Care Transitions in COPD and beyond Laura Cole RN, MSN,CPHQ

Objectives Why readmissions and care coordination are important Overview of care transitions Strategies to reduce readmissions in the COPD populations Discussion of current practices in the community Identify opportunities to continue to drive changes

Readmission Rates by Diagnosis

Collaboration for Care Journey

Causes of readmissions Low Literacy

Causes of readmissions Low Literacy No family support

Causes of readmissions Low literacy Access to Primary Care No family support

Causes of readmissions Low literacy Access to Primary Care No family support Social Determinants

Causes of readmissions Low literacy Access to Primary Care Provider Communication No family support Social Determinants

Causes of readmissions Low literacy Access to Primary Care Provider Communication No family support Fragmentation Social Determinants

Causes of readmissions Low literacy Access to Primary Care Provider Communication Provider/ Patient Bias No family support Social Determinants Fragmentation

Causes of readmissions Low literacy Access to Primary Care Provider Communication Provider/ Patient Bias No family support Social Determinants Fragmentation Lack of standardization

Developing a plan for your care transitions efforts Do you have every one at the table? What is our data telling us? What are quick wins versus long term projects? Resource: AHRQ's Hospital Guide to Reducing Medicaid Readmissions

Design interventions AHRQ guide for Medicaid Readmissions

Data Drives Change

Where are the bright spots in your health system What is important to your organization? What unit is doing well? What are they doing differently? What programs can you build off? Access Health, CHF, Primary Care, Home Health How are you connecting with other providers?

Understand the patients needs The continuum of engagement framework

County Health Rankings

Connect with the community

What is a Community? HJ

What is a Community?

Patient support groups/ Foundations Complimentary Medicine providers Housing Advocates/ homeless services Pain clinics Urgent cares Food banks EMS Home Care Business coalitions United Way Community Health Workers Office on Aging AARP Family-Caregivers Emergency Rooms Medicaid Agency Faith based organizations Rehab Hospitals SC Thrive Hospice Outpatient Rehab Pharmacy Correction system Public Health nurse Agencies on Aging Skilled nursing Specialist Home Health WellVista Aging and disability resource centers Community Resources Health Plans Hospital DME Free clinics HOP contact GED/ literacy programs Primary Care Forming a cross‐continuum team has several concrete and practical benefits. Some of the immediate benefits include: • Declare to your referral partners your organization’s readmission reduction goals; • Describe the range of efforts your organization is implementing to reduce readmissions; • Understand what your cross-setting referral partners are doing to reduce readmissions; • Understand what information your receivers need to facilitate a safe and stable transition into their setting to avoid a readmission; • Form and strengthen multidisciplinary relationships among providers who share the care of common patients (putting a face to a name); and • Identify partners that will help your hospital achieve quality, satisfaction, and/or cost goals. Forming a cross‐continuum team does not need to represent a major new strategic business decision. Cross‐continuum teams start with the providers with whom you commonly share high-risk patients. Acknowledge that not all possible partners are at the table, and allow the group to expand naturally over time. Once you start hosting cross-continuum team meetings, other providers will want to be included. Trade Associations Transportation FQHC Electronic Medical Records Legal Aid Senior Centers Mental Health Low volume Health Plans DSS Adult Daycare Substance Abuse Assisted Living facilities/ Retirement Villages PACE programs Community based social workers Universities/Technical Schools

Specific Strategies to reduce readmissions in COPD

Cost of COPD 49 billion in direct and indirect cost Cost of a COPD patient is $6,000 higher than non- COPD patient Average cost of ER visit: $647 Average cost of Admission: $7242; $20,757; $44,909 Readmission: 13-14% of COPD patients had a 30 day readmission 41-49% were readmitted in 60 days 40% of COPD cost could be avoided Commercially insured patients cost more then Medicare patients

Managing your population Utilization Co-morbidities Physical activity reduces risk of readmission Social determinants Psychosocial Medications End of life Pulmonary rehabilitation/ Baker,Zou, Su (2013) Risk assessment of readmissions following initial COPD- related hospitalization Project BOOST Puhan,M, Scharplatz M, Troosters T,Steurer, J

Changing the way we think We know there is a disparity in our program. The black patients are not receiving the same services as the white patients. Know what do we do??

Discussion How does understanding the whole person inform your care? How do you actively collaborate with cross-setting partners? How do you deliver proactive, persistent post hospital care?

How SCHA can help Building relationships Identifying internal gaps and silos Facilitating discussions with external partners Data interpretation and process improvement Provide trended and benchmarked data Create actionable strategies and accountability Education Provide tools and resources with best practices Provide educational events

Summary Changing from fee for service to integrated payment system no outcome, no income Sustainability of successes Patient and family centered care Addressing disparities Navigation of the health system We, not me Navigate, advocate and support Don’t over medicalize View through a social/ behavioral lens What get’s measured get’s done