Carolinas Medical Center NorthEast Overview 8/14/2014. Hospital to Physician Office to Home: A Respiratory Led Program Across the Continuum of Care

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1 Hospital to Physician Office to Home: A Respiratory Led Program Across the Continuum of Care Charley P. Starnes, RRT, RCP Clinical Respiratory Specialist- COPD Education Carolinas Medical Center NorthEast Profile 457 beds 3,201 employees Level IV Neonatal Intensive Care Unit (>26 weeks) Level III Trauma Center Accredited Chest Pain Center Emergency Care Center: 78,749 visits in 2012 CMC-Kannapolis (Free-Standing Emergency Department): 23,016 visits in 2012 Jeff Gordon Children s Hospital (53 beds) Sanger Heart & Vascular Institute Health and Fitness Institute (Pulmonary Rehabilitation) Cabarrus College of Health Sciences Bariatric Center of Excellence Comprehensive Batte Cancer Center; Levine Cancer Institute Majority market share holder in Cabarrus County 542 physicians on active medical staff Carolinas Medical Center NorthEast Overview We are the third largest facility in Carolinas Healthcare System (CHS) with 457 beds located in Concord, North Carolina ( We serve as a teaching hospital, offering a Family Medicine Residency in affiliation with UNC School of Medicine and a sports medicine fellowship through Sports Medicine and Injury Center 1

2 Who Owns COPD?? Potential Lung Health Risks in Cabarrus County Large Tobacco Manufacturer Textile Industry Exposure to dust/irritants from: Construction Agriculture Motorsports Important Milestones July Respiratory department implementation of a Clinical Respiratory Specialist The Respiratory Care department placed a dedicated therapist in the ED CMC-NE kicked off the Beacon COPD Disease Management Program in January 2012 The goal was to develop a standardized disease management program that followed the patient throughout the continuum of care (ED-Inpatient-Medical Home) The outpatient RT Pilot Program began in the Medical Home the week of November 20, 2012 Role of the Clinical Respiratory Specialist Identify patients with admissions for COPD Acute Exacerbation Meet one on one with patients to assess level of knowledge regarding COPD diagnosis and symptom management Educate patients on COPD and respiratory medications Refer patients to Clinical Case Management for home health services, financial concerns, etc. 2

3 Patient identification process beginning July 2011 Review RT work list for patients admitted for respiratory symptoms Modified process in April 2012 Review RT work list For patients admitted for respiratory symptoms & review patient list provided by Case Management Review patient charts for history, diagnosis of, or admission for COPD Review patient charts for history, diagnosis of, or admission for COPD Establish patient priority based on current admission diagnosis and previous admission history Establish patient priority based on current admission diagnosis and previous admission history Educate patients on COPD and respiratory medications COPD disease process and symptom management Avoiding risk factors/respiratory triggers Rescue vs. maintenance inhalers Proper technique for individual inhaler devices Proper frequency for maintenance inhalers why it is important to take them at the proper frequency Pursed-lip & diaphragmatic breathing techniques for dyspnea management Explain benefits of pulmonary rehab & and refer to program SMOKING CESSATION Problems with Inhaler Use: A Call for Improved Clinician and Patient Education James B Fink MSc, RRT, FAARC & Bruce K Rubin MEngr, MD, MBA,FAARC Respiratory Care September 2005 It is estimated that 28%-68% of patient do not know how to use their inhalers effectively enough to benefit from the medication Next to pills, the inhaler is the most common medication form in the world 39-67% of doctors, nurses, and respiratory therapists are unable to adequately describe or perform critical steps of inhaler use 3

4 What s in your med bag??? Refer patients to Clinical Case Management for home health services, financial concerns, etc. Transportation issues Palliative Care Consults Medication affordability Rehab facilities placement Home Health Services DME services Current COPD TeleHealth Process Inpatient COPD RN TeleHealth 4

5 Ms. K Pre-Dedicated Therapist RT in the ED Dedicated Therapist Readmission for COPD exacerbation in <24 hours of discharge 70 year old Female History of COPD, HTN Diagnosed with COPD 15 years ago Former smoker- 1-2 packs/day since age 20 NEVER hospitalized for COPD exacerbation Lives alone in a retirement community AMAZING family/friend support ABG s BiPAP initiation & management Airway management Ventilator initiation & management Cardiac Arrests Respiratory Distress Trauma Codes ABG s BiPAP initiation & management Airway management Ventilator initiation & management Cardiac Arrests Respiratory Distress Trauma Codes All respiratory treatments utilizing protocol RT to assess & treat Respiratory device education COPD READMISSIONS (YTD-June) MS-DRG: 190: Chronic obstructive pulm disease w/mcc, 191: Chronic obstructive pulm disease w/cc, 192: Chronic obstructive pulm disease w/occ/mcc Beacon COPD Project The Medical Home Respiratory Therapist Program 5

6 The Medical Home RT Pilot Program began the week of November 20, COPD Population Screener An outpatient COPD algorithm was created based on GOLD guideline criteria to ensure standardization of treatment between outpatient providers. The PCP Pilot sites were: Kannapolis Internal Medicine Carolina Internal Medicine Ardsley Internal Medicine-Concord Cabarrus Family Medicine- Mt. Pleasant Cabarrus Family Medicine- Harrisburg A validated questionnaire that can help identify people age >= 35 who are at risk for COPD through the identification of symptoms and risk. The tool may lead to increased awareness of COPD, earlier symptom recognition and use of spirometry for accurate diagnosis. COPD POPULATION Screener - DRIVE4COPD 1. During the patient 4 weeks, how much of the time did you feel short of breath? 2. Do you ever cough up any stuff, such as mucous or phlegm? 3. Please select the answer that best describes you in the past 12 months: I do less than I used to because of my breathing problems. 4. Have you smoked at least 100 cigarettes in you entire life? Medical Home: Embedded Respiratory Therapist Program Total Patient Screened and % High Risk Note: Pilot program data from November 20, 2012 thru August 30, % of patients screened are high risk How old are you? 6

7 Pilot Site Specific Screening Data Identify Patients There are more opportunities for our RT s in the outpatient settings as our high risk pool is significant Retrieves and triages screeners from front office Receives direct referral from MD Enroll in Program Calls patients who score Schedules patient for Completes chart review high risk to perform initial RT appointment for (H&P, last PFT, recent phone functionality spirometry and COPD admissions) assessment education Verifies chart information, discuss screener, and assesses level of knowledge regarding COPD Respiratory Therapists: Establishing a Patient Panel RT s also identify patients through direct MD referral of hard to manage COPD patients. Visit Process 1506 Patients Screened High Risk % RT Phone Assessments % RT Medical Home Visits Performs spirometry, Obtains medical if needed, and Educates patients history determines COPD on COPD diagnosis and stage disease process risk factors and triggers reviews COPD self management plan Provides smoking Refer patient to Pulmonary cessation education Rehab, if applicable Educates patients on COPD medications and proper use rescue vs. maintenance medications Proper device technique Document notes in EMR There are more RT opportunities in the outpatient settings as our high risk pool is significant Each patient received at least 1 follow-up phone call 2-4 weeks post visit 7

8 What s in your med bag??? Respiratory Therapists: Patient Interventions Performed 364 office visits 61% 60% 222 First Time Spirometry Performed 217 Smoking Cessation, Referrals, Smoking Packets Ms. X 47 year old female Screener score of 7 No diagnosis of COPD Current 1 pack/day smoker Phone interview conducted and appointment scheduled with RT Patient no call/no show times 2 and then cancels the 3 rd appointment 46% 167 Patients Treated Compliant to the Gold Guidelines 4 months later.. Patient calls to schedule another appointment and shows up!! Mother had just died from COPD/Pneumonia Father just diagnosed with stage 4 lung cancer 8

9 COPD Community Outreach Health Fairs Drive4COPD Free Clinics Faith Community Health Ministry Pulmonary Rehab Program Better Breathers Club Great American Smoke Out Autumn Jubilee Silver Sneakers Disease Specific Care Certification (DSC) from The Joint Commission in: Patient Education Chronic Obstructive Pulmonary Disease December 13,

10 The principal goals of pulmonary rehabilitation are to reduce symptoms, improve quality of life, and to increase physical and emotional participation in daily activities. Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) The Benefits of Pulmonary Rehabilitation in COPD: Improves exercise capacity Reduce the perceived intensity of breathlessness Improves health-related quality of life Reduces the number of hospitalizations and days in the hospital Reduces anxiety and depression associated with COPD Strength and endurance training of the upper limbs improves arm function Benefits extend well beyond the immediate period of training Improves survival Respiratory muscles training can be beneficial, especially when combined with general exercise training Improves recovery after hospitalization for an exacerbation Enhances the effect of long-acting bronchodilators **Patients at all stages of disease benefit from exercise training programs with improvements in exercise tolerance and symptoms of dyspnea and fatigue** Any Questions? 10