COPD insider

Transforming COPD care through collaboration

 

What would happen if we blurred the lines between departments and disease states when shaping care for COPD patients? The answer may surprise you.

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COPD is considered a multisystem disease that’s often accompanied by comorbidities. Guidelines recommend the holistic assessment and management of those comorbidities, as well as the use of coordinated, collaborative and team-based care. This is no small task, but it can lead to incredibly large benefits.

 

Read on for some collaboration case studies and insider tips on bringing the extraordinary benefits of collaboration to life.

A case for collaboration

 

One excellent example is outlined by Keith T. Kanel, MD, MHCM, FACP, the Designer, Project Director, and Principal Investigator of The Primary Care Resource Center Program—an award-winning, large-scale model for reducing community hospital readmissions.

 

In the beginning, Dr. Kanel and his team were applying known solutions. But, despite their efforts, they struggled to transform care. Dr. Kanel recalls the Albert Einstein quote, "We can't solve problems by using the same kind of thinking we used when we created them."

 

Dr. Kanel and his team knew that in order to establish a meaningful solution, they would need to think differently. He explains, “We met. We brainstormed. We strategized. Finally we decided to completely reframe the problem and approach it from a design perspective.”

If we were going to fail, we would do it quickly. If we were going to succeed, we would do it boldly.”

Keith T. Kanel, MD, MHCM, FACP

Clinical Associate Professor of Medicine University of Pittsburgh

With this new mindset, Dr. Kanel investigated and discovered that about 50% of patients within his organization who had COPD had comorbities of either congestive heart failure (CHF) or ischemic heart disease. Dr. Kanel recognized that COPD and CHF case managers were working in siloes and, in some cases, from a completely different set of evidence-based guidelines. They were inspired to incite change immediately by taking a patient-centric, not disease-centric, approach. Treaters worked together to discuss patient history, current symptoms, treatment goals and care pathways.

Contributors

Jerry Krishnan

Jerry Krishnan, MD, PhD

Associate Vice Chancellor for Population Health Sciences

University of Illinois Hospital and Health Sciences System

Keith Kanel

Keith T. Kanel, MD, MHCM, FACP

Clinical Associate Professor of Medicine University of Pittsburgh
Krystal Craddock

Krystal Craddock, BSRC, RRT-NPS, AEC

COPD Case Manager

Department of Respiratory Care at UC Davis Medical Center

Roberto Benzo

Roberto Benzo, MD, MSc

Motivational Based Health Coaching
Chikita Mann

Chikita Mann, MSN, RN, CCM Disability RN

Case Manager Supervisor

Genex Services, LLC for the State of Georgia

Vernon Pertelle

Vernon Pertelle, RRT

President and CEO

StratiHealth

Management Consultant for ACOs

Chris Landon

Chris Landon, MD, FFAP, FCCP, CMD

Director of Pediatrics, Ventura County Medical

Director of Pediatric Diagnostics Center and CEO, Landon Pediatric Foundation

“We decided to expand our scope of disease management to COPD, CHF and MI in our prototype. When we realized that management of medications was an issue, we added a
full-time pharmacist, too!”

Keith T. Kanel, MD, MHCM, FACP
Clinical Associate Professor of Medicine University of Pittsburgh

Scaling for ultimate impact

 

Dr. Kanel and his team’s prototype was awarded a large grant from the CMS Innovation Center, which enabled the program to be scaled. In just four months, Primary Care Resource Center Program were added to six additional health centers across Western Pennsylvania and Northern West Virginia.

Remarkable results1

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Managed more than 14,000 hospital discharges of patients with COPD, HF, or AMI.
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Enrolled nearly 9,000 unique patients into longitudinal care plans.
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Logged 40,541 face-to-face contacts with hospitalized patients for care management, education, medication reconciliation, self-management skill building, and advance directive planning.
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Made more than 28,000 telephone calls to (or on behalf of) patients.
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Conducted more than 2,300 outpatient visits to patients’ homes or post-acute care facilities

As a result of this intense set of interventions, PRHI’s 30-day all-cause readmission rate for the three target conditions fell from 20.4 percent to 15.3 percent, for a net readmission reduction of 25.0 percent1

Today, many hospitals have chosen to sustain the centers even after grant funding had dissipated.

How to leverage collaboration to create a program of your own

Insider debate: What should collaboration look like today?    

 

While we’re seeing more programs intended to blur the lines between disease states for better patient care, such as the successful, multi-site prototype Dr. Kanel described, there are still some compelling questions posed by the group.

If we developed a strategy that is program- or disease-agnostic, would that help us be more patient-centric?”

Jerry Krishnan, MD, PhD

Professor of Medicine and Public Health and Associate Chancellor for Health Affairs for Population Health Sciences

University of Illinois and Health Sciences System

Jerry Krishnan, MD, PhD, and Professor of Medicine and Public Health, Associate Chancellor for Health Affairs for Population Health Sciences at the University of Illinois and Health Sciences System, asks, “Do we need a different program for every comorbidity we see in COPD care? Is coordinating care across programs and disease states enough to improve care and reduce readmission rates? Should we be developing a strategy that is program- or disease-agnostic?”
Vernon Pertelle, President and CEO of StratiHealth, explains, “I think it's important to look at the whole person and not focus solely on one program or one disease —even if we are making strides in collaboration and coordination across departments. We already know that COPD is a chronic, complex illness with multiple systemic effects and comorbidities that requires an integrated approach for its optimal management.” Pertelle goes on to state that not only are there missed opportunities with a siloed approach, there are simply not enough resources for any redundancy or duplication of efforts.
It's important to look at the whole person and not focus solely on one program or one disease.”

Vernon Pertelle, RRT

President and CEO

StratiHealth

Management Consultant for ACOs

It’s important that we have forums like this to share insights and ideas. To make real improvements in COPD care, we have to remember that collaboration begins with us.”

Chikita Mann, MSN, RN, CCM Disability RN

Case Manager Supervisor

Genex Services, LLC for the State of Georgia

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As COPD continues to plague millions of people, we continue searching for solutions. Each new initiative or program is another step forward in care delivery. As you and your team embark on new, innovative initiatives, rely on COPD insider for the proven strategies that can bring success closer.

References

1. Iyer AS, Bhat SP, Garner JJ, et al. Depression is associated with readmission for acute exacerbation of chronic obstructive pulmonary disease. Ann Am Thorac Soc. 2016;13(2):197-203.

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