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The need for system solutions to solve care challenges

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Treatment for COPD patients too often begins and ends with a trip to the emergency room.

 

Forward-thinking practices across the country are enacting system-wide team approaches that are centered on care navigators and involve all levels of care delivery. “As we straddle the fee-based and value-based worlds, this approach,” says Garry Kauffman, “will drive care forward and enable teams to meet rising standards.”

Defining the care navigator

 

So many care settings. So many treaters. So many opportunities for patients to slip through the cracks.

 

Care navigators facilitate the longitudinal, multi-setting process and serve as patient advocates at every step.

 

Learn more about the role of care navigators – and the transformative value they bring.

It's hard to get an individual provider engaged unless the system becomes engaged.”

Amy Shaheen, MD MSc

Professor of Medicine, Division of General Medicine and Clinical Epidemiology, UNC Director of Population Health Services, University of North Carolina School of Medicine

Contributors

M. Bradley Drummond, MD, MHS

M. Bradley Drummond, MD, MHS

Clinical Associate Professor
University of North Carolina School of Medicine’s Division of Pulmonary Diseases and Critical Care Medicine
Garry Kauffman, RRT, FAARC, MPA, FACHE

Garry Kauffman, RRT, FAARC, MPA, FACHE

RT, Owner

Kauffman Consulting, LLC

Bobbie V. Kumar, MD, MBA, FAAFP

Bobbie V. Kumar, MD, MBA, FAAFP

Medical Director, Swedish Edmonds Urgent Care

Director, Complex Care Management for Vituity

Kimberly Palczynski, RRT

Kimberly Palczynski, RRT

RT COPD Navigator

Inova Health

Amy Shaheen, MD, MSc

Amy Shaheen, MD, MSc

Professor of Medicine, Division of General Medicine and Clinical Epidemiology, UNC
Director of Population Health Services, UNC School of Medicine
Tammy Stucki, RRT-ACCS

Tammy Stucki, RRT-ACCS

Pulmonary Disease Navigator
Intermountain Healthcare, Dixie Regional Medical Center
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By integrating care and delivering it more seamlessly, entire systems can support higher quality treatment and help reduce COPD readmissions.

Read on to learn some of our leading insider tips on system solutions – and how you can begin to bring them to life today.

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I'm reminded by a quote from Warren Buffett, who, I'm pretty sure, is not a family practice physician or pulmonologist, but I think it applies: ‘Price is what you pay, value is what you get.’ I think that's the challenge for us – to do the right thing in the right way by the right folks. But you've got to be able to afford that up-front cost.

 

You need a consult when you do, you need access to a pharmacist, a respiratory therapist, and that costs money up-front. But everything that you mentioned, and you likewise, when you engage the right people at the right time, good things happen. And I think that's just something that we've got to pivot on, as soon as possible. We've done it in other diseases – with congestive heart failure and cancer – and the pivot seems to be it's time to do it, to get the entire team engaged.”

Garry Kauffman, MPA, RRT, FAARC, FACHE  

RT, Owner

Kauffman Consulting, LLC

System solution 1: Better measuring, better managing

Once the entire system is engaged with a patient, it’s easier to track and manage care. The team can see when patients are trending toward an exacerbation and proactively intervene.

 

The keystone solution: targeted symptom measurement.

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Collaborate with the care team to determine which symptoms to measure across populations.

 

Yield longitudinal data to systematically drive quality


“Every year, a patient should have their symptoms assessed, then ranked on where they stand with peers,” says Shaheen. “From there, you create an automated system that issues an alert when a patient is not well controlled.” This reduces the burden of management across the entire system.

 

In the absence of an automated process, teams can still get the job done, but doing so requires labor. When Dr. Bobbie Kumar ran a private practice, she had a medical assistant and LPN comb through patient records to make sure there were no care gaps. When they found one, they called the patient back for a follow-up visit.

 

Whether automated or not, monitoring patients is foundational to implementing a systems approach, because it establishes key metrics and makes key data accessible and meaningful to the entire care team.”

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“So every year a patient should have their symptoms assessed, if it's not. Then the provider has a ranking of where they fall and how many of their patients have had symptoms assessed. And then, it's a step-wise algorithm, and each time they'll get an alert saying, ‘Hey, your patient's still not well-controlled. It's time to titrate their medicine, think about this medicine next.’

 

And so, we will help them titrate their medicine. Giving them clinical decision support at the time of a visit is very, very important, instead of just saying you have to do this right, but you're not sure what's right, and you don't have time to look it up. I think providing that clinical decision support just in time is a really important tool for doing that, but still, it's hard to get people engaged.

 

So you've got carrots and you've got sticks. You can look and see how you compare to everyone else. You can reimburse based on measures, which sometimes works, sometimes doesn't. Or you can provide the clinical support. And so, coaching models ­– there are primary care coaching models where you can send coaches into practices and help them figure out the best flow to make those things happen. I think it’s a really important aspect of primary care and helping them do the right thing at the right time.

 

You can do population health, so setting aside time, like you were saying, for the DME, but set aside time for a primary care doctor. You've got one day – one clinic day every month – where you're going to just look at your panels and do panel management, where, you say, who's missing this rescue inhaler – this person should be on an LAMA.”

Amy Shaheen, MD MSc  

Professor of Medicine, Division of General Medicine and Clinical Epidemiology, UNC

Director of Population Health Services, University of North Carolina School of Medicine

System solution 2: Education from all angles

When patients don’t know how to best manage their COPD, they run the risk of falling victim to it. They may not be managing their lifestyle, their therapies, or their care plan. They may not even know what to do in case of an exacerbation (other than head straight to the emergency room).

 

Shaheen says many of her patients reported a concerning fact: They weren’t using their rescue inhalers when they had trouble breathing, because they thought they should only use them when they were being picked up by a rescue squad.

 

Her solution? Institute inhaler education – and even shift how you refer to inhalers. Watch the video to learn more.

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“When we look at hundreds of doctors in our health system and 75% of the patients who had COPD had a rescue inhaler in their lists. You think that's a no-brainer, right? Why doesn't everybody have it? But when you actually start accounting for it and measuring it, and people go, oh, how are they not on that yet, we actually see the numbers go up, so that 90% of patients now have a rescue inhaler listed. And then, when we start introducing inhaler education, we start hearing from our patients. You talk about the patients a lot, and I'm like, well why didn't you use your rescue inhaler? We have had a number of doctors say, well, they thought it was when they called the rescue squad…

 

And it's really given me insight from my patients that you only use it in a rescue situation. So a lot of the providers have started calling it their symptom inhaler.”

Amy Shaheen, MD MSc  

Professor of Medicine, Division of General Medicine and Clinical Epidemiology, UNC

Director of Population Health Services, University of North Carolina School of Medicine

Being an intermediary for the primary care physician

The challenge

Patient education needs to take place before discharge – and after. The question is: with so many stakeholders, who should take the lead?

According to Tammy Stucki, hospital staff can provide invaluable education – and actually be an intermediary for the PCP.

Bridging the educational gap

Create a pulmonary navigator system

 

  • Educate patients in the hospital
  • Invite them back 7-10 days later (when their steroid regimen usually is ending), as they may not be able to see a physician for three weeks
  • Conduct follow-up phone calls every day for 30 days to help ensure that patients retain all needed information

This helps to be an intermediary for the primary care physician

 

  • Assess patient health and share findings
  • Give recommendations to help avoid COPD readmissions
  • Let patients know where they can come for a resource if their symptoms start to flare up again
Initially, we were playing defensive medicine and the frequent flyers were coming back again. We found that one of the biggest disconnects we had was patient education.”

Tammy Stucki, RRT-ACCS

Pulmonary Disease Navigator, Intermountain Healthcare, Dixie Regional Medical Center

System solution 3: Pinging the PCP

With so many treaters involved, it’s not unusual for PCPs to be in the dark about ER visits. This highlights a consistent gap in care – after discharge, but before PCP intervention. This seemingly small issue can have serious consequences.

 

  • The system needs to pay for potentially avoidable COPD readmissions
  • The PCP can’t make necessary treatment modifications
  • The patient is underserved and likely heading toward a repeat issue

 

“The PCP,” says Kumar, “needs more integration with specialists to determine an integrated care approach.”

 

Insider solution: Send an electronic message to the PCP about every patient’s ER visit.

 

See how Brad Drummond achieved this efficiently with automated alerts.

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“One of the challenges with many institutions is that the primary care providers may or may not be affiliated with the emergency room that the patient has gone to. And so, we've struggled with understanding how can we get that information to the primary care provider. One of the things – a pilot study that we did as an example – was that any patient who was sent to the emergency room, treated for COPD exacerbation, but then discharged from the emergency room – we identified this as a high-risk group, because on the inpatient side, you have the transitionalist, other care teams are going to reach out. So what we did is we generate an automatic messaging prompt through our electronic health record, which would send that primary care provider a message that simply said, ‘Hey, your patient was seen and discharged from the emergency department. We know that these patients with COPD have high mortality in the next year. They should be on full maximal inhaled therapies. They should be educated about the appropriate use of their inhalers, and here are some contact and resource information if you think they need to see a pulmonologist.’


It was simply that — that message of your patient was here. And we often got replies back that the primary care provider, especially when they're outside of our system, had no idea the patient was even in the emergency room. And so, things like that, that information highway gap is important for that transition.”

M. Brad Drummond, MD, MHS  

Clinical Associate Professor

University of North Carolina School of Medicine’s Division of Pulmonary Diseases and Critical Care Medicine

When we develop these care pathways that integrate primary care with a pulmonary specialist, we can chip away at the things that make the most sense.”  

M. Brad Drummond, MD, MHS

Clinical Associate Professor, University of North Carolina School of Medicine’s Division of Pulmonary Diseases and Critical Care Medicine

System solution 4: Catering to the elderly

You can’t simply release patients, especially those who are elderly, and expect them to thrive without follow-up care. Calling elderly patients or trying to engage them on Skype or FaceTime can be problematic because of the technology.

 

“Nothing beats face-to-face engagement,” says pulmonary disease navigator Tammy Stucki. She helped institute a smart strategy to bridge the technology divide: an exacerbation clinic.

Watch the video to see how this system:

 

  • Keeps patients on track for better care
  • Bridges communication between patients and physicians
  • Empowers physicians to modify their care plans
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We've taken, as respiratory therapists, a little bit different avenue in the post-discharge era. We can give them a 30-day prescription to come visit the exacerbation clinic. We have found, with our elderly population, that they don't work very well with technology. They don't understand telehealth yet. Maybe in another 10 years, when some of our generation gets a little bit more used to electronic modes, telehealth, I think, will grow exponentially with that.

 

But for now, we have our patients come back in within that 7- to 10-day period, because that's usually about when their steroid regimen stops, and it helps to build a bridge between patient and physician to be able to help them modify their care plans, to be able to keep the physician informed. Because we've also found that only about 50% of the patients have their follow-up visits with their PCPs within 14 days. And that's a critical point. And we've been able to at least extend our readmissions to late readmissions instead of early within the first seven to 10 days. So that tends to help another avenue for the COPD patients.”

Tammy Stucki, RRT-ACCS    

Pulmonary Disease Navigator

Intermountain Healthcare, Dixie Regional Medical Center

System solution 5: Collaborating to treat the whole patient

Readmissions aren’t just related to breathing. They can be tied to a myriad of factors, including mental health and socioeconomic challenges. Helping patients breathe is a primary COPD goal, but it can be met with struggle if the healthcare system doesn’t look at all the other challenges facing the COPD sufferer. Admittedly, that’s difficult to do in the 15-minute time slots most PCPs have for patients.

 

The answer lies in system solutions – with a robust team centered on the patient. Here are three smart ways to provide services that were once seen as ancillary, but are now seen as vital. Deploy a:

  • social worker to screen for depression
  • nutritionist to devise diets for struggling diabetics
  • cardiologist to assess cardiovascular comorbidities

 

Then, use your patient/data management system to share updates and key findings with the extended care team. This can help unify care and drive treatment of the whole patient – to secure quality from the start.

You have to have the whole system in place. You have to have embedded behavioral health, so that every time a patient gets discharged, it doesn't matter if it's for COPD or heart failure, we will screen them for depression.”  

Amy Shaheen, MD MSc

Professor of Medicine, Division of General Medicine and Clinical Epidemiology, UNC, Director of Population Health Services, University of North Carolina School of Medicine

Even small gains can be a big deal

 

COPD is an insidious malady. By using a system approach, care teams can do more to get ahead of it – even if the gains are only incremental. Drummond likens the process to turning a large ship. It eventually moves in the right direction, even if it happens slowly.

 

The best way to get going is to simply start, says Drummond: “When you begin to identify key deficits and streamline things, you start the process moving. And when you’ve overcome one problem, you can then move to the next.”

 

He concludes: “Thirty years ago, everyone died from COPD, and there was nothing anyone could do. But now we can multiply our care as a system – and we all need to lead this forward.”

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