Carolinas HealthCare System established a steering committee and five focus groups, each led by a physician, to focus on COPD readmissions. The focus groups covered guideline development, disease management, staff education, patient education, and outpatient respiratory therapy. The steering committee assigned deliverables to each team to ensure accountability.

Patient education and community outreach

  • Personalize interventions based on patient needs.
  • Provide patient/caregiver with appropriate support, education, and resources.
  • Develop educational materials based on Carolinas HealthCare System’s Health Literacy Guidelines using a hybrid picture/text model.
  • Test materials on focus group.
  • Use a variety of teaching methods to support patient in self-management.

Disease management

  • Create process to ensure primary care physician (PCP) is informed regarding any transitions of care, updated plans of care, and visit outcomes.
  • Create process to ensure patients get the appropriate referrals (i.e., palliative care, hospice, etc.).
  • Develop a process to identify “at-risk” patients who could benefit from post-hospital transition home visits or telephone follow-up.
  • Develop a follow-up documentation protocol so that PCP or other healthcare providers are well informed
  • Use coaching sessions and allow patients to set their own goals to encourage self-management, and develop process to capture these goals in EHR.

Staff education

  • Develop training program for providers and staff based on evidence-based guidelines.
  • Establish communication systems to share relevant information with other healthcare providers and care managers.
  • Train providers in “Teach Back Methodology,” “Ask Me 3,” and “Motivational Coaching.”

Guideline development

  • Incorporate existing guidelines and other nationally recognized best practice care into high-risk patient algorithm.
  • Develop standardized assessment methods to achieve disease control and mitigate risk for complications.
  • Create processes and procedures for clinical decision support at the point of service.
  • Establish screening documents or criteria to assess and identify individual patient care needs.
  • Develop disease registry.

Oversight committee

  • Determine process and outcome measures of success.
  • Align measures of success with Beacon, Carolinas HealthCare System, and CMC-NorthEast quality and business goals.
  • Sustain and monitor data for continuous improvement.

See releated article: Reducing COPD Readmissions with a Cross-Continuum Approach

Source: Carolinas HealthCare System. Used with permission. 

Publication Date: Monday, April 21, 2014