in Quality of Life

Resources Readmissions www.ihi.org/Topics/Readmissions Modified: April 27 2017 STate Action on Avoidable Rehospitalizations (STAAR… www.ihi.org/Engage/Initiatives/Completed/STAAR Modified: February 26 2015 AACVPR.org ("Statistical Brief 121," 2008 datawww.ihi.org/.../TargetingPatientTransitionstoReduceReadmissions.asp… Modified: January 9 2014