Many repeat hospitalizations are not planned. Hospital readmissions for Chronic Obstructive Pulmonary Disease (COPD) are often the result of inadequate out-of-hospital care, a suboptimal understanding of the disease or medications, and lack of knowledge of the steps for self-care. This constellation can be viewed as a patient safety issue.
Signature Healthcare Brockton Hospital‘s solution was to design a program for COPD patients which empowers them to participate in self-directed care, improve pulmonary health, and reduce preventable readmissions.
The objective of the program was to build knowledge of COPD and treatment medications and to impart an understanding of actions which can be employed for the prevention of a return to the hospital. A team approach empowers the patient with the tools for self-care, builds confidence in participating in self-care, and provides support when vulnerable. A robust medication reconciliation and clinical care processes help provide safer care and a more reliable outcome for patients.
PROBLEM IDENTIFICATION & SOLUTION
The problem was identified because we had an unacceptably high 30-day all-cause readmission rate for COPD patients of 24% in October 2014. Many Brockton Hospital patients returned repeatedly for hospitalization.
Through problem-solving the causes of patients’ readmissions, we realized that patients often did not have knowledge of the elements that could help prevent difficulty with their disease, have knowledge of their medications, and did not know what steps to take to rescue themselves from an early exacerbation of COPD.
Beginning in January 2015, a task force of clinicians working with COPD patients came together to identify best practices in each of their areas which could be woven into a program to support COPD patients. We developed educational materials, planned instruction on medications and use of the delivery systems, outlined a robust medication reconciliation process, taught how to clean nebulizer machines and techniques for rescue breathing, constructed a care map designed to educate and build the patient’s confidence in self-care, designed an order set to drive the program, outlined an assessment process for Pulmonary rehab, developed care tools, engaged community partners, and planned a follow-up phase of 30 days with a case manager. We piloted elements of the program in April and May 2015, and implemented the full program in June 2015.
PATIENT & FAMILY INVOLVEMENT
Patients were involved from the time they were admitted to the hospital with a diagnosis of COPD or shortness of breath. They were engaged from Day 1 by care team members with education and review of the program tools. Respiratory therapists counseled for smoking cessation and performed oxygen needs assessment. Patients were assessed for Pulmonary rehab. Family members were often included in the education. Team members reviewed materials and responded to patient and family questions daily. Patients were discharged from the hospital with their educational materials, self-assessment tools to monitor their condition, medications, visiting nurse support, and a case manager to support them through the 30 days following the hospital discharged.
INSPIRING EMPLOYEES TO FOCUS ON PATIENTS & FAMILIES
As the news of the task force’s work was seeping into the hospital, other clinicians who were not initial participants came forward because they believed they were able to add to the COPD patient’s experience. As employee team members began working with patients and families, they became even more excited about elements of the program. When patients’ and families’ comments of praise for the program began to come in, many employees/team members felt an increase in their professional satisfaction and began to look for other chronic diseases where a focused program might be able to have the same impact.
TRANSFORMATION OF CARE DELIVERY
The PATHWAYS COPD program redesigned care in a patient-centric way, to add value to the care experience for COPD patients. The program has enhanced the collaborative work of the team and made the patient an invested partner in care. Design of this program has also improved our medication reconciliation process and our post-discharge support. By engaging community partners, VNA nursing colleagues, and PCPs, the program provides more coordinated support in the out-patient setting. A partnership with faculty and students from the Brockton School of Nursing has enabled us to provide home care services to patients who would not have qualified for traditional home care services.
IMPACT ON PATIENT EXPERIENCE & OUTCOMES
The October 2014 COPD readmission rate was 24%, with a mean rate for October 2014 through April 2015 (the middle of the piloting phase) of 20.5% (median of 20.9 %). Since program initiation in June 2015, Brockton Hospitals’ mean 30-day readmission rate for June 2015 through January 2016 is 11.8% (median of 9.6%).
During the year preceding implementation, there were 538 admissions for COPD and 113 readmissions (average: 9.4 readmissions/month). Comparing 8 months prior to the program initiation with the 8 months of data since the program has been functioning, there were 75 readmissions versus 38. Assuming an average cost of $8,400/readmission following a COPD admission, we estimate a healthcare cost savings of more than $300,000.
Patients like the program. A letter from a patient explained the improvements she made since starting the COPD program. What stood out in her letter was her affirmation that she “had been hospitalized many times before, but this time was different.” Another patient commented he was back at work and playing volleyball twice weekly. A third commented that he belongs to an over-55 community and has been telling all his friends, “If you have COPD, you have to go to Signature Healthcare for help.”