Optimizing Care for Complex Patients with COPD Janice Gasaway, RN, MN, Director Quality & Safety Elvin Perkins, MBA, Chronic Disease Project Manager 1
Cone Health System: Who We Are Regional Health System serving 6 counties in piedmont NC Six hospitals - Total Beds: 1,273 Two medical centers Three urgent care centers CHMG - 106 physician practice sites Medical Staff: 1,000 Triad HealthCare Network - Accountable Care Organization (ACO) Why COPD? 1. Engaged Pulmonary Critical Care Physicians! 2. A Leading Cause of Death and Disability 80% of US deaths are due to: Heart Disease Cancer Chronic lower respiratory dx 3. Impairs Quality of Life 4. Leading Cause of Hospitalization for Older Adults 5. Cost Burden: Est. > $200B over next 5 years Cone Health 23% of total claims 2
Data-Driven Initial Data One hospital, all patients with principal or secondary diagnosis 3007 visits 2/3 via ED 1223 total inpatient stays 848 patients 247 patients had multiple admissions (2-10) 25% of readmissions were within 4 days 50% within 10 days 65 had 3 or more admissions to the hospital 258 hospitalizations, 1812 days 7.7% of patients accounted for 21% of IP stays and 21% of days ± 44% of patients presenting to ED are admitted **Related Co-morbidities, Certain Zip Codes, Times of Day.. Heart Failure Similarities Pneumonia: Common Link January June, 2010 2011 1939 admissions 1571 patients 274 patients had multiple admissions (2-7) 67 pts. had 3 or more admissions (228 total) 4% of admitted pts. accounted for 12% of total admissions 210 admissions 78 patients 2-7 admissions per patient 1232 Patient Days Median LOS: 13 days 76% had COPD, 71% had Heart Failure, 58% had both Only 44% had received both influenza and pneumococcal vaccine 11/4/2014 6 3
Methodology TEAMWORK. Data.. Understanding the problem, recognizing successes Mapping the processes Identifying steps in the process that limit success Triage, Hand-offs, Scheduling follow ups, patient understanding Understanding what causes the step to fail Developing solutions Leadership Structure Steering Committee Three Clinical Teams ED-to-Office ED-to-Inpatient Patient and Community Resource Team Facilitated by Quality Improvement Specialists 20 physicians & mid-level providers Cone HealthLink Emergency Department IP Nursing Respiratory Therapy Office employees C-P Rehab Care Management Case Management Social Work 4
Critical Variables Identified System Standards: Follow up appointments Consultation Identification of high utilizers Office Identification of high risk Scheduling Follow up & Cancellations After hours appointments GOLD Strategies Staff knowledge Emergency Department Differential Diagnosis Identification GOLD Strategies Vaccinations Follow up appointments Inpatient Identification of high risk GOLD Strategies Engagement of the whole team Staff knowledge Critical Variables Identified Patients Personal Life IP Office ED Financial constraints Anxiety & Depression Knowledge of disease Knowledge of when and how to react Objective ways to assess Ability to navigate system Knowledge 5
Improvement Strategies System Identify and flag high risk patients Retrospective: Admissions & ED visits COPD stage, CAT Setting Standards 7 days to follow up appointment post ED or Hospitalization Consultation with pulmonary specialists Inpatient referrals with critical team members - multidisciplinary Vaccination Campaign Office Identification of high-risk patients Scheduling Same day access Ensuring scheduling of follow up appointments Process to address cancellations After hours appointments In-Basket pools for scheduling COPD flow sheet in navigator screen Use of CAT score Documentation of COPD stage Synopsis view COPD profile Staff & Patient Education Improvement Strategies ED Differential diagnosis tool COPD, Heart Failure, Pneumonia COPD order sets Workflow to ensure post-discharge appointments Vaccinations for COPD high risk patients Best Practice Advisory to trigger workflow Admission Discharge Algorithm Department champions Inpatient Order sets build Clinical Pathway Inpatient consultations Screening for Depression / Anxiety Action Plan Staff & Patient education Pilot and hospital roll-out Department and hospital champions Emmi Solutions Patient Story video 6
Patient Engagement Cone Health COPD GOLD Obstructive Lung Disease patients in the Cone Health community who are at high risk for exacerbations Retrospective: COPD + 3 or more admissions in 6 months COPD patients who need to ENGAGE in their health Understand COPD and how to live with it Know how to prevent and respond to exacerbations Financial Impact: 6 Months Health Care Cost avoidance $4.5M in six months July-December 2013 80% 60% 40% 20% 0% Decline in admissions % ED arrivals who were admitted % ED arrivals who were admitted Time Period Reduced LOS LOS Wesley Long Hospital Jan June 2011 6.0 July Dec 2011 5.7 Jan June 2012 5.7 July Dec 2012 6.0 Jan June 2013 5.8 July Dec 2013 4.8 Reduced admission rate by 11% 409 avoided admissions Statistically significant reduction, P- value = 0.000 Value per admission: $10,500 Last 3 mos. of 2013, 477 admissions 477 days avoided Valued at $450/day Savings in 3 mos: $214,650 7
Proportion 11/4/2014 COPD GOLD Admissions Admission rate 70% (Currently 61%) Percentage of COPD GOLD Who Arrived @ ED and Were Admitted by CY 2011 2012 2013 2014 1.0 1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 Tests performed with unequal sample sizes June 2011 September 2011 December 2011 March 2012 June 2012 September 2012 December 2012 March 2013 June 2013 September 2013 December 2013 March 2014 Time Period UCL=0.8483 _ P=0.6145 LCL=0.3807 Readmissions: All-Cause, All-Payer Rate FY11: 15.0% FY12: 12.7% FY13: 12.0% FY14: 12.9% Count FY11: 9.2 FY12: 7.1 FY13: 6.8 FY14: 4.9 8
9