3/11/15. COPD Disease Management Tackling the Transition. Objectives. Describe the multidisciplinary approach to inpatient care for COPD patients

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1 Faculty Disclosures COPD Disease Management Tackling the Transition Dr. Cappelluti has no actual or potential conflicts of interest associated with this presentation. Jane Reardon has no actual or potential conflicts of interest associated with this presentation. Dr. Ewing has no actual or potential conflicts of interest associated with this presentation. A Multidisciplinary Team Approach Schwarting Senior Symposium 2015 March 17th Erika Cappelluti, MD, PhD, MA, FCCP, ABIHM Medical Director, Department Respiratory Care Hartford Hospital Director, PFT Lab Hartford Hospital Medical Director, Center for the Healing Arts, Helen & Harry Gray Cancer Center Objectives Some Facts COPD is the 3 rd leading cause of death in the US Describe the multidisciplinary approach to inpatient care for COPD patients Describe the benefits of a MED to BED process for COPD discharges 120,000 deaths per year 15 million Americans with COPD dx COPD is responsible for more than 1.5 million ER visits per year 725,000 hospitalizations annually are related to COPD Healthcare costs approach $60 BILLION Some More Facts 21% of all patients with COPD are readmitted within 30 days of discharge Costs for readmissions are 18% higher than for initial stays As of October 2014, CMS reduced payments by 3% to hospitals with high rates of all-cause readmissions (COPD, CHF, pneumonia and acute MI) In 2013 alone, over 2,000 hospitals were penalized for an estimated $280 million dollars 1

2 COPD at Hartford Hospital COPD Readmission Rates-2013 Readmission rate higher than expected Reimbursement implications Cost of care almost double Variability in care Transitions of care often less than optimal Patients without understanding of disease progression, acute symptoms, and zone management action plan Goals of Care and Advance Planning limited High incidence of depression and anxiety COPD Readmission Rates-2014 COPD Index Admission Discharged to: HOME WITH HOME CARE SERVICES 35.9% 43.1% HOME ROUTINE 31.6% 30.7% SKILLED NURSING FACILITY 28.4% 19.9% LONG TERM CARE FACILITY 1.6% 2.6% HOSPICE INPATIENT MEDICAL FACILITY 1.3% 0.7% HOME WITH HOSPICE HOME CARE 0.5% 1.5% FEDERAL HOSPITAL 0.3% 0.7% OTHER INPT FACILITY 0.3% 0.4% COPD Readmission Diagnosis 2013 COPD Readmission Diagnosis

3 Inpatient Management Transition of Care Post acute care strategies Our Team. o Pulmonary Division o Hospitalist Division o Department of Medicine o Pulmonary Rehabilitation o Respiratory Care o Nursing o Pharmacy o Research Department o Nutrition o Integrative Medicine Division Inpatient COPD Disease Management Tool Inpatient COPD Disease Management Tool CAT Test How is your COPD? Take the COPD Assessment Test (CAT) This questionnaire will help you and your healthcare professional measure the impact COPD (Chronic Obstructive Pulmonary Disease) is having on your wellbeing and daily life. Your answers and test score, can be used by you and your healthcare professional to help improve the management of your COPD and get the greatest benefit from treatment. If you wish to complete the questionnaire by hand on paper, please click here and then print the questionnaire. If you complete the questionnaire on-line, for each question below, click your mouse to place a mark (X) in the box that best describes you currently. COPD Assessment Test 3

4 PHQ-9 (Depression Questionnaire) In-Check Dial: Pulmonary Airflow Meter Choose the most appropriate inhaler for patient based on inspiratory flow capacity Inpatient Management All patients to receive aerosolized treatments for 24 hours and reassessed Standards of care Steroids Antibiotics Imaging / testing Transitional criteria Spirometry and risk stratification based on GOLD guidelines Alpha-1 antitrypsin screening Triggers for pulmonary and integrative medicine consults Triggers for palliative medicine Depression screening using PHQ-9 Trigger for social work intervention Nutrition screening Smoking cessation interventions Candidacy for Pulmonary Rehab outpatient classes Patient Education Areas of Focus COPD Disease Trajectory Triggers Action plans : zone management Energy Conservation/ breathing techniques Mobility Nutrition Proper technique and sequencing of medications Role of In-check Dial PEP : Airway Clearance DME needs Advance Care Planning Candidates for Integrative Medicine Outpatient follow up appointments & Phone call Zone Management AEROBIKA : Airway Clearance and PEP therapy PEP therapy 4

5 Inpatient Management Transition of Care Post acute care strategies Transition of Care Disposition algorithm Inpatient disease management tool to be faxed to PCP and pulmonary office Data to be captured using REDCAP survey Hand off : medication reconciliation MED TO BED Outpatient follow up appointments & communication to PCP & pulmonologist Role of outpatient pulmonary rehab classes Outpatient follow up appointment within 5-7 days of discharge in BRIDGE/TRANSITIONAL CLINIC MED to BED Engage pharmacy to provide bedside education near the time of discharge Engage pharmaceutical companies to provide drug samples Average number of meds at time of follow up 17!!! Education is key for CLARITY and COMPLIANCE Biggest gaps include insurance coverage of meds and med changes that occur during the admission Outpatient follow-up appointments & communication to PCP & pulmonologist are also important elements Transitional clinic adds value Reducing COPD Readmissions Future Directions/Areas of Concentration Operationalize med to bed-insurance coverage, samples Education/communication with patients paramount!! Follow up appointments are key Appropriate disposition also key Effective communication with providers in the community Increase institutional buy-in for resources Ultimately, patients need to assume responsibility for their health Readmissions are influenced by social and medical factors that may not be easily modifiable income, insurance and comorbid mental health diagnoses 5

6 COPD Readmission Rates

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