Model of Care in a Comprehensive Sleep Program

Transcription

1 Model of Care in a Comprehensive Sleep Program Dara Vega, RN, RCP Project Manager II, Ambulatory program supervisor, Kaiser Permanente Sleep Medicine Department; Fontana, CA Objectives: Identify current challenges in sleep medicine and directions for the future Discuss methods of utilizing team-based care to improve the ability to manage sleep disorders Define the critical role of emerging technologies to enhance the delivery of sleep medicine care

2 Model of Care in a comprehensive Sleep Program Sleep Labs Moving Beyond the Basics Dara T. Vega, RN, CRTT, RPSGT Manager Fontana Sleep Center SCPMG/Kaiser Permanente

3 Conflict of Interest Disclosures Speaker: Dara Vega 1. I do not have any potential conflicts of interest to disclose, OR 2. I wish to disclose the following potential conflicts of interest: Type of Potential Conflict Details of Potential Conflict Grant/Research Support Consultant Speakers Bureaus Financial support Other 3. The material presented in this lecture has no relationship with any of these potential conflicts, OR 4. This talk presents material that is related to one or more of these potential conflicts, and the following objective references are provided as support for this lecture:

4 Objectives During the course of this program you will: You will understand the current challenges sleep Technologists and sleep labs are facing. Examine how and where to shift areas of focus in treating patients with sleep disordered breathing issues. Learn about one model of care practiced at the Kaiser Permanente Fontana Sleep Center

5 State of Sleep In America million suffer from chronic sleep loss and sleep disorders 80 to 90% of remain unidentified and undiagnosed Primary Care physicians seldom ask patients about their sleep

6 Trends in Sleep Medicine

7 Detrimental Health Consequences High Blood Pressure STROKE HEART ATTACK Heart Attack INCREASED RISK OF EARLY DEATH

8 Economic Impact

9 Increased Public Awareness

10 AASM Accredited Sleep Labs

11 Medicare Spending

12 HSAT Effect PSG 1X HST 4X 1. Financial viability of additional growth of attended PSG labs? 2. Alters the expertise required for techs

13 Sleep Lab Closures Sleepcare Diagnostics Closing: Cincinnati Based Sleep Disorder and CPAP Center Sleep Health Centers close 39 labs in New England & Arizona 12/2011 Irving s Total Sleep shutters testing sites UCI to Close Sleep Center

14 Blue Print for Change Institute of Medicine Care System Supportive payment & regulatory environment Organizations that facilitate the work of patient centered teams High performing patient centered teams Outcomes: Safe Effective Efficient Personalized Timely Equitable Redesign Imperatives: Six Challenges Reengineer care processes Effective use of communication technologies Knowledge & skills management Development of effective teams Coordination of care across the patient conditions, services, sites of care over time Executive Summary." Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press, 2001.

15 Future of Healthcare Outcomes Based Medicine Team Based Care Physician PA Physician RN LVN/MA Office Visit RCP/ techs Office Visits Web encounters Text/ /Phone Automated mechanisms Patient Patient

16 What is Sleep Medicine? OSA OSA Sleep labs CPAP follow up Non PAP Rx Insomnia psychiatry Clearance of DOT Narcolepsy RLS Neuro Respiratory Failure Pulm Pediatrics Insomnia Peri operative Respiratory Failure In Patient Narcolepsy RLS Pediatrics Neonates

17 Kaiser Permanente Experience (Fontana Medical Center) Network of 8+ Sleep Centers in Southern California Serving 800,000+ patients Monthly volume: 1000 referrals encounters 400 new OSA diagnoses 300 new PAP orders per month

18 Service Growth

19 Personnel Patient Volume (per month) visits 5000 telephone 180 inlab PSG (night) 20 inlab PSG (day) 440 HST (diagnostic) 400+ APAP trials Personnel 3 Physicians 2 Dentist 1 PA 1 RN 7 RPSGT (days) 9Rcp (days) 5 RPSGT/RT (nights) 1 LVN 4 medical assistant 3Managers (day and night) 6 Clerical staff Registry Staff

20 Peri Operative Program Ambulatory PSG Sleep Center Services Case Manager Attended PSG Research Hypo ventilation & Complex sleep disordered breathing Follow up Program Commercial Driver Remote Ambulatory Program CPAP Clinic DME Closet CPAP Follow up program Alternative Therapy Program Pediatrics Provent OA Therapy Pre natal OSA program Dental visits Weight loss program Winx Sleep Physician Consultation Insomnia Program Inpatient Hypercapnic Respiratory Failure Program

21 Reorganize Sleep Labs to Sleep Centers Team Based Practice Protocol driven care Group appointments Using technology to improve efficiencies

22 Traditional Indications for PSG OSA (90%) Pediatric (5%) Miscellaneous (5%)

23 Reasons for Attended PSG OSA (20%) Hypoventilation Hypoxemia (25%) Other (2%) Parasomnias (2%) CSA (15%) PLMD (4%) Commercial drivers (6%) Hypersomnia (MSLT\MWT) (8%) Pediatric (18%)

24 Traditional Technologist Skills PT SETUP APPLICATION IMPEDANCE LEVELS PSG Collection Titration DIAGNOSTIC MSLT MWT CPAP BIPAP SCORING ADULT PEDIATRICS

25 New PSG Technologist Skills PT SETUP APPLICATION IMPEDANCE LEVELS Complex Therapy Protocols VAPS ASV Dead Space Therapy MATRx / Provent Enhanced Diagnostics Clinical Assessment Capnography Transcutaneous Monitoring

26 Role of the Sleep Physician Team Leader Interpret Sleep Studies Direct consultation for complex patients Create a clinical care pathways via protocols for patients to be implemented by case managers Build staff capacity Build projects often in collaboration with other departments

27 Roles of Case Management Team Physician Support HST Setup APAP setup Mask fitting Remote monitoring Therapy compliance checks Maintains equipment Occasionally communicates physician directed messages to patient (minimal clinical assessment) Task Oriented Physician Extenders Patient education (class or individual) Communicates testing results with patient Clinical assessment and clinical decision making Referring or triaging to specific services Consults directly with sleep physicians Communicates directly with referring provider or other non sleep dept medical staff. Clinical Judgment

28 Team Based Care Booking Team Generalist HSAT Team Alternative Therapy Team Insomnia/Shift worker Team Complex Sleep Disorders Team In Lab Team Dispensing Team

29 Complex Sleep Disordered patients DX OF COMPLEX SLEEP DISORDER PSG MD CONSULT RN/RCP CASE MANAGER DIAGNOSTIC WORKUP PFT s ABG ECHO CXR FOLLOW UP Labs Adherence to therapy Oximetry study

30 Protocol Driven Care

31 HSAT Protocol & Workflow HSAT Protocol & Workflow CLASS OR INDIVIDAUL APPOINTMENT PRELIMINARY RESULTS BY RCP POSITIVE REPEAT HSAT NEGATIVE IN LAB REFERRAL APAP TRIAL Insomnia class MD CONSULT APAP TRIAL with O2 probe for? Hypoventilation CSA FOLLOW UP PRN

32 HSAT to Attended Sleep Studies Referrals HYPOVENTILATION PROTOCOL Strongly consider if initial baseline oxygen saturations are persistently below 90%, look at T90. Persistently low saturations during OSA periods with poor recovery (usually below 90%) Oximetry probe trial unless on oxygen prior to in lab. Cancel in lab if oximetry >90% CENTRAL SLEEP APNEA Flow and Abdominal and thoracic belts flat lined during CSA periods AutoPAP trial regardless, to check for high residual AHI, about AHI >15 hr History of CHF or narcotics predispose to CSA HYPOXEMIA Low oxygen saturations noted during the entire sleep study History of oxygen supplementation ADDITIONAL REASONS Patient failed HSAT and strongly request in lab Patient on home oxygen and did not disclose Patient lives >40 miles away

33 Encounter Efficiency

34 Insomnia Background Cognitive Behavioral Therapy (CBT) is effective in treating individuals with chronic insomnia, typically delivered in multiple sessions and individually (or small groups.) Our challenge is to deliver CBT cost efficiently given the high prevalence (30%) in the population. Edinger et al (Sleep 2007) revealed 1 session CBT protocol to be reasonably comparable in effectiveness to multi session CBT. Other studies (Espie, Sleep 2007) showed group format (4 6 persons) also effective. Kaiser Permanente (Fontana MC) 430K members (129K chronic insomnia) 1 Session CBT in Large Group Format

35 INSOMNIA PROGRAM BY REFERRAL, SELF REFERRAL OR CASE MANAGER AFTER REVIEWS AMBULATORY STUDY INDIVIDUAL CONSULTATIONS BY PA FOR SPANISH SPEAKING OR PEDIATRICS CBT CLASS 120 MINUTES INSTRUCTED BY THE PHYSICIAN ASSISTANT FOLLOW UP CALLS BY PA/LVN INDIVIDUAL APPOINTMENTS

36 Technology

37 Wireless Modem

38 CPAP Adherence at 3 months Fox et al, SLEEP, Vol. 35, No. 4, 2012

39 Outcomes

40 Impact of case management Improved adherence to non invasive ventilation from 10% to 90% Classroom format for insomnia CBT proven to be cost effective (89% subjective improvement; reduced insomnia medication fills; 25% reduction in primary care office visits 1 yr. after program) Primary care physician survey: 100% reported closed loop sleep program reduced time spent managing sleep disorders; 88% reported case management program improved care over physician (sleep or primary care physician) management.

41 Challenges Recruiting and training staff Quality Improvement Continuous education Integrating new technologies Rapid improvement model Patient traffic control

42 Summary Shift Sleep labs to Sleep centers Own your own: close looped process Move from tasks to care management Build skills to partner with patients

43 Future For Sleep Medicine

44 Acknowledgements Dr. Dennis Hwang, Chief of Service KP Fontana Sleep Center Dr. David Quam, Medical Director KP Fontana Medical Center KP Fontana Sleep Center Rosa Woodrum, RRT, Department administrator Julie DeWittte RRT, Assistant Manager Cindy Gulley, Physician Assistant Jeremiah Chang, Research Associate