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

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

Greetings from Lake George, NY… Queen of American lakes

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

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

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.

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

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

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?

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

LET’S START WITH A FEW STATISTICS

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

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;360:1418-28 40 – 75% preventable if existing standards of care were implemented.

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

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

THE VICIOUS CYCLE “FREQUENT FLYERS” HOSPITAL EXACERBATIONS HOME

CONTINUUM OF CARE Patients going from hospital to home

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) www.newswise.com/articles/view/57421

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

MAILBOX

“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)

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

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

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%)

HOW CAN THE PROBLEM OF READMISSION BE EFFECTIVELY ADDRESSED?

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

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

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

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

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.

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?

DREAMT

IMPLEMENTATION OR “HOW DO WE GET THERE?”

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

KEY WORD FOR ALL PROGRAMS TRANSITION

HOSPITAL INPATIENT PROGRAMS St. Luke’s Hospital, Cedar Rapids, IA Crouse Lung Partners, Syracuse NY

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 www.innovations.ahrq.gov/content.aspx?id=2006

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.

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 .

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

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

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

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

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

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

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

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

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

HOSPITAL / HOME CARE PROGRAM Pittsburgh Regional Health Initiative (Regional Consortium of Medical, Business and Civic Leaders)

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

PRHI CRITICAL ELEMENTS OF REDUCING READMISSIONS Nurse or RT Care Manager Home Visits Patient Engagement Patient Education Material Patient Action Plan

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 48-72 hours of discharge Arrange for and encourage pt’s to keep MD appt. one week post discharge Monitor patient progress

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

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

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

Yesterday, Today & Tomorrow

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

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

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

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

CARE PLUSTM DISEASE MANAGEMENT PROGRAMS Sleep Apnea Syndromes COPD Restrictive Lung Diseases CHF

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

Enrollment Rx (new patient)

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

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

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

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)

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

CONTINUITY OF CARE Seamless care from hospital to home

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

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

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

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

Thank you for your attention …

ARE THERE ANY QUESTIONS?