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

2. 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

3. 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

4. Video

5. 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?

6. 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

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

8. 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

9. 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.

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

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

12. 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.”

13. There is not a “Silver Bullet”
to fix this

14. 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

15. 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

16. Resources Readmissions www.ihi.org/Topics/Readmissions
Modified: April
STate Action on Avoidable Rehospitalizations (STAAR…
Modified: February
AACVPR.org
("Statistical Brief 121," 2008 datawww.ihi.org/.../TargetingPatientTransitionstoReduceReadmissions.asp…
Modified: January