1 Chronic Obstructive Learning Collaborative Sponsored by AMGA and Boehringer Ingelheim Pharmaceuticals, Inc. July 24-26, 2013 Chicago, IL University of Michigan Faculty Group Practice Improving the quality of care for patients with Chronic Obstructive Pulmonary Disease
UMHS COPD Teams Structure COPD QI Steering Committee Pulmonary Hospitalist Nursing Respiratory Therapy Quality Data Analysis COPD Hospital Multidisciplinary Team Pulmonary Hospitalist Nursing Respiratory Therapy Emergency Department Visiting Nurse Discharge Planning
3 COPD QI Steering Committee MeiLan Han, MD Committee Co-Lead, Associate Professor (Pulmonary) DeAnn VanSickle, RN Committee Co-Lead, Clinical Affairs Steven Bernstein, MD Director, Quality Management Program (QMP); Professor (General Medicine) Susan Blitz, MD Director, Taubman Gen. Medicine Clinic; Director, Employee Health; Assoc. Professor (Gen Med) Jeff Capuano Analyst, QMP Todd Georgia, RRT Respiratory Therapist (Adult) Cheryl Grostic Administrative Specialist, QMP Catherine Meldrum, RN Lung Volume Reduction Program Nurse Lead Satyen Nichani, MD Hospitalist, Assistant Prof (Gen Med) Kelly Schultz, RN Quality Improvement Representative Karla Stoermer Grossman, RN Asthma QI Steering Committee Co-Lead, Certified Asthma Educator Annie Sy, PharmD Manager, QMP
4 COPD Hospital Multidisciplinary Team DeAnn VanSickle, RN Chair. Clinical Affairs Kelly Board, RN Nurse, Emergency Department Kelly Campbell, RRT Pulmonary Function Lab Manager Deborah Crawford, RN Nurse, Adult Medicine Deborah Diemer Administrative Assistant, Clinical Affairs James Freer, MD Associate Professor (Emergency Medicine) Todd Georgia, RRT Respiratory Therapist (Adult) MeiLan Han, MD Associate Professor (Pulmonary) Toni Henkemeyer, RN Manager, Michigan Visiting Nurses Hae-Won Kim Hospitalist, Assistant Professor (Gen Med) Catherine Meldrum, RN Lung Volume Reduction Program Nurse Lead Satyen Nichani, MD Hospitalist, Assistant Professor (Gen Med) Kelly Schultz, RN Clinical Affairs Rachel Wilken, RN Discharge Planning Mark Zhang Data Analyst, Clinical Affairs
5 Project Overview: Initial Goals Improve the quality of care provided to COPD patients Maximize the quality of life of patients with COPD Reduce rates of emergency department visits and hospitalizations for patients with COPD
6 Project Overview: Specific Goals Increase number of patients with spirometrically confirmed diagnosis Improve the quality of spirometry performed in primary care clinics Track quality metrics for COPD patients Standardize COPD education materials across the health system Increase collaboration across the health system between clinicians caring for COPD patients
7 Project Overview: Our COPD Registry Inclusion Criteria: COPD Diagnosis on Problem List AND 1 ED Visit or 1 Hospitalization or 2 Ambulatory Care Visits at UMHS AND At least 40 years old AND Must have had COPD diagnosis spirometrically confirmed within last 10 years with FEV1/FVC ration of <70% Registry measures pulled electronically Occasional chart review to assure data integrity
8 Current State of Registry: Late June 2013 Qty. Description 1639 Measurable COPD patients that meet registry criteria 843 COPD patients with a problem summary list diagnosis and NO confirming spirometry 112 COPD patients with a problem summary list diagnosis, NO confirming spirometry, and a rule-out condition (BOOP, Lung Cancer, etc.) 2594 TOTAL PATIENTS
9 University of Michigan COPD Registry Data in registry validated; measurable population identified Report from May 2013; 1631 patients age 40 years or older # Measure Name Measure Denominator 1 Spirometry performed All Eligible COPD patients 2 Current PFT FEV1/FVC < 70% All Eligible COPD patients 3 Bronchodilator prescribed All Eligible COPD patients 4 Immunizations - Pneumococcal All Eligible COPD patients Time Frame Search Criteria prior 10 years through end of reporting period prior 10 years through end of reporting period All Active Meds listed on Problem Summary List Through end of previous reporting period (Mar. 2012) Overall % 100% 92% 92% 75% 5 Immunizations - Influenza** All Eligible COPD patients 9/1/2012-4/30/2013 NA 6 Tobacco Status Documented All Eligible COPD patients Through end of reporting period 92% 7 Current Tobacco User All Eligible COPD patients who have had their tobacco status documented Through end of reporting period 20%
10 Percent of UM Patients Who Met Measures as of March 2013 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% FEV1/FVC <70% Bronchodilator Medication Tobacco Use Documented Current Tobacco User Primary Care (N=463) 93% 85% 93% 30% Pulmonary Only (N=509) 95% 97% 84% 10% Jointly Managed (N=479) 88% 95% 98% 17% All UMHS 92% 92% 92% 20%
11 UM COPD Registry by Clinic, March 2013 Green is above target; red is below target Individual clinics listed under each heading
12 UM COPD Registry by Clinic, March 2013 Pulmonary clinics are separated out
13 UMHS All Payor COPD Performance Measures March 2011- March 2013 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% FEV1/FVC <70% Bronchodilator Medication Influenza Vaccine Pneumococcal Vaccine Tobacco Use Documented Current Tobacco User March 2011 (n=1845) 87% 85% 73% 70% 27% Tobacco Counseling Documented March 2012 (n=1724) 90% 88% 75% 81% 25% 69% March 2013 (n=1631) 92% 92% 92% 20%
14 Project Overview: Screening Tools COPD Screener from Boehringer Ingleheim & the COPD Alliance Considered use with Use Interactive Voice Response (IVR) system
15 Project Overview: Hospital Group Chart Reviews Patient who were readmitted within 30 days Admission Source Discharge Disposition Completion of discharge planning during hospitalization Follow up appointments in pulmonary & primary care Diagnoses for each admission
16 Hospital Group Chart Review Contributing Factors Factors Contributing to Readmission Other 9 Number of Contributing Factors Per Patient Psychiatric Issues 2 Five 1 Non-compliance with Treatment 6 Four 4 Psychosocial Issues 12 Three 10 Current Smoker 12 On Home O2 &/or Bipap 18 Two 13 Chronic problems from comorbidities 27 One 6 0 5 10 15 20 25 30 Number of Patients 0 2 4 6 8 10 12 14
Chart Review Results 17
18 Project Overview: Assessment Tools CAT (COPD Assessment Tool) measures the impact of COPD
19 Other Assessment Tools EXACT-Pro (Exacerbations of Chronic Pulmonary Disease Tool) is 14 item daily electronic diary Creating our own tool Looking for a way to assess patients to determine if ready for discharge in comparison to baseline status Little concrete physiological numbers in COPD to determine if patient has improved from admission Literature has not determined that there is one tool for this purpose
20 Project Overview: Educational Materials Goal of standardization across all care settings American College of Physicians Living With COPD book selected as the UMHS COPD book Available in English and Spanish
21 Other Educational Materials Supplemental Materials from the COPD Foundation Slim Skinny Reference Guides for patients Big Fat Reference Guide for patients and clinicians Clinician pocket cards
22 Future Educational Plans Offer inservices on COPD and inhaler device training to primary care, inpatient units, and staff training groups Consider creating a COPD e-learning module for staff Assure all materials are available on internal patient education clearinghouse
23 Project Overview: Spirometry Improvement Goals: Standardize spirometry in primary care clinics Improve access to testing Educate clinicians how to use spirometry in clinic settings Awarded grant 2 years ago to participate in National Asthma Control Initiative (NACI) Champions Spirometry 360 Train the Trainer Pilot Program
24 Spirometry Improvement Work 6 Pilot Sites received training, over reading services and support to incorporate spirometry into their primary care practices Created online education materials for coaches and providers based on Spirometry 360 materials Regularly communicated helpful tips and performance reports from over reader system to clinics
25 Spirometry Improvement Work Created guideline and encounter sheets Provided tech support for software and spirometer problems Completed Go & See Visits to 5 sites to determine best practice in workflow Multidisciplinary Produced flowchart for distribution
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27 Results by Clinic Each coach and provider should complete at least 10 tests per month to maintain competency (minimum 2 of each at UMHS clinics) Our passing rate goal was 80% Test results by clinic for April 2012 through March 2013: Spirometry Results by Clinic Clinic 1 Clinic 2 Clinic 3 Clinic 4 Clinic 5 Clinic 6 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Total 6 6 1 0 1 1 2 1 2 7 0 0 27 Passing Tests 10 13 2 2 4 7 2 2 5 14 4 1 66 Total Tests 60% 46% 50% 0% 25% 14% 100% 50% 40% 50% 0% 0% 41% 0 0 0 Passing Tests 1 1 2 Total Tests 0% 0% 0% 3 1 6 7 6 3 7 5 7 7 4 7 63 Passing Tests 5 2 8 11 7 4 13 6 10 12 4 7 89 Total Tests 60% 50% 75% 64% 86% 75% 54% 83% 70% 58% 100% 100% 71% 6 3 5 1 8 5 1 29 Passing Tests 12 5 9 1 10 8 1 46 Total Tests 50% 60% 56% 100% 80% 63% 100% 63% 0 1 0 1 0 1 3 4 1 11 Passing Tests 5 3 2 3 2 2 5 5 4 31 Total Tests 0% 33% 0% 33% 0% 50% 60% 80% 25% 35% 4 5 9 Passing Tests 5 6 11 Total Tests 80% 83% 82%
28 Next Steps for Spirometry New spirometry model needed Traveling pulmonary function tech versus increased access to spirometry sites Collaborative discussions with Geisinger Health System have been helpful Will pilot traveling tech at one clinic in the next few months Bring spirometer to site Use laptop to transmit results into electronic medical record
29 Celebrating Accomplishments Continued quality improvement support Project manager-type role Funding for one position focused on chronic disease improvement in ambulatory care Multidisciplinary teams representing entire health system Improved performance seen in registry metrics Education materials selected PDCA works!
30 Challenges & Lessons Learned Important to hold regular team meetings Data is a necessary part of decision making Involve all levels of staff from clinical settings Patience with implementation of an electronic medical record
31 Future Steps Improve data pull from EMR to registry Utilization of screening tools in ambulatory care Study of inpatient tool for assessment of readiness for discharge Pilot new spirometry delivery model
32 Questions for the Group What have others done with assessment and screening tools? What types of spirometry models do you use in primary care settings and how do you assure quality results? Are any willing to collaborate on publishing results of their struggles with COPD improvement work?