COPD

Readmission

Reduction Program

Transition Program

April 2014

Janet Fantazia RRT BSHS AE-C

Pulmonary Rehab Coordinator

Pulmonary Services SMCS

Over View

3rd Leading Cause of Death in US (ALA Aug 2013)

CMS and Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality worldwide (Lancet Jan 2014)

12 million people diagnosed and 12 million people have it and do not know (NIH July 2013)

In 2010 the US spent $295 billion in direct health care expenditures with additional costs not captured in claims due to under-diagnosis and misdiagnosis (NBCH Sept 2012)

AARC 2014

499 Billion spent of COPD exceeding heart failure

Among all disease state-COPD patients have the high-test readmission rates in the nation

2

3rd Leading Cause of Death US

1 Heart Disease

2 Cancer

3 COPD

4 Strokes

The Problem

CMS Mortality and Readmission Summary

CMS developed hospital outcome measures to assess 30-day mortality and readmission rates following admissions for acute exacerbation of chronic obstructive pulmonary disease (COPD) Between 1998 and 2008 the number of patients hospitalized annually for acute exacerbations of COPD increased by approximately 18 percent

CMS plans to publicly report these measures on Hospital Compare beginning in 2014 as part of the Hospital Inpatient Quality Reporting (IQR) program

Additionally CMS plans to include the COPD readmission measure in the Fiscal Year 2015 Hospital Readmissions Reduction Program (HRRP)

Mortality and readmission rates for patients with COPD vary widely by hospital suggesting that opportunities exist for hospitals to improve the quality of care provided to COPD patients

AARC Times April 2014 Article

ldquoA readmission is a failed transitionrdquo

Community issues include failure of communication between hospital and community Above all the planning process needs to encompass both the hospital and the community

No quarterback however skillful can complete passes without downfield receivers with whom he has trained and no receiver can catch a pass from a quarterback who does not know how and when to throw Patients are not footballs but teamwork is teamwork ldquo (AARC April 2014)

Avoiding Unnecessary 30 Day

Readmissions

Early identification of patients at risk for readmission

Emergency Department Case Management

Transition from inpatient to outpatient

Continuum of Care Partnership with SNF HH etc

7

30 Day Readmission COPD

8

SMCS COPD readmission rate is at 218

for 2013

The national average in a dry run study

completed in 2013 by CMS was 211

Our target is to decrease COPD

readmissions to 117

COPD CoMorbidities

Cardiovascular Disease (CHF)

Diabetes

Depression

Anemia

Mal-nutrition

Gastric Reflux

Osteoporosis

Cancer

Pneumonia

Pulmonary Embolus

Hospital Admission

HF Orders Flag Team

CM Identify Risk-MIDAS

SRMC ndash CTC 7 dayswk

Home Health bullHigh Risk within 48 hours

bull Integrated Care Model

Disease Tele-management

bullMod Risk within 48 hours

bullMinimum 30 day follow

Skilled Nursing Facility

bullSNF Discharge Orders

bullHH Liaisons- Post DC

bullSNF Forum

HF Clinic bullUnUnderinsured

bullPrimary NP run

bullMultidisciplinary team

bullSMCS- Pharmacist PCP

bullOBCM

bull Incentives for fu visit within 7 days

Cardiologist

bullEducation and follow up needs

Wellspace bullSliding Scale provide PCP

bullMental Health

bullTreatment for addictions

bullPartner with Sutter

bullMultiple locations

ER bullCM 247

bullEducation to staff

bullSNF admit from ER

Skilled Nursing Facility

bullSNF HF Discharge Orders

bullHH Liaisons- Post DC

bullSNF Forum

Respiratory Care

bull IP Patient amp Staff COPD Education

bullSNF COPD Discharge Orders

bullCM COPD Transition Note

bullCOPD Stop Light

bullSNF Staff COPD Education

bullSNF Forum

bullPulmonary Rehab-Post DC

Respiratory Care amp SNF

Partnership

Coordination Transition of Care

My Story

Non-pharmacolgical treatments

IP Education

Following Global Initiative Chronic Lung

Disease (GOLD)

Disease Management (PNATrach)

MedicationsDevices- Assist Reconciliation

SNF COPD Discharge Orders

(PNA too)

14

CM COPD Transition Note

(PNA too)

COPD Stop Light

(PNA too)

SNF Staff Education

Disease management

Improving the Quality of Care a Team Approach to

Transition of Care

Increase patient ability to self-manage symptom and

their care

Tools of the trade Oxygen Therapy-Medications-

Challenges with Devices Manage and Prevent

Exacerbations

Improve the health and well being and patient

satisfaction

Pulmonary Rehab and Activity

GOLD 2014 ldquoAll COPD patients with breathlessness when walking at their own pace on level ground appear to benefit from rehabilitation and maintenance of physical activity

Physical Therapy at SNF

MaintenanceActivity SNF

Refer to Pulmonary Rehab upon discharge if candidate

Next Steps

Finish Order Sets and Care Transition Notes

Staff Education (IP and SNF)

Quarterly Forum

CM and Transition Teams

Pulmonary Rehab

PCP follow up appointment when DC SNF

Questions

Over View

3rd Leading Cause of Death in US (ALA Aug 2013)

CMS and Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality worldwide (Lancet Jan 2014)

12 million people diagnosed and 12 million people have it and do not know (NIH July 2013)

In 2010 the US spent $295 billion in direct health care expenditures with additional costs not captured in claims due to under-diagnosis and misdiagnosis (NBCH Sept 2012)

AARC 2014

499 Billion spent of COPD exceeding heart failure

Among all disease state-COPD patients have the high-test readmission rates in the nation

2

3rd Leading Cause of Death US

1 Heart Disease

2 Cancer

3 COPD

4 Strokes

The Problem

CMS Mortality and Readmission Summary

CMS developed hospital outcome measures to assess 30-day mortality and readmission rates following admissions for acute exacerbation of chronic obstructive pulmonary disease (COPD) Between 1998 and 2008 the number of patients hospitalized annually for acute exacerbations of COPD increased by approximately 18 percent

CMS plans to publicly report these measures on Hospital Compare beginning in 2014 as part of the Hospital Inpatient Quality Reporting (IQR) program

Additionally CMS plans to include the COPD readmission measure in the Fiscal Year 2015 Hospital Readmissions Reduction Program (HRRP)

Mortality and readmission rates for patients with COPD vary widely by hospital suggesting that opportunities exist for hospitals to improve the quality of care provided to COPD patients

AARC Times April 2014 Article

ldquoA readmission is a failed transitionrdquo

Community issues include failure of communication between hospital and community Above all the planning process needs to encompass both the hospital and the community

No quarterback however skillful can complete passes without downfield receivers with whom he has trained and no receiver can catch a pass from a quarterback who does not know how and when to throw Patients are not footballs but teamwork is teamwork ldquo (AARC April 2014)

Avoiding Unnecessary 30 Day

Readmissions

Early identification of patients at risk for readmission

Emergency Department Case Management

Transition from inpatient to outpatient

Continuum of Care Partnership with SNF HH etc

7

30 Day Readmission COPD

8

SMCS COPD readmission rate is at 218

for 2013

The national average in a dry run study

completed in 2013 by CMS was 211

Our target is to decrease COPD

readmissions to 117

COPD CoMorbidities

Cardiovascular Disease (CHF)

Diabetes

Depression

Anemia

Mal-nutrition

Gastric Reflux

Osteoporosis

Cancer

Pneumonia

Pulmonary Embolus

Hospital Admission

HF Orders Flag Team

CM Identify Risk-MIDAS

SRMC ndash CTC 7 dayswk

Home Health bullHigh Risk within 48 hours

bull Integrated Care Model

Disease Tele-management

bullMod Risk within 48 hours

bullMinimum 30 day follow

Skilled Nursing Facility

bullSNF Discharge Orders

bullHH Liaisons- Post DC

bullSNF Forum

HF Clinic bullUnUnderinsured

bullPrimary NP run

bullMultidisciplinary team

bullSMCS- Pharmacist PCP

bullOBCM

bull Incentives for fu visit within 7 days

Cardiologist

bullEducation and follow up needs

Wellspace bullSliding Scale provide PCP

bullMental Health

bullTreatment for addictions

bullPartner with Sutter

bullMultiple locations

ER bullCM 247

bullEducation to staff

bullSNF admit from ER

Skilled Nursing Facility

bullSNF HF Discharge Orders

bullHH Liaisons- Post DC

bullSNF Forum

Respiratory Care

bull IP Patient amp Staff COPD Education

bullSNF COPD Discharge Orders

bullCM COPD Transition Note

bullCOPD Stop Light

bullSNF Staff COPD Education

bullSNF Forum

bullPulmonary Rehab-Post DC

Respiratory Care amp SNF

Partnership

Coordination Transition of Care

My Story

Non-pharmacolgical treatments

IP Education

Following Global Initiative Chronic Lung

Disease (GOLD)

Disease Management (PNATrach)

MedicationsDevices- Assist Reconciliation

SNF COPD Discharge Orders

(PNA too)

14

CM COPD Transition Note

(PNA too)

COPD Stop Light

(PNA too)

SNF Staff Education

Disease management

Improving the Quality of Care a Team Approach to

Transition of Care

Increase patient ability to self-manage symptom and

their care

Tools of the trade Oxygen Therapy-Medications-

Challenges with Devices Manage and Prevent

Exacerbations

Improve the health and well being and patient

satisfaction

Pulmonary Rehab and Activity

GOLD 2014 ldquoAll COPD patients with breathlessness when walking at their own pace on level ground appear to benefit from rehabilitation and maintenance of physical activity

Physical Therapy at SNF

MaintenanceActivity SNF

Refer to Pulmonary Rehab upon discharge if candidate

Next Steps

Finish Order Sets and Care Transition Notes

Staff Education (IP and SNF)

Quarterly Forum

CM and Transition Teams

Pulmonary Rehab

PCP follow up appointment when DC SNF

Questions

3rd Leading Cause of Death US

1 Heart Disease

2 Cancer

3 COPD

4 Strokes

The Problem

CMS Mortality and Readmission Summary

CMS developed hospital outcome measures to assess 30-day mortality and readmission rates following admissions for acute exacerbation of chronic obstructive pulmonary disease (COPD) Between 1998 and 2008 the number of patients hospitalized annually for acute exacerbations of COPD increased by approximately 18 percent

CMS plans to publicly report these measures on Hospital Compare beginning in 2014 as part of the Hospital Inpatient Quality Reporting (IQR) program

Additionally CMS plans to include the COPD readmission measure in the Fiscal Year 2015 Hospital Readmissions Reduction Program (HRRP)

Mortality and readmission rates for patients with COPD vary widely by hospital suggesting that opportunities exist for hospitals to improve the quality of care provided to COPD patients

AARC Times April 2014 Article

ldquoA readmission is a failed transitionrdquo

Community issues include failure of communication between hospital and community Above all the planning process needs to encompass both the hospital and the community

No quarterback however skillful can complete passes without downfield receivers with whom he has trained and no receiver can catch a pass from a quarterback who does not know how and when to throw Patients are not footballs but teamwork is teamwork ldquo (AARC April 2014)

Avoiding Unnecessary 30 Day

Readmissions

Early identification of patients at risk for readmission

Emergency Department Case Management

Transition from inpatient to outpatient

Continuum of Care Partnership with SNF HH etc

7

30 Day Readmission COPD

8

SMCS COPD readmission rate is at 218

for 2013

The national average in a dry run study

completed in 2013 by CMS was 211

Our target is to decrease COPD

readmissions to 117

COPD CoMorbidities

Cardiovascular Disease (CHF)

Diabetes

Depression

Anemia

Mal-nutrition

Gastric Reflux

Osteoporosis

Cancer

Pneumonia

Pulmonary Embolus

Hospital Admission

HF Orders Flag Team

CM Identify Risk-MIDAS

SRMC ndash CTC 7 dayswk

Home Health bullHigh Risk within 48 hours

bull Integrated Care Model

Disease Tele-management

bullMod Risk within 48 hours

bullMinimum 30 day follow

Skilled Nursing Facility

bullSNF Discharge Orders

bullHH Liaisons- Post DC

bullSNF Forum

HF Clinic bullUnUnderinsured

bullPrimary NP run

bullMultidisciplinary team

bullSMCS- Pharmacist PCP

bullOBCM

bull Incentives for fu visit within 7 days

Cardiologist

bullEducation and follow up needs

Wellspace bullSliding Scale provide PCP

bullMental Health

bullTreatment for addictions

bullPartner with Sutter

bullMultiple locations

ER bullCM 247

bullEducation to staff

bullSNF admit from ER

Skilled Nursing Facility

bullSNF HF Discharge Orders

bullHH Liaisons- Post DC

bullSNF Forum

Respiratory Care

bull IP Patient amp Staff COPD Education

bullSNF COPD Discharge Orders

bullCM COPD Transition Note

bullCOPD Stop Light

bullSNF Staff COPD Education

bullSNF Forum

bullPulmonary Rehab-Post DC

Respiratory Care amp SNF

Partnership

Coordination Transition of Care

My Story

Non-pharmacolgical treatments

IP Education

Following Global Initiative Chronic Lung

Disease (GOLD)

Disease Management (PNATrach)

MedicationsDevices- Assist Reconciliation

SNF COPD Discharge Orders

(PNA too)

14

CM COPD Transition Note

(PNA too)

COPD Stop Light

(PNA too)

SNF Staff Education

Disease management

Improving the Quality of Care a Team Approach to

Transition of Care

Increase patient ability to self-manage symptom and

their care

Tools of the trade Oxygen Therapy-Medications-

Challenges with Devices Manage and Prevent

Exacerbations

Improve the health and well being and patient

satisfaction

Pulmonary Rehab and Activity

GOLD 2014 ldquoAll COPD patients with breathlessness when walking at their own pace on level ground appear to benefit from rehabilitation and maintenance of physical activity

Physical Therapy at SNF

MaintenanceActivity SNF

Refer to Pulmonary Rehab upon discharge if candidate

Next Steps

Finish Order Sets and Care Transition Notes

Staff Education (IP and SNF)

Quarterly Forum

CM and Transition Teams

Pulmonary Rehab

PCP follow up appointment when DC SNF

Questions

The Problem

CMS Mortality and Readmission Summary

CMS developed hospital outcome measures to assess 30-day mortality and readmission rates following admissions for acute exacerbation of chronic obstructive pulmonary disease (COPD) Between 1998 and 2008 the number of patients hospitalized annually for acute exacerbations of COPD increased by approximately 18 percent

CMS plans to publicly report these measures on Hospital Compare beginning in 2014 as part of the Hospital Inpatient Quality Reporting (IQR) program

Additionally CMS plans to include the COPD readmission measure in the Fiscal Year 2015 Hospital Readmissions Reduction Program (HRRP)

Mortality and readmission rates for patients with COPD vary widely by hospital suggesting that opportunities exist for hospitals to improve the quality of care provided to COPD patients

AARC Times April 2014 Article

ldquoA readmission is a failed transitionrdquo

Community issues include failure of communication between hospital and community Above all the planning process needs to encompass both the hospital and the community

No quarterback however skillful can complete passes without downfield receivers with whom he has trained and no receiver can catch a pass from a quarterback who does not know how and when to throw Patients are not footballs but teamwork is teamwork ldquo (AARC April 2014)

Avoiding Unnecessary 30 Day

Readmissions

Early identification of patients at risk for readmission

Emergency Department Case Management

Transition from inpatient to outpatient

Continuum of Care Partnership with SNF HH etc

7

30 Day Readmission COPD

8

SMCS COPD readmission rate is at 218

for 2013

The national average in a dry run study

completed in 2013 by CMS was 211

Our target is to decrease COPD

readmissions to 117

COPD CoMorbidities

Cardiovascular Disease (CHF)

Diabetes

Depression

Anemia

Mal-nutrition

Gastric Reflux

Osteoporosis

Cancer

Pneumonia

Pulmonary Embolus

Hospital Admission

HF Orders Flag Team

CM Identify Risk-MIDAS

SRMC ndash CTC 7 dayswk

Home Health bullHigh Risk within 48 hours

bull Integrated Care Model

Disease Tele-management

bullMod Risk within 48 hours

bullMinimum 30 day follow

Skilled Nursing Facility

bullSNF Discharge Orders

bullHH Liaisons- Post DC

bullSNF Forum

HF Clinic bullUnUnderinsured

bullPrimary NP run

bullMultidisciplinary team

bullSMCS- Pharmacist PCP

bullOBCM

bull Incentives for fu visit within 7 days

Cardiologist

bullEducation and follow up needs

Wellspace bullSliding Scale provide PCP

bullMental Health

bullTreatment for addictions

bullPartner with Sutter

bullMultiple locations

ER bullCM 247

bullEducation to staff

bullSNF admit from ER

Skilled Nursing Facility

bullSNF HF Discharge Orders

bullHH Liaisons- Post DC

bullSNF Forum

Respiratory Care

bull IP Patient amp Staff COPD Education

bullSNF COPD Discharge Orders

bullCM COPD Transition Note

bullCOPD Stop Light

bullSNF Staff COPD Education

bullSNF Forum

bullPulmonary Rehab-Post DC

Respiratory Care amp SNF

Partnership

Coordination Transition of Care

My Story

Non-pharmacolgical treatments

IP Education

Following Global Initiative Chronic Lung

Disease (GOLD)

Disease Management (PNATrach)

MedicationsDevices- Assist Reconciliation

SNF COPD Discharge Orders

(PNA too)

14

CM COPD Transition Note

(PNA too)

COPD Stop Light

(PNA too)

SNF Staff Education

Disease management

Improving the Quality of Care a Team Approach to

Transition of Care

Increase patient ability to self-manage symptom and

their care

Tools of the trade Oxygen Therapy-Medications-

Challenges with Devices Manage and Prevent

Exacerbations

Improve the health and well being and patient

satisfaction

Pulmonary Rehab and Activity

GOLD 2014 ldquoAll COPD patients with breathlessness when walking at their own pace on level ground appear to benefit from rehabilitation and maintenance of physical activity

Physical Therapy at SNF

MaintenanceActivity SNF

Refer to Pulmonary Rehab upon discharge if candidate

Next Steps

Finish Order Sets and Care Transition Notes

Staff Education (IP and SNF)

Quarterly Forum

CM and Transition Teams

Pulmonary Rehab

PCP follow up appointment when DC SNF

Questions

CMS Mortality and Readmission Summary

CMS developed hospital outcome measures to assess 30-day mortality and readmission rates following admissions for acute exacerbation of chronic obstructive pulmonary disease (COPD) Between 1998 and 2008 the number of patients hospitalized annually for acute exacerbations of COPD increased by approximately 18 percent

CMS plans to publicly report these measures on Hospital Compare beginning in 2014 as part of the Hospital Inpatient Quality Reporting (IQR) program

Additionally CMS plans to include the COPD readmission measure in the Fiscal Year 2015 Hospital Readmissions Reduction Program (HRRP)

Mortality and readmission rates for patients with COPD vary widely by hospital suggesting that opportunities exist for hospitals to improve the quality of care provided to COPD patients

AARC Times April 2014 Article

ldquoA readmission is a failed transitionrdquo

Community issues include failure of communication between hospital and community Above all the planning process needs to encompass both the hospital and the community

No quarterback however skillful can complete passes without downfield receivers with whom he has trained and no receiver can catch a pass from a quarterback who does not know how and when to throw Patients are not footballs but teamwork is teamwork ldquo (AARC April 2014)

Avoiding Unnecessary 30 Day

Readmissions

Early identification of patients at risk for readmission

Emergency Department Case Management

Transition from inpatient to outpatient

Continuum of Care Partnership with SNF HH etc

7

30 Day Readmission COPD

8

SMCS COPD readmission rate is at 218

for 2013

The national average in a dry run study

completed in 2013 by CMS was 211

Our target is to decrease COPD

readmissions to 117

COPD CoMorbidities

Cardiovascular Disease (CHF)

Diabetes

Depression

Anemia

Mal-nutrition

Gastric Reflux

Osteoporosis

Cancer

Pneumonia

Pulmonary Embolus

Hospital Admission

HF Orders Flag Team

CM Identify Risk-MIDAS

SRMC ndash CTC 7 dayswk

Home Health bullHigh Risk within 48 hours

bull Integrated Care Model

Disease Tele-management

bullMod Risk within 48 hours

bullMinimum 30 day follow

Skilled Nursing Facility

bullSNF Discharge Orders

bullHH Liaisons- Post DC

bullSNF Forum

HF Clinic bullUnUnderinsured

bullPrimary NP run

bullMultidisciplinary team

bullSMCS- Pharmacist PCP

bullOBCM

bull Incentives for fu visit within 7 days

Cardiologist

bullEducation and follow up needs

Wellspace bullSliding Scale provide PCP

bullMental Health

bullTreatment for addictions

bullPartner with Sutter

bullMultiple locations

ER bullCM 247

bullEducation to staff

bullSNF admit from ER

Skilled Nursing Facility

bullSNF HF Discharge Orders

bullHH Liaisons- Post DC

bullSNF Forum

Respiratory Care

bull IP Patient amp Staff COPD Education

bullSNF COPD Discharge Orders

bullCM COPD Transition Note

bullCOPD Stop Light

bullSNF Staff COPD Education

bullSNF Forum

bullPulmonary Rehab-Post DC

Respiratory Care amp SNF

Partnership

Coordination Transition of Care

My Story

Non-pharmacolgical treatments

IP Education

Following Global Initiative Chronic Lung

Disease (GOLD)

Disease Management (PNATrach)

MedicationsDevices- Assist Reconciliation

SNF COPD Discharge Orders

(PNA too)

14

CM COPD Transition Note

(PNA too)

COPD Stop Light

(PNA too)

SNF Staff Education

Disease management

Improving the Quality of Care a Team Approach to

Transition of Care

Increase patient ability to self-manage symptom and

their care

Tools of the trade Oxygen Therapy-Medications-

Challenges with Devices Manage and Prevent

Exacerbations

Improve the health and well being and patient

satisfaction

Pulmonary Rehab and Activity

GOLD 2014 ldquoAll COPD patients with breathlessness when walking at their own pace on level ground appear to benefit from rehabilitation and maintenance of physical activity

Physical Therapy at SNF

MaintenanceActivity SNF

Refer to Pulmonary Rehab upon discharge if candidate

Next Steps

Finish Order Sets and Care Transition Notes

Staff Education (IP and SNF)

Quarterly Forum

CM and Transition Teams

Pulmonary Rehab

PCP follow up appointment when DC SNF

Questions

AARC Times April 2014 Article

ldquoA readmission is a failed transitionrdquo

Community issues include failure of communication between hospital and community Above all the planning process needs to encompass both the hospital and the community

No quarterback however skillful can complete passes without downfield receivers with whom he has trained and no receiver can catch a pass from a quarterback who does not know how and when to throw Patients are not footballs but teamwork is teamwork ldquo (AARC April 2014)

Avoiding Unnecessary 30 Day

Readmissions

Early identification of patients at risk for readmission

Emergency Department Case Management

Transition from inpatient to outpatient

Continuum of Care Partnership with SNF HH etc

7

30 Day Readmission COPD

8

SMCS COPD readmission rate is at 218

for 2013

The national average in a dry run study

completed in 2013 by CMS was 211

Our target is to decrease COPD

readmissions to 117

COPD CoMorbidities

Cardiovascular Disease (CHF)

Diabetes

Depression

Anemia

Mal-nutrition

Gastric Reflux

Osteoporosis

Cancer

Pneumonia

Pulmonary Embolus

Hospital Admission

HF Orders Flag Team

CM Identify Risk-MIDAS

SRMC ndash CTC 7 dayswk

Home Health bullHigh Risk within 48 hours

bull Integrated Care Model

Disease Tele-management

bullMod Risk within 48 hours

bullMinimum 30 day follow

Skilled Nursing Facility

bullSNF Discharge Orders

bullHH Liaisons- Post DC

bullSNF Forum

HF Clinic bullUnUnderinsured

bullPrimary NP run

bullMultidisciplinary team

bullSMCS- Pharmacist PCP

bullOBCM

bull Incentives for fu visit within 7 days

Cardiologist

bullEducation and follow up needs

Wellspace bullSliding Scale provide PCP

bullMental Health

bullTreatment for addictions

bullPartner with Sutter

bullMultiple locations

ER bullCM 247

bullEducation to staff

bullSNF admit from ER

Skilled Nursing Facility

bullSNF HF Discharge Orders

bullHH Liaisons- Post DC

bullSNF Forum

Respiratory Care

bull IP Patient amp Staff COPD Education

bullSNF COPD Discharge Orders

bullCM COPD Transition Note

bullCOPD Stop Light

bullSNF Staff COPD Education

bullSNF Forum

bullPulmonary Rehab-Post DC

Respiratory Care amp SNF

Partnership

Coordination Transition of Care

My Story

Non-pharmacolgical treatments

IP Education

Following Global Initiative Chronic Lung

Disease (GOLD)

Disease Management (PNATrach)

MedicationsDevices- Assist Reconciliation

SNF COPD Discharge Orders

(PNA too)

14

CM COPD Transition Note

(PNA too)

COPD Stop Light

(PNA too)

SNF Staff Education

Disease management

Improving the Quality of Care a Team Approach to

Transition of Care

Increase patient ability to self-manage symptom and

their care

Tools of the trade Oxygen Therapy-Medications-

Challenges with Devices Manage and Prevent

Exacerbations

Improve the health and well being and patient

satisfaction

Pulmonary Rehab and Activity

GOLD 2014 ldquoAll COPD patients with breathlessness when walking at their own pace on level ground appear to benefit from rehabilitation and maintenance of physical activity

Physical Therapy at SNF

MaintenanceActivity SNF

Refer to Pulmonary Rehab upon discharge if candidate

Next Steps

Finish Order Sets and Care Transition Notes

Staff Education (IP and SNF)

Quarterly Forum

CM and Transition Teams

Pulmonary Rehab

PCP follow up appointment when DC SNF

Questions

Avoiding Unnecessary 30 Day

Readmissions

Early identification of patients at risk for readmission

Emergency Department Case Management

Transition from inpatient to outpatient

Continuum of Care Partnership with SNF HH etc

7

30 Day Readmission COPD

8

SMCS COPD readmission rate is at 218

for 2013

The national average in a dry run study

completed in 2013 by CMS was 211

Our target is to decrease COPD

readmissions to 117

COPD CoMorbidities

Cardiovascular Disease (CHF)

Diabetes

Depression

Anemia

Mal-nutrition

Gastric Reflux

Osteoporosis

Cancer

Pneumonia

Pulmonary Embolus

Hospital Admission

HF Orders Flag Team

CM Identify Risk-MIDAS

SRMC ndash CTC 7 dayswk

Home Health bullHigh Risk within 48 hours

bull Integrated Care Model

Disease Tele-management

bullMod Risk within 48 hours

bullMinimum 30 day follow

Skilled Nursing Facility

bullSNF Discharge Orders

bullHH Liaisons- Post DC

bullSNF Forum

HF Clinic bullUnUnderinsured

bullPrimary NP run

bullMultidisciplinary team

bullSMCS- Pharmacist PCP

bullOBCM

bull Incentives for fu visit within 7 days

Cardiologist

bullEducation and follow up needs

Wellspace bullSliding Scale provide PCP

bullMental Health

bullTreatment for addictions

bullPartner with Sutter

bullMultiple locations

ER bullCM 247

bullEducation to staff

bullSNF admit from ER

Skilled Nursing Facility

bullSNF HF Discharge Orders

bullHH Liaisons- Post DC

bullSNF Forum

Respiratory Care

bull IP Patient amp Staff COPD Education

bullSNF COPD Discharge Orders

bullCM COPD Transition Note

bullCOPD Stop Light

bullSNF Staff COPD Education

bullSNF Forum

bullPulmonary Rehab-Post DC

Respiratory Care amp SNF

Partnership

Coordination Transition of Care

My Story

Non-pharmacolgical treatments

IP Education

Following Global Initiative Chronic Lung

Disease (GOLD)

Disease Management (PNATrach)

MedicationsDevices- Assist Reconciliation

SNF COPD Discharge Orders

(PNA too)

14

CM COPD Transition Note

(PNA too)

COPD Stop Light

(PNA too)

SNF Staff Education

Disease management

Improving the Quality of Care a Team Approach to

Transition of Care

Increase patient ability to self-manage symptom and

their care

Tools of the trade Oxygen Therapy-Medications-

Challenges with Devices Manage and Prevent

Exacerbations

Improve the health and well being and patient

satisfaction

Pulmonary Rehab and Activity

GOLD 2014 ldquoAll COPD patients with breathlessness when walking at their own pace on level ground appear to benefit from rehabilitation and maintenance of physical activity

Physical Therapy at SNF

MaintenanceActivity SNF

Refer to Pulmonary Rehab upon discharge if candidate

Next Steps

Finish Order Sets and Care Transition Notes

Staff Education (IP and SNF)

Quarterly Forum

CM and Transition Teams

Pulmonary Rehab

PCP follow up appointment when DC SNF

Questions

30 Day Readmission COPD

8

SMCS COPD readmission rate is at 218

for 2013

The national average in a dry run study

completed in 2013 by CMS was 211

Our target is to decrease COPD

readmissions to 117

COPD CoMorbidities

Cardiovascular Disease (CHF)

Diabetes

Depression

Anemia

Mal-nutrition

Gastric Reflux

Osteoporosis

Cancer

Pneumonia

Pulmonary Embolus

Hospital Admission

HF Orders Flag Team

CM Identify Risk-MIDAS

SRMC ndash CTC 7 dayswk

Home Health bullHigh Risk within 48 hours

bull Integrated Care Model

Disease Tele-management

bullMod Risk within 48 hours

bullMinimum 30 day follow

Skilled Nursing Facility

bullSNF Discharge Orders

bullHH Liaisons- Post DC

bullSNF Forum

HF Clinic bullUnUnderinsured

bullPrimary NP run

bullMultidisciplinary team

bullSMCS- Pharmacist PCP

bullOBCM

bull Incentives for fu visit within 7 days

Cardiologist

bullEducation and follow up needs

Wellspace bullSliding Scale provide PCP

bullMental Health

bullTreatment for addictions

bullPartner with Sutter

bullMultiple locations

ER bullCM 247

bullEducation to staff

bullSNF admit from ER

Skilled Nursing Facility

bullSNF HF Discharge Orders

bullHH Liaisons- Post DC

bullSNF Forum

Respiratory Care

bull IP Patient amp Staff COPD Education

bullSNF COPD Discharge Orders

bullCM COPD Transition Note

bullCOPD Stop Light

bullSNF Staff COPD Education

bullSNF Forum

bullPulmonary Rehab-Post DC

Respiratory Care amp SNF

Partnership

Coordination Transition of Care

My Story

Non-pharmacolgical treatments

IP Education

Following Global Initiative Chronic Lung

Disease (GOLD)

Disease Management (PNATrach)

MedicationsDevices- Assist Reconciliation

SNF COPD Discharge Orders

(PNA too)

14

CM COPD Transition Note

(PNA too)

COPD Stop Light

(PNA too)

SNF Staff Education

Disease management

Improving the Quality of Care a Team Approach to

Transition of Care

Increase patient ability to self-manage symptom and

their care

Tools of the trade Oxygen Therapy-Medications-

Challenges with Devices Manage and Prevent

Exacerbations

Improve the health and well being and patient

satisfaction

Pulmonary Rehab and Activity

GOLD 2014 ldquoAll COPD patients with breathlessness when walking at their own pace on level ground appear to benefit from rehabilitation and maintenance of physical activity

Physical Therapy at SNF

MaintenanceActivity SNF

Refer to Pulmonary Rehab upon discharge if candidate

Next Steps

Finish Order Sets and Care Transition Notes

Staff Education (IP and SNF)

Quarterly Forum

CM and Transition Teams

Pulmonary Rehab

PCP follow up appointment when DC SNF

Questions

COPD CoMorbidities

Cardiovascular Disease (CHF)

Diabetes

Depression

Anemia

Mal-nutrition

Gastric Reflux

Osteoporosis

Cancer

Pneumonia

Pulmonary Embolus

Hospital Admission

HF Orders Flag Team

CM Identify Risk-MIDAS

SRMC ndash CTC 7 dayswk

Home Health bullHigh Risk within 48 hours

bull Integrated Care Model

Disease Tele-management

bullMod Risk within 48 hours

bullMinimum 30 day follow

Skilled Nursing Facility

bullSNF Discharge Orders

bullHH Liaisons- Post DC

bullSNF Forum

HF Clinic bullUnUnderinsured

bullPrimary NP run

bullMultidisciplinary team

bullSMCS- Pharmacist PCP

bullOBCM

bull Incentives for fu visit within 7 days

Cardiologist

bullEducation and follow up needs

Wellspace bullSliding Scale provide PCP

bullMental Health

bullTreatment for addictions

bullPartner with Sutter

bullMultiple locations

ER bullCM 247

bullEducation to staff

bullSNF admit from ER

Skilled Nursing Facility

bullSNF HF Discharge Orders

bullHH Liaisons- Post DC

bullSNF Forum

Respiratory Care

bull IP Patient amp Staff COPD Education

bullSNF COPD Discharge Orders

bullCM COPD Transition Note

bullCOPD Stop Light

bullSNF Staff COPD Education

bullSNF Forum

bullPulmonary Rehab-Post DC

Respiratory Care amp SNF

Partnership

Coordination Transition of Care

My Story

Non-pharmacolgical treatments

IP Education

Following Global Initiative Chronic Lung

Disease (GOLD)

Disease Management (PNATrach)

MedicationsDevices- Assist Reconciliation

SNF COPD Discharge Orders

(PNA too)

14

CM COPD Transition Note

(PNA too)

COPD Stop Light

(PNA too)

SNF Staff Education

Disease management

Improving the Quality of Care a Team Approach to

Transition of Care

Increase patient ability to self-manage symptom and

their care

Tools of the trade Oxygen Therapy-Medications-

Challenges with Devices Manage and Prevent

Exacerbations

Improve the health and well being and patient

satisfaction

Pulmonary Rehab and Activity

GOLD 2014 ldquoAll COPD patients with breathlessness when walking at their own pace on level ground appear to benefit from rehabilitation and maintenance of physical activity

Physical Therapy at SNF

MaintenanceActivity SNF

Refer to Pulmonary Rehab upon discharge if candidate

Next Steps

Finish Order Sets and Care Transition Notes

Staff Education (IP and SNF)

Quarterly Forum

CM and Transition Teams

Pulmonary Rehab

PCP follow up appointment when DC SNF

Questions

Hospital Admission

HF Orders Flag Team

CM Identify Risk-MIDAS

SRMC ndash CTC 7 dayswk

Home Health bullHigh Risk within 48 hours

bull Integrated Care Model

Disease Tele-management

bullMod Risk within 48 hours

bullMinimum 30 day follow

Skilled Nursing Facility

bullSNF Discharge Orders

bullHH Liaisons- Post DC

bullSNF Forum

HF Clinic bullUnUnderinsured

bullPrimary NP run

bullMultidisciplinary team

bullSMCS- Pharmacist PCP

bullOBCM

bull Incentives for fu visit within 7 days

Cardiologist

bullEducation and follow up needs

Wellspace bullSliding Scale provide PCP

bullMental Health

bullTreatment for addictions

bullPartner with Sutter

bullMultiple locations

ER bullCM 247

bullEducation to staff

bullSNF admit from ER

Skilled Nursing Facility

bullSNF HF Discharge Orders

bullHH Liaisons- Post DC

bullSNF Forum

Respiratory Care

bull IP Patient amp Staff COPD Education

bullSNF COPD Discharge Orders

bullCM COPD Transition Note

bullCOPD Stop Light

bullSNF Staff COPD Education

bullSNF Forum

bullPulmonary Rehab-Post DC

Respiratory Care amp SNF

Partnership

Coordination Transition of Care

My Story

Non-pharmacolgical treatments

IP Education

Following Global Initiative Chronic Lung

Disease (GOLD)

Disease Management (PNATrach)

MedicationsDevices- Assist Reconciliation

SNF COPD Discharge Orders

(PNA too)

14

CM COPD Transition Note

(PNA too)

COPD Stop Light

(PNA too)

SNF Staff Education

Disease management

Improving the Quality of Care a Team Approach to

Transition of Care

Increase patient ability to self-manage symptom and

their care

Tools of the trade Oxygen Therapy-Medications-

Challenges with Devices Manage and Prevent

Exacerbations

Improve the health and well being and patient

satisfaction

Pulmonary Rehab and Activity

GOLD 2014 ldquoAll COPD patients with breathlessness when walking at their own pace on level ground appear to benefit from rehabilitation and maintenance of physical activity

Physical Therapy at SNF

MaintenanceActivity SNF

Refer to Pulmonary Rehab upon discharge if candidate

Next Steps

Finish Order Sets and Care Transition Notes

Staff Education (IP and SNF)

Quarterly Forum

CM and Transition Teams

Pulmonary Rehab

PCP follow up appointment when DC SNF

Questions

Skilled Nursing Facility

bullSNF HF Discharge Orders

bullHH Liaisons- Post DC

bullSNF Forum

Respiratory Care

bull IP Patient amp Staff COPD Education

bullSNF COPD Discharge Orders

bullCM COPD Transition Note

bullCOPD Stop Light

bullSNF Staff COPD Education

bullSNF Forum

bullPulmonary Rehab-Post DC

Respiratory Care amp SNF

Partnership

Coordination Transition of Care

My Story

Non-pharmacolgical treatments

IP Education

Following Global Initiative Chronic Lung

Disease (GOLD)

Disease Management (PNATrach)

MedicationsDevices- Assist Reconciliation

SNF COPD Discharge Orders

(PNA too)

14

CM COPD Transition Note

(PNA too)

COPD Stop Light

(PNA too)

SNF Staff Education

Disease management

Improving the Quality of Care a Team Approach to

Transition of Care

Increase patient ability to self-manage symptom and

their care

Tools of the trade Oxygen Therapy-Medications-

Challenges with Devices Manage and Prevent

Exacerbations

Improve the health and well being and patient

satisfaction

Pulmonary Rehab and Activity

GOLD 2014 ldquoAll COPD patients with breathlessness when walking at their own pace on level ground appear to benefit from rehabilitation and maintenance of physical activity

Physical Therapy at SNF

MaintenanceActivity SNF

Refer to Pulmonary Rehab upon discharge if candidate

Next Steps

Finish Order Sets and Care Transition Notes

Staff Education (IP and SNF)

Quarterly Forum

CM and Transition Teams

Pulmonary Rehab

PCP follow up appointment when DC SNF

Questions

Coordination Transition of Care

My Story

Non-pharmacolgical treatments

IP Education

Following Global Initiative Chronic Lung

Disease (GOLD)

Disease Management (PNATrach)

MedicationsDevices- Assist Reconciliation

SNF COPD Discharge Orders

(PNA too)

14

CM COPD Transition Note

(PNA too)

COPD Stop Light

(PNA too)

SNF Staff Education

Disease management

Improving the Quality of Care a Team Approach to

Transition of Care

Increase patient ability to self-manage symptom and

their care

Tools of the trade Oxygen Therapy-Medications-

Challenges with Devices Manage and Prevent

Exacerbations

Improve the health and well being and patient

satisfaction

Pulmonary Rehab and Activity

GOLD 2014 ldquoAll COPD patients with breathlessness when walking at their own pace on level ground appear to benefit from rehabilitation and maintenance of physical activity

Physical Therapy at SNF

MaintenanceActivity SNF

Refer to Pulmonary Rehab upon discharge if candidate

Next Steps

Finish Order Sets and Care Transition Notes

Staff Education (IP and SNF)

Quarterly Forum

CM and Transition Teams

Pulmonary Rehab

PCP follow up appointment when DC SNF

Questions

IP Education

Following Global Initiative Chronic Lung

Disease (GOLD)

Disease Management (PNATrach)

MedicationsDevices- Assist Reconciliation

SNF COPD Discharge Orders

(PNA too)

14

CM COPD Transition Note

(PNA too)

COPD Stop Light

(PNA too)

SNF Staff Education

Disease management

Improving the Quality of Care a Team Approach to

Transition of Care

Increase patient ability to self-manage symptom and

their care

Tools of the trade Oxygen Therapy-Medications-

Challenges with Devices Manage and Prevent

Exacerbations

Improve the health and well being and patient

satisfaction

Pulmonary Rehab and Activity

GOLD 2014 ldquoAll COPD patients with breathlessness when walking at their own pace on level ground appear to benefit from rehabilitation and maintenance of physical activity

Physical Therapy at SNF

MaintenanceActivity SNF

Refer to Pulmonary Rehab upon discharge if candidate

Next Steps

Finish Order Sets and Care Transition Notes

Staff Education (IP and SNF)

Quarterly Forum

CM and Transition Teams

Pulmonary Rehab

PCP follow up appointment when DC SNF

Questions

SNF COPD Discharge Orders

(PNA too)

14

CM COPD Transition Note

(PNA too)

COPD Stop Light

(PNA too)

SNF Staff Education

Disease management

Improving the Quality of Care a Team Approach to

Transition of Care

Increase patient ability to self-manage symptom and

their care

Tools of the trade Oxygen Therapy-Medications-

Challenges with Devices Manage and Prevent

Exacerbations

Improve the health and well being and patient

satisfaction

Pulmonary Rehab and Activity

GOLD 2014 ldquoAll COPD patients with breathlessness when walking at their own pace on level ground appear to benefit from rehabilitation and maintenance of physical activity

Physical Therapy at SNF

MaintenanceActivity SNF

Refer to Pulmonary Rehab upon discharge if candidate

Next Steps

Finish Order Sets and Care Transition Notes

Staff Education (IP and SNF)

Quarterly Forum

CM and Transition Teams

Pulmonary Rehab

PCP follow up appointment when DC SNF

Questions

CM COPD Transition Note

(PNA too)

COPD Stop Light

(PNA too)

SNF Staff Education

Disease management

Improving the Quality of Care a Team Approach to

Transition of Care

Increase patient ability to self-manage symptom and

their care

Tools of the trade Oxygen Therapy-Medications-

Challenges with Devices Manage and Prevent

Exacerbations

Improve the health and well being and patient

satisfaction

Pulmonary Rehab and Activity

GOLD 2014 ldquoAll COPD patients with breathlessness when walking at their own pace on level ground appear to benefit from rehabilitation and maintenance of physical activity

Physical Therapy at SNF

MaintenanceActivity SNF

Refer to Pulmonary Rehab upon discharge if candidate

Next Steps

Finish Order Sets and Care Transition Notes

Staff Education (IP and SNF)

Quarterly Forum

CM and Transition Teams

Pulmonary Rehab

PCP follow up appointment when DC SNF

Questions

COPD Stop Light

(PNA too)

SNF Staff Education

Disease management

Improving the Quality of Care a Team Approach to

Transition of Care

Increase patient ability to self-manage symptom and

their care

Tools of the trade Oxygen Therapy-Medications-

Challenges with Devices Manage and Prevent

Exacerbations

Improve the health and well being and patient

satisfaction

Pulmonary Rehab and Activity

GOLD 2014 ldquoAll COPD patients with breathlessness when walking at their own pace on level ground appear to benefit from rehabilitation and maintenance of physical activity

Physical Therapy at SNF

MaintenanceActivity SNF

Refer to Pulmonary Rehab upon discharge if candidate

Next Steps

Finish Order Sets and Care Transition Notes

Staff Education (IP and SNF)

Quarterly Forum

CM and Transition Teams

Pulmonary Rehab

PCP follow up appointment when DC SNF

Questions

SNF Staff Education

Disease management

Improving the Quality of Care a Team Approach to

Transition of Care

Increase patient ability to self-manage symptom and

their care

Tools of the trade Oxygen Therapy-Medications-

Challenges with Devices Manage and Prevent

Exacerbations

Improve the health and well being and patient

satisfaction

Pulmonary Rehab and Activity

GOLD 2014 ldquoAll COPD patients with breathlessness when walking at their own pace on level ground appear to benefit from rehabilitation and maintenance of physical activity

Physical Therapy at SNF

MaintenanceActivity SNF

Refer to Pulmonary Rehab upon discharge if candidate

Next Steps

Finish Order Sets and Care Transition Notes

Staff Education (IP and SNF)

Quarterly Forum

CM and Transition Teams

Pulmonary Rehab

PCP follow up appointment when DC SNF

Questions

Pulmonary Rehab and Activity

GOLD 2014 ldquoAll COPD patients with breathlessness when walking at their own pace on level ground appear to benefit from rehabilitation and maintenance of physical activity

Physical Therapy at SNF

MaintenanceActivity SNF

Refer to Pulmonary Rehab upon discharge if candidate

Next Steps

Finish Order Sets and Care Transition Notes

Staff Education (IP and SNF)

Quarterly Forum

CM and Transition Teams

Pulmonary Rehab

PCP follow up appointment when DC SNF

Questions

Next Steps

Finish Order Sets and Care Transition Notes

Staff Education (IP and SNF)

Quarterly Forum

CM and Transition Teams

Pulmonary Rehab

PCP follow up appointment when DC SNF

Questions

Questions

References Ambrosino N and Goldstein R Series lsquolsquoComprehensive Management Of End-stage COPDrsquorsquo Number 5 in this Series

Nonpharmacological treatment and relief of symptoms in COPD Eur Respir J 2008 32 218ndash228DOI 1011830903193600134007 Journals Ltd 2008

American Lung Association Disparities in Lung Health Series Taking Her Breath Away- The rise of COPD in Women 2013 Retrieved from website httpwwwlungorgassetsdocumentspublicationslung-disease-datarise-of-copd-in-women-summarypdf

CDC Ten Leading Causes of Death and Injury 2010 httpwwwcdcgovinjurywisqarsLeadingCauseshtml

Chatila W Thomashow B etal Comorbidities in Chronic Obstructive Pulmonary Disease Proc Am Thorac Soc May 1 2008 5(4) 549ndash555 httpwwwncbinlmnihgovpmcarticlesPMC2645334pdfPROCATS54549pdf

Chestnetorg CMS Adds Two Measures to Hospital IQR Program August 21 2013 httpwwwchestnetorgNewsHealthcare-News201308CMS-Adds-Two-Measures-to-Hospital-IQR-Programp=1

CMS Medicare Hospital Quality Chartbook Performance Report on Outcome 2013 Prepared by

Yale New Haven Health Services Corporation Center for Outcomes Research and Evaluation httpwwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-InstrumentsHospitalQualityInitsDownloads-Medicare-Hospital-Quality-Chartbook-2013pdf

COPD GOLD Global Initiative for Chronic Obstructive Lung Disease 2014 Guidelines httpwwwgoldcopdorg

Jaacutecome C and Marques A Pulmonary Rehabilitation for Mild COPD A Systematic Review Respir Care April 2014 594 588-594 published ahead of print October 8 2013 doi104187respcare02742

JencksS Medicare Penalty for COPD Readmissions American Association of Respiratory Care (AARC) April 2014 Retrieved from website httpmydigimagrrdcomdisplay_articlephpid=1656442ampid_issue=200625

Magnus P Ekstroumlm The rise and fall of COPD mortality The Lancet Respiratory Medicine - 1 January 2014 ( Vol 2 Issue 1 Pages 4-6 ) DOI 101016S2213-2600(13)70257-1

ManninoD and KiriVictor Lancet Int J Changing the Burden of Chronic Obstructive Pulmonary Disease Sep 2006 1(3) 219ndash233 Published online Sep 2006 PMCID PMC2707151 wwwncbinlmnihgovpmcarticlesPMC2707151

NBCH (National Business Coalition on Healthcare and Drive for COPD September 2012 Retrieved from website wwwnbchorgnbchfilesccLibraryFilesFilename000000002422NBCH_AB_COPD_FPDF

Neil B Minkoff MD Analysis of the Current Care Model of the COPD Patient A Health Outcomes Assessment and Economic Evaluation Vol 11 No 6 S-a July 2005 JMCP Supplement to Journal of Managed Care Pharmacy wwwamcporgJMCP2005July-AugustSupplementSupplement_PDFs148201033html

QualityNet CMS National Dry Run Chronic Obstructive Pulmonary Disease (COPD) 30-Day Mortality and Readmission Measures Aug 27 2013