COPD Case Management led by Respiratory Therapists · Discharge plan 4. Transfer or referral 5. Reassessment. COPD –ROAD™ Education Education Session 1 • What is COPD Diagnosing

University of California Davis ROAD™ Center

COPD Case Management led by

Respiratory Therapists

Krystal M Craddock, BSRC, RRT-ACCS, RRT-NPS, AE-C, CCM

COPD Case Management Coordinator

Clinical Education and QI Coordinator

Department of Respiratory Care

UC Davis Medical Center, Sacramento CA

UC Davis ROAD™ Center

[email protected]

A HEALTHIER WORLD THROUGH BOLD INNOVATION

Conflict of Interest

I have affiliations with, special interests, or have conducted business with the following companies that in context with this presentation might possibly constitute a real or perceived conflict of interest:

• Monaghan Medical

• Philips Respironics

• Sunovion Pharmaceuticals

• Boehringer Ingelheim

Objectives

• List key elements of education for a hospitalized

patient with COPD.

• Recall the necessary treatments and equipment the

COPD patient requires at discharge to allow for

successful management of their disease at home.

• Describe how RT’s can play a key role in team

multidisciplinary care of the COPD patient.


30-Day Readmissions

• Hospital Readmissions Reduction Program (HRRP)

under the Affordable Care Act (ACA):

“Designed to provide incentives for hospitals to implement

strategies to reduce the number of costly and unnecessary hospital

readmissions”.

• Started with AMI, Pneumonia, and CHF in October

2012.

• COPD, THA, and TKA were added October 2015.

• Aspiration pneumonia, Sepsis coded with PNA, CABG in

2017.


Value Based Care

• Also as part of the ACA.

• The Hospital Value-Based Purchasing (VBP) Program is a

CMS initiative that rewards acute-care hospitals with

incentive payments for the quality care provided to

Medicare beneficiaries.

The quality of care provided to Medicare patients

How closely best clinical practices are followed

How well hospitals enhance patients’ experiences of care during

hospital stays

• Hospital Consumer Assessment of Healthcare Providers and Systems

(HCHAPS) and Consumer Assessment of Healthcare Providers and

Systems (CHAPS) scores.


Accessed from: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf

What This Does for Our Profession

But More Importantly…

COPD – The Challenge

• Goal for UC Davis Develop Quality

Improvement Program

for COPD Care

• Improve the Standard

of Care

• Increase Public

Awareness of COPD

Integrate and

Synchronize COPD

Services

Reduce AECOPD

Hospitalizations and

Readmissions


COPD – Trends

• AECOPD in the UC Davis Health System

Increasing Hospitalizations

• Fiscal Year (FY) 2009: 459

• FY 2011: 587

Increasing Length of Stay (LOS)

• FY 2009: 6.27 days

• FY 2011: 7.57 days

Increasing Cost of Hospital Admission

• FY 2009: $14,259

• FY 2011: $26,355

Estimated COPD Related Cost in U.S.

• $73 Billion Annually


Total Direct Cost: $15,470,385

National Benchmark 4.4 Days

Compare to FY 1999: $7,100

COPD Case Management Program

• COPD ROAD™ Education

4 sessions <1 hour at

bedside

Inhaler Device Technique

Confirmed

Teaching Tools

• Lung Models

• iPad Videos

• Drawing

• Device Demos

• Bubbles

• UC Davis Pages


COPD Case Management Program

• Select Patients Screening Tool

COPD Exacerbation

Physical Assessment

• CAT score

Meets Exclusion Criteria?

• “Pharmacy Education”

Meets ROAD Program Criteria?

• Complete Education

• Reconcile Medications Home Respiratory Medications

Inpatient Respiratory Medications


Things to Remember…

• ABCDEF of COPD™

Anticholinergic

Beta-Agonist

Corticosteroid

Daliresp (Roflumilast)

Exercise and Education

Flu Shot and Friends


Things to Remember…

• CMS Standards of Discharge Planning

1. Identification of patients in need of

discharge planning

2. Discharge planning evaluation

3. Discharge plan

4. Transfer or referral

5. Reassessment

COPD – ROAD™ Education

Education Session 1

• What is COPD

Diagnosing COPD

COPD IS TREATABLE

• Treatments for COPD

Stages of COPD

• Normal Lung Anatomy vs.

COPD Lung Anatomy

The Respiratory System

Alterations from COPD

• Slowing the Progression


Start Thinking and Planning for

Hospital Discharge

• DME Equipment

Nebulizer

Home Oxygen?

NIV?

• Medications for COPD

• Home Health

• PCP

Get to Know Your Resources!



Education Session 2

• Medications

Classifications

Maintenance vs. Rescue

Method of Action

• Inhalation Devices

Demonstration (Case

Manager)

Return Demonstration

(Patient)

• Bronchial Hygiene

Aerobika


GOLD Guidelines


GOLD Update

• Pharmacological treatment recommendations

were arguably the biggest change.

• Continuous assessment and evaluation of our

patients with COPD is necessary.

• GOLD is advising more individualized care of

the patient.

• COPD exacerbation hospital discharges

should include an integrated team care

approach.


COPD Medication Regimen

• Which is the right

medication regimen for my

patient?

Are they appropriate per

GOLD Guidelines?

Is the patient using them?

Are they using them

correctly?

Can they afford them?

Can we do better?

• Not “one size fits all”!



Education Session 3

• Early S&S AECOPD

• Controlled Breathing

Techniques

Practice with Pt.

• Coping with SOB

Stress Management

• Preventing Infection

Vaccinations

• Referrals for Outpatient

Resources

Smoking Cessation

Pulmonary Rehabilitation



Education Session 4

• Discharge Instructions

• Oxygen Safety

Whether Prescribed for Home

Use or Not

• STOP-Bang Score

Evaluate for OSA

• ROADTM COPD Action Plan

Medications

• Dose and Frequency

• Rescue or Maintenance?

• Picture of Device


ROAD™ – After Hospital Discharge

• Follow Up

Call Pt. at 3-5 days

• PCP Appointment F/U

• Referral Status Update

• Discharge Medications

Call Pt. at 6-8 weeks

• PCP Appointment F/U

• Referral Status Update

• Medication Effectiveness


COPD –“Pharmacy Education”

• Patients who meet exclusion criteria for

ROAD™ COPD Program: Severe psychiatric history

Current Recreational Drug and/or ETOH abuse

Dementia

Refusal of full ROAD™ education

• Reconcile Medications Home Respiratory Medications

Inpatient Respiratory Medications

Transition Prior to D/C


COPD –“Pharmacy Education”

• Bedside education

provided: “What is COPD?”

Medications

• Classifications

• Maintenance vs. Rescue

• Method of Action

Inhalation Devices

• Demonstration (Case

Manager)

• Return Demonstration

(Patient)

• “Behind the scenes”

Same as ROAD™

Patient: Home medications:

• Are they appropriate?

• Is the patient using

them?

• Are they using the right?

• Can they afford them?

• Can we do better?

Communication

• Patient and family, RT,

Transition of Care (TOC)

pharmacist, Hospitalist,

social work, nursing


ROAD™ – Demographics

Referrals to Program:

270 Patients Seen

3/13/2012 - 3/13/2018

• Women: 60%

• Mean Age: 68yrs

Prior COPD Education: 13%

Average BMI: 26.8

Average pk/yrs: 50

• Smokers on Admission: 99

Up to Date Flu Vaccine: 67%

Up to Date Pneumovax: 63%

Asthma/COPD Overlap: 28%

Anxiety/Depression: 36%

OSA Diagnosed: 17%


Source

EMR ScreeningTool

MD

RT

ROAD™ – Lung Function

Severity Based on PFT’s:Average Spirometry:


COPD Stage

Mild

Moderate

Severe

Very Severe

0

10

20

30

40

50

60

70

FEV1/FVCPre

FEV1/FVCPost

FEV1% Pre FEV1% Post

Of 54% With PFT's on File

% Predicted Pre and Post Bronchodilator

ROAD™ – Medications

Maintenance Medications Prior to and

After COPD Case Management: Other Cohort Findings:

0

50

100

150

200

250

Prior to CM After CM


72% of patients followed up

with PCP within 2 weeks of

hospital discharge.

28% of patients quit smoking (6

month follow up) after bedside

smoking cessation with RRT

COPD Case Manager

Average CAT score

improvement of 4 points (24%

response)

* MCID for CAT: 2 points

ROAD™ Patient Satisfaction

Excellent Very Good

Good Fair

Poor Does Not Apply

Did Not Answer

• Response Rate: 30%

54% Excellent

27%Very Good

14% Good

1% Fair

0 Poor

2% Does not apply

2% Did not answer all columns

• Highest Rated Responses: Was the COPD CM courteous and

professional?

Where you satisfied getting advice or

help when needed from your RT COPD

CM?

Overall satisfaction

• Lowest Rated Response: Overall quality of life may improve as a

result of your experiences with the

COPD Case Managers?


ROAD™ COPD Program Statistics

Decrease in LOS and

Readmission Rate <30 Days:

ROAD™ Center

FY 2011

0

2

4

6

8

10

12

14

16

LOS (Days)Readmission<30 Days (%)

ROAD™ Center FY 2011

Cost Savings:

• Average LOS: 5.13 Days

Decreased from 7.57 Days

Projected Cost Savings

• $8,599

• Readmission Rate <30 Days

after Discharge: 7.4%

Decreased from 16% FY 2011


• $611,963

• Total Projected Cost Savings:

• $2,933,775


Pharmacy Patient Cohort Findings

• COPD patients that

were ruled out of

ROAD™ Program

• 1000Patients 10% Psychiatric History

25% Current ETOH/drug use

14% Dementia

34% COPD not primary focus

17% Refused ROAD™ or there

was too little time for this

education to be provided

(Hem/onc, CHF education)

05

10152025303540

Exclusion Reason

Exclusion

Reason


Pharmacy Patient Cohort Findings

• 60% admissions required changes/additions to their COPD

medication regimen.

• Smokers on admission = 54%

• ROAD™ patients = 40%

• Average pack years = 42.3

• Readmission Rate <30 Days after Discharge: 8%

Decreased from 16% FY 2011


• $2,108,400


Hospital Outcomes

• As a result of the ROAD program’s tactics for quality

improvement, the organization has noted a consistent annual

reduction in hospital readmission rates.


• Definitive

Healthcare data

shows UCD:

Lowest readmissions

at less than 80% of

other hospitals

nation wide

96% lowest mortality

for COPD patients.

Hospital Outcomes


Why Do We Do This? It’s Beyond

the Numbers….

Conclusions

• Development of a Quality Improvement Program for

COPD care offers benefits for hospitals with COPD

admissions and readmissions on the rise.

• Respiratory Care Practitioners (RCP’s) perform a vital

role for integrating COPD care by improving patient

education and coordination of patient care services.

• RCP’s facilitating healthcare navigation and

utilization for COPD patient results in improved

outcomes and Cost Savings for the patient, the

hospital, and the patient’s medical insurance

company.


References

• Ford ES. Hospital discharges, readmissions, and ED visits for COPD or

bronchiectasis among US adults: findings from the nationwide inpatient sample

2001-2012 and nationwide emergency department sample 2006-2011. Chest

2015;147(4):989-998.

• Jemal A, Ward E, Hao Y, Thun M. Trends in the leading causes of death in the

United States, 1970-2002. JAMA. 2005. Sep 14;294(10):1255-9.

• Connors AF Jr, Dawson NV, Thomas C, et al. Outcomes following acute

exacerbation of severe chronic obstructive lung disease. The SUPPORT

investigators. Am J Respir Crit Care Med. 1996. Oct;154(4):959-67.

• Foster JA, Yawn BP, Maziar A, et al. Enhancing COPD management in primary

care settings. MedGenMed. 2007;9(3):24.

• Jones SE, Green SA, Clark AL, et al. Pulmonary rehabilitation following

hospitalization for acute eacerbation of COPD: referrals, uptake and adherence.

Thorax 2014:69(2):181-182.


[email protected] HEALTHIER WORLD THROUGH BOLD INNOVATION

“Empathy is not an occupational

hazard”-Dr. Samuel Louie

Documents

COPD Case Management led by Respiratory Therapists · Discharge plan 4. Transfer or referral 5. Reassessment. COPD –ROAD™ Education Education Session 1 • What is COPD Diagnosing