COPD Readmission Reduction Project

Credits Tiwanna J. Dial, BSRT, RRT, RCP Respiratory Care Quality Specialist Program Content Amanda Byrd, RRT,RCP,BSMG Director, Respiratory Care Services Program Oversight * Scott J. Johnson, MD, FCCP Pulmonary/Critical Care Physician Resource

Overview of the Project Started in November 2017 Led by staff Respiratory Therapist Focused on patients with COPD Exacerbation and Chronic Respiratory Failure Can encompass all aspects of the respiratory system Provides more awareness to all forms of respiratory disease for the patient Obstructive Airway Targets COPD awareness Focused education to prevent readmission for COPD and to improve quality of life

Program Focus Comprehensive Respiratory Care Obstructive Airway Can encompass all aspects of the respiratory system Provides more awareness to all forms of respiratory disease for the patient Obstructive Airway Targets COPD awareness Focused education to prevent readmission for COPD and to improve quality of life Collaboration with Providers Pulmonary Rehab Pulmonary Consult/Outpatient Follow Up FirstQuit Smoking Cessation Program Referrals

Program Mission To provide patients with: Healthier lungs for improved Quality of Life Efficient lungs for day to day tasks Ability to perform tasks in order to be more independent Live without limits With this program we want to help patients HEAL from years of misuse and misunderstanding of their disease process and medications.

Program Benefits With ONE physician order: FirstHealth has a Respiratory Consult system in place that can: Provide a COPD Navigator to help the patient take an active role in their health to prevent readmissions. Allow therapists to collaborate with hospitalists and providers in treating COPD and other respiratory diseases to deliver optimized care Promote therapist discussions with patients regarding their current needs and provide for them in a more timely manner Allow therapists to customize treatments for the patient’s current need to include: medication time adjustments, cough and hygiene therapies, sleep apnea and rehab referrals

Program Goals To improve a patient's functional status Reduce dyspnea Improve exercise tolerance To help patient feel more in control of their disease process through education To improve quality of life Preserve optimal lung function Improve symptoms Prevent the recurrence of frequent exacerbations

Collaboration It takes EVERYONE Working Together Respiratory Therapists: Knowledgeable of COPD and respiratory diseases and the difficulties that come with having the disease. The COPD Navigator focuses specifically on additional one on one education for the patient Hospitalists: Assume the primary care role and must understand the patient entirely, to include their COPD. Responsible for directing the patient’s care. Nursing: Knowledgeable of the full scope of the patient. They have an invaluable perspective. Strong Nurse - Patient relationships are beneficial in treating COPD and its comorbidities. Social Workers/ Case Managers: Address life issues, i.e. travel, affording medications, home life assistance. Bringing them in early to proactively address these issues can lead to improved compliance. Psychiatry: Psychological issues like depression can contribute to patient’s lack of participation in their healthcare. A psychiatrist can help them take ownership of these issues. Pharmacy: Can ensure patients have accurate medications and the most affordable medications. Ensuring patients have their medications leads to better compliance.

piloted on medical nursing unit (pilot phase to end August 2018) Program Outline piloted on medical nursing unit (pilot phase to end August 2018) Medications Home Respiratory Medication Regimen Inpatient Respiratory Medication Regimen Discharge medications Educate Three to Four Sessions for a total =/< 1 hr Visual Aids and Handouts Inhaler demo Action Plan Referrals FirstQuit Pulmonology (if not established with a provider) Pulmonary Rehabilitation NIV (Trilogy) therapy (if indicated) Follow Up Reinforcement prior to discharge Follow up 7 to 10 days post discharge

Request Pulmonary Consult RC Consult w/ Medications Program Guide Disease and medication education Discuss available Resources LOS > 2 LOS < 2 Prior Admit with Same Diagnosis: YES Request Pulmonary Consult COPD Navigator RC Consult w/ Medications   COPD/ ARF Admission Continued Education on Disease and Medication usage NO previous PFT, PFT Spirometry 24 to 48 hours prior to Discharge Follow up post Discharge Tracking on future admission NO Follow up post discharge Recommend Pulmonary Referral upon discharge *This is not absolute but a guideline for COPD/ARF admission *ARF (Acute Respiratory Failure) *PFT Spirometry may be ordered regardless of prior admission history or if previous PFT has been done *Pulmonology Consult may be ordered regardless of LOS or Prior Admission History

Education and Self Management All education is adjusted for each patient and length of stay. First Meeting Initial History and Review of Disease What is COPD Diagnosing COPD Treatments for COPD Stages of COPD Normal Lung Anatomy vs. COPD Lung Anatomy Illustrations and/or video Smoking Cessation

Education and Self Management Second Meeting Use of MDI/DPI/Nebulizer Proper Administration Technique MDI/DPI demonstration with simulation device Types of Medications and how they Work Bronchodilators Steroids Bronchial Hygiene Devices and Coughing techniques Smoking Cessation

Education and Self Management Third Meeting Recognizing Early Signs and Symptoms of an exacerbation Controlled Breathing Techniques Diaphragmatic Breathing Pursed-Lip Breathing Tripod Breathing Pulmonary Rehabilitation Preventing Infection Flu and pneumonia vaccinations Clean Air / Smoking Cessation

Education and Self Management Fourth Meeting Discharge Instructions for COPD Review medications Review Action Plan Fill out Management Plan Review Smoking Cessation Obstructive Sleep Apnea (OSA) Evaluation STOP-Bang Questionnaire Pulmonary Rehabilitation Pulmonary Rehab questionnaire

Post Discharge Follow Up Continued Follow Up Call 7 to 10 days post discharge At this time antibiotics are almost, or are completed if given Nursing usually will do f/u at 48 to 72 hours Question appointments Discuss medication effectiveness Concerns Call 6-8 Weeks Ask about referrals Assess medication effectiveness

COPD Readmission Analysis Tracked Internally for Real Time Results Not Risk Adjusted Unable to capture readmissions to non-FirstHealth facilities Monitor CMS publicly reported data

Summary A COPD program is a tool to aid in preventing patient readmissions COPD is part of Medicare’s Hospital Readmission Reduction Program that penalizes excess 30 day all-cause readmission after an exacerbation Education and rehab are 2 trends currently in use across the country to prevent readmission FirstHealth COPD Navigator, with the use of the Respiratory Care Consult, can aid providers in preventing readmissions.