Beginning this October, hospitals will face penalties from the Centers for Medicare & Medicaid Services (CMS) for excess chronic obstructive pulmonary disease (COPD) readmissions—and many organizations are scrambling to manage a patient population that has been off their radar. One exception is Charlotte, N.C.-based Carolinas HealthCare System, which has been actively managing its COPD population for years.
In 2010, a project team led by Jean Wright, MD, vice president of innovation, recognized there was a huge need for COPD management in three counties served by the system. A few miles from Wright’s hospital, a cigarette plant handed out free cigarettes to employees at the end of every week. “COPD is a big disease, but one we weren’t focusing on,” Wright says. “Most patients with COPD have at least one other chronic condition and are high utilizers of healthcare services. We thought if we could target a disease where there wasn’t a lot of management already, we could make a difference.”
The strategy worked: During the pilot, the COPD readmission rate dropped from 21.8 percent in 2010 to 13 percent in 2013.
To improve COPD outcomes during the pilot, Carolinas HealthCare System staff continually identified patients with COPD, and then ensured these patients received the care they needed so they were less likely to be hospitalized. The tactics they used during the pilot included the following:
Use technology to address an unmet need. The health system’s focus on better COPD management was buoyed by a $16 million Beacon Community grant, funded through the American Recovery and Reinvestment Act (ARRA). As part of Community Care of Southern Piedmont, Carolinas HealthCare System was one of only 17 communities nationwide to receive ARRA funding to build health information exchanges and expand IT capabilities in both inpatient and outpatient settings.
“The grant gave us the technology infrastructure to improve care coordination in the community,” says Wright, who served as principal investigator for the project. Specifically, the grant helped the health system link its hospitals and primary care medical homes. It also helped with meaningful use adoption.
Conduct a root-cause analysis on COPD readmissions. Initially, project leaders assumed patient adherence was most often to blame for COPD readmissions in the health system. However, a root-cause analysis revealed that problems with patients’ home equipment were actually more prevalent. Case in point: After one patient was readmitted six times in six months, a case manager discovered that a faulty valve in the patient’s nebulizer was to blame.
Focus on the emergency department (ED). The root-cause analysis also revealed that inadequate patient education and poor access to primary care were driving COPD readmissions from the ED. To address these problems, project leaders embedded a respiratory therapist in the ED to educate patients about disease management. ED nurses also booked follow-up appointments for COPD patients with a primary care medical home.
In addition, the health system created a flag in the EHR, which highlights COPD patients who return to the ED three times in six months. This helped staff prioritize which patients to focus on.
Improve inpatient COPD care management. COPD patients are identified at admission, and both a case manager and respiratory therapist follow each patient’s treatment and discharge plan daily. All patients were assigned a medical home and received education on their disease and inhaler usage. They also had a follow-up appointment scheduled within two to seven days of discharge. In addition, all patients received a call from a nurse within 48 hours of discharge, and received weekly and “as needed” calls from a case manager for 90 days.
Bring screening and respiratory therapists to key primary care offices. With their grant funding, the project team also embedded respiratory therapists one day a week in the five employed physician practices that had the highest number of COPD patients. While at the primary care offices, the respiratory therapists took specific steps to identify, enroll, and treat patients (see the exhibit below).
“Instead of trying to teach patients in the two or three days they are in the hospital, we thought, why not try it when they are in the outpatient setting?” Wright says. In just one year, respiratory therapists reached 5,000 COPD patients in the five primary care offices—10 times the number they typically reach in an inpatient environment.
Wright is cautiously optimistic about her health system’s decreased readmissions, recognizing that variances in flu season, unemployment rates, and other factors can affect readmissions from one year to the next.
To better understand which factors continue to drive readmissions, Carolinas HealthCare System is teaming up with a vendor to help analyze readmission data across the system. Together, they have developed a tool that case managers use on the inpatient units to show a patient’s risk of readmission in the next 30 days. The tool uses analytics to stratify all patients (not just those with COPD) by risk of readmission.
Wright offers this advice for developing a disease management strategy for the COPD population:
Develop a working structure. 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 (see the exhibit below). The steering committee assigned deliverables to each team to ensure accountability.
Access related tool: COPD Deliverables
Act like private investigators. To better understand patients with COPD, physicians, case managers, nurses, and respiratory therapists conduct regular follow-up interviews with COPD patients who are readmitted to the hospital. The interviews have helped the project team see the wide array of factors that affect a patient’s ability to keep COPD under control.
Recognize that pulmonologists do not “own” COPD. Unlike other chronic diseases, a specialist does not typically manage COPD. Instead, primary care practices usually treat these patients, Wright says. Understanding this helped the project team know where to focus: their existing primary care medical homes.
Educate physicians on evidence-based guidelines. Carolinas HealthCare System is currently embedding the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines in their EHR, so primary care physicians have immediate access to the protocols and can treat patients according to these pathways.
Start a pulmonary rehabilitation program. Many communities lack pulmonary rehab, which is why Carolinas HealthCare System added the service five years ago. Wright says these programs are critical for providing COPD patients with supervised exercise, education, and group support.
Use dashboards to keep physicians engaged. Carolinas HealthCare System uses a dashboard to track all-cause readmissions. The health system shares this dashboard every month with primary care physicians so they can see how they compare with their peers.
Start small to work out the kinks. Project leaders piloted the COPD outpatient program with five primary care practices, and later this year, they will include other practices. “Many organizations design these programs to roll out to the system at once, but we took an innovator’s approach,” Wright says. “Like an EHR rollout, you want to make sure the program works well in one place before you move on to the next.”
As the stakes get higher thanks to CMS penalties, Wright recommends focusing on just three to five COPD strategies to start. Otherwise, a project to reduce COPD readmissions can become overwhelming.
“Of all the metrics around readmissions, organizations will feel COPD most acutely because they are not prepared,” Wright says. “It’s a challenging population, and many organizations don’t know how much of their readmissions are being driven by COPD. In the future, we are all going to use more predictive analytics to determine which patients will likely come back to us. Our therapies, interventions, and programs like pulmonary rehab will be more targeted.”
Laura Ramos Hegwer is a freelance writer and editor based in Lake Bluff, Ill.
Interviewed for this article: Jean Wright, MD, MBA, vice president of innovation, Carolinas HealthCare System, Charlotte, N.C.
This article is based in part on a presentation at an Institute for Healthcare Improvement conference in December 2013.
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