COPD Readmission Prevention Program

Description

In 2013-14, with an eye on the Centers for Medicare and Medicaid Services' Hospital Readmissions Reduction Program expansion to include chronic obstructive pulmonary disease (COPD), Genesis HealthCare System began a readmission prevention program. The program concept had roots in the organization's administrative suite in Zanesville, Ohio. The current program design includes a regular reassessment in order to continually advance COPD patient care.

Using several evidence-based approaches, the program operates in a systems continuum. The program starts with inpatient nursing and respiratory therapy staff, with further care coordination formally transferred to two program navigators. Both navigators are Registered Nurses with critical care experience and both are also certified Tobacco Treatment Specialists (TTS).

This care coordination focus also intersects with patients' family and friends, providers, pharmacists, durable medical equipment providers, social workers and appropriate community agencies for any specific assistance.

No start-up funding was utilized since Genesis administration recognized that sustainable financial and patient-care benefits would likely emerge once the program was operational.

In 2017, Genesis HealthCare System achieved the U.S. News & World Report's highest rating possible for both COPD and Heart Failure.

In 2018, Genesis began utilizing Medicare Bundled Payments for several chronic health conditions, including COPD, adding advanced care coordination to the organization's continual efforts to improve care for their patients.

Services offered

The program's overall approach addresses known areas of care coordination breakdown ("patient handoffs, follow-up care, ongoing care for those with chronic conditions, and care when something goes wrong").

At time of index admission:

• Case management patient screening for potentially high readmission risks
• Initial problem-solving for the identified risks
• Disease and self-management education provided by nurses and respiratory therapists

At discharge:

• Using a specific electronic record discharge order set, the high risk patient's information is immediately sent to the COPD nurse navigators
• Optional patient choice: use of bedside discharge medication delivery to eliminate the chance of missed medication doses

After discharge:

• COPD nurse navigators engage with patients and further evaluate risks using the Modified LACE Index tool
• The outpatient hospital-associated COPD clinic nurse practitioner is available for patients unable to see their primary provider after discharge or for acute clinical care needs
• An on-site pulmonologist is also available as needed

Immediately post discharge, nurse navigators call patients within 48-72 hours. They assist the patient in obtaining a follow-up appointment within 5-7 days of discharge with either the patient's primary care provider or the COPD Clinic's nurse practitioner. An additional goal is a follow-up appointment during the 14-21 day post-discharge interval.

The nurse navigators monitor patients' progress with follow-up phone calls as needed, providing timely disease and self-management education. They continue to trouble-shoot unmet related social determinants of health, for example, the ability to purchase and correctly use medications.

When the acute illness has stabilized, pulmonary function testing is encouraged. If the patient is eligible, pulmonary rehabilitation, another evidence-based intervention, is also encouraged.

During original implementation, transportation and patient reluctance were noted as barriers. To address these issues, the program developed new services in 2018:

• Transportation coordination: Collaborating with the community's public transportation provider, South East Area Transit (SEAT) allows navigators, providers, families or patients themselves to coordinate transportation for appointments. Through SEAT's online portal, nurse navigators are able to make transportation arrangements during follow-up calls with patients.
• Efforts to engage reluctant patients:
  • Increased focus on relationship-building during inpatient stays with patient, family and friends.
  • Health literacy assessments using the REALM-R tool has led to better understood individualized care plans.

During 2018, the navigator program also provided three additional collaborations:

Expanded continuum of care outreach: To accommodate care of the more complex COPD patient, the original 30-day post-discharge interval program focus expanded to include a call routine for reaches to include 90 days post-discharge.

For all patients, immediately post-discharge, nurse navigators call patients within 48-72 hours. They assist the patient in obtaining a follow-up appointment within 5-7 days of discharge with either the patient's primary care provider or the COPD Clinic's nurse practitioner. An additional goal is a follow-up appointment during the 14-21 day post-discharge interval. More complex patients are followed with the extended follow-up protocol.

Nurse navigators monitor patients' progress with follow-up phone calls as needed, providing timely disease and self-management education. They continue to trouble-shoot unmet related social determinants of health, for example, the ability to purchase and correctly use medications.

Muskingum Valley Health Centers collaboration: Partnering with this Federally Qualified Health Center has allowed streamlined scheduling. For both post-discharge follow-up and any acute visit needs, using electronic scheduling access has minimized duplicated services and maximized outpatient acute visit access. The ability to access the outpatient clinic for appropriate acute problems also helps decrease the need for patients to seek emergency room (ER) care.

Increased collaboration with Palliative Care (PC) Specialists: Since COPD has no cure, as the disease progresses patients might increasingly experience air hunger and associated anxiety. These and other disease-related symptoms can be closely managed by the palliative care team in both the inpatient and outpatient setting. Home visits by PC nurse practitioners and registered nurses allow frequent assessments and care plan adjustments, also saving the patient and families travel time to clinic or emergency room.

Results

In 2016, the program's success was highlighted by the Advisory Board Company as a Crimson Program demonstrating chronic disease management efforts that impacted hospital admissions and care utilization. In its initial six months, readmission rates decreased by 34%, saving its organization over $500,000.

Ongoing successes make the program sustainable from an administrative perspective. Additionally, the organization has been contacted by several of the state's academic medical centers and other hospitals to further understand program elements for possible replication.

As the program continues to grow and engage more patients, staff are seeing an increased number of COPD patients referred by those patients who experience better health and improved quality of life due to program participation.

The program's most recent data in 2018 demonstrate the organization's COPD readmission rate is 16.15% versus 17.1% in 2017, both data points favorable in comparison to Hospital Compare national rate of 19.6%.

Contact Information

Rob Williamson RN, BSN, CRN, Pulmonary Nurse Navigator
Genesis HealthCare System
740.454.5644
RWilliamson@genesishcs.org