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 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 Title II Title III Title IV Title V Title VI Title VII Title VIII Title IX Title X - Quality, Affordable Health Care for All Americans The Role of Public Programs Improving the Quality and Efficiency of Health Care Prevention of Chronic Disease & Improving Public Health Health Care Workforce Transparency and Program Integrity Improving Access to Innovative Medical Therapies Community Living Assistance Services and Supports Act Revenue Provisions 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 1. Determine the readmission rate window (Medicare: 30 day window averaged over 3 year periods) 2. 3. 4. 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 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 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 COPD ● 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 selfcare 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 on 1st day of hospital admission Coordinating continuum of care Discharge instructions Screen for risk factors, engage selfmanagement skills and set goals Deploy home follow-up protocols Begins 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 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 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 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 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 selfmanagement 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 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 Clinical Care – newly created entity in February 2011 Klingensmith 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 CARE PLUSTM 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 – ↑ some readmissions results in a ↓ mortality rate, and conversely, certain patients who are not readmitted have lower survival rates (↑mortality rate) Attitudes 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?