What would happen if we blurred the lines between departments and disease states when shaping care for COPD patients? The answer may surprise you.
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.
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.
Associate Vice Chancellor for Population Health Sciences University of Illinois Hospital and Health Sciences System
Clinical Associate Professor of Medicine University of Pittsburgh
COPD Case Manager Department of Respiratory Care at UC Davis Medical Center
Motivational Based Health Coaching
Case Manager Supervisor Genex Services, LLC for the State of Georgia
President and CEO StratiHealth Management Consultant for ACOs
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
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.
Managed more than 14,000 hospital discharges of patients with COPD, HF, or AMI.
Enrolled nearly 9,000 unique patients into longitudinal care plans.
Logged 40,541 face-to-face contacts with hospitalized patients for care management, education, medication reconciliation, self-management skill building, and advance directive planning.
Made more than 28,000 telephone calls to (or on behalf of) patients.
Conducted more than 2,300 outpatient visits to patients’ homes or post-acute care facilities
Do not script everything. Allow a team to design their own methods and protocols. When the team’s creativity was unleashed, we saw amazing things happen.”
Keith T. Kanel, MD, MHCM, FACP Clinical Associate Professor of Medicine University of Pittsburgh
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I understand “We invested in three types of training, which are recommended for any team to replicate.”
Quality improvement “We mapped out our entire process and value streams, to create our own data flow and control charts to track performance”
Disease management "We partnered with two national organizations, the American Heart Association and the COPD Foundation, who provided on-site training"
Practical training "Didactic University Training programs included simulations of interactions with patients and motivational interviewing"
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I understand A smaller, yet successful program was implemented in Ventura County, California, led by Chris Landon, MD, FFAP, FCCP, CMD, Director of Pediatrics at Ventura County Medical, Pediatric Diagnostics Center, and CEO of the Landon Pediatric Foundation. The program, called The COPD Access to Community Health, employs a multidisciplinary team of behavioral specialists, dieticians and home healthcare nurses. A COPD specialty clinic was also established as part of the initiative.
It’s important to understand where patients are in their lives and on their journeys. If you pay attention, they will contribute valuable information.”
Chris Landon, MD, FFAP, FCCP, CMD Director of Pediatrics, Ventura County Medical Director of Pediatric Diagnostics Center and CEO, Landon Pediatric Foundation
Patients are experts in their own lives, and when given the opportunity, they will tell you what works, what didn’t work in the past and what they believe should be the next step.”
Roberto Benzo, MD, MSc Motivational Based Health Coaching
While Dr. Landon agrees that collaborating with case managers across disease states is key to better care, he believes that the patient is a critical part of the team. He explains, “It’s important to understand where patients are in their lives and on their journeys. If you pay attention, they will contribute valuable information.” Dr. Landon recalls a time when he discovered his homeless patients had consistently better pulmonary function than those who lived at home or in a care facility. He says, “Turns out that these patients had to bicycle and walk everywhere. Needless to say, this revelation helped us gain support for our pulmonary rehabilitation unit.”
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I understand Krystal Craddock, COPD case manager at UC Davis, discusses the importance of taking a holistic approach when caring for patients with COPD. She explains, “We’re starting to see more collaboration between COPD care teams and those from other departments and disease states. It’s important that every comorbid condition be addressed, of course, but we also want to remember to see the whole patient.” Craddock insists that she is fortunate her role on the care team as educator enables her to spend time with the patient. “I believe that if we can provide effective care, stay focused on the patient, and empathize with this population, decreasing readmission rates will follow.”
I believe that if we can provide effective care, stay focused on the patient, and empathize with this population, decreasing readmission rates will follow.”
Krystal Craddock, BSRC, RRT-NPS, AEC COPD Case Manager
Department of Respiratory Care at UC Davis Medical Center
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I understand There is perhaps no component of caring for a COPD patient with comorbidities that requires more collaboration across departments and disease states than discharge planning. Chikita Mann says, “The discharge process is fragmented. We are pulling it together within five minutes. The patient will be given various prescriptions and be seen by multiple doctors.” Mann maintains that the discharge process is especially critical with the COPD patient. “You can't do this within five minutes. You can't do it within 10 minutes. A discharge should begin the moment that the patients steps in the door. Until we begin to realize that the discharge process begins when the patient is admitted, we risk providing suboptimal care and that’s not good for the healthcare system or the patient.”
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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I understand 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
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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