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
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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
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
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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
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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
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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

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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



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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
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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?
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DISEASE MANAGEMENT PROGRAMS FOR COPD AND CHF