COPD: Improving Care with CarelinkCareNow Janine Jordan MD, CHQCM, FACP Julie Caldwell CRT, Donna Mahoney MHCDS, CPHQ, Patty Resnik MJ, MBA, RRT, FACHE, CPHQ, Carelink CareNow Staff
Christiana Care Health System, Newark, DE
INTRODUCTION Chronic Obstructive Pulmonary Disease (COPD) is a common preventable and treatable disease characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases.
RESULTS /OUTCOME In the first year 330 members with COPD were enrolled in the program. 248 (75%) participating for at least 30 days. 83% had spirometry testing and were appropriately staged according to the GOLD standard.
COPD affects 12 million Americans and is among the top 10 conditions of eBrightHealth Accountable Care Organization (ACO), affecting 14% (over 6000) beneficiaries. Hospital utilization and expenditures for this population exceeded other ACO and Medicare compare groups, with total expenditures accounting for over 12% of total ACO claims.
50% were either Stage 3 (severe) or Stage 4 (very severe). Over 95% of members received flu and pneumococcal vaccinations. 15% of the stage 3 or 4 members participated in pulmonary rehabilitation. Following program participation, hospital readmissions within 30 days of discharge decreased by 54.3% for stage 3 or 4 members (from 31.3% to 14.3%), and by 12.6% (from 25.6% to 22.4%) for all members.
OBJECTIVES / PURPOSE To improve quality of care and outcomes for CarelinkCareNow members in our at-risk ACO population with Chronic Obstructive Pulmonary Disease by 15% within one year.
All unplanned returns within 30 days decreased by 11.7% (from 39.3% to 34.7%) for stage 3 or 4 members and by 16.6% (from 39.3% to 32.8%) for all members.
RESULTS: OUTCOMES INTERVENTIONS In January 2017, CarelinkCareNow’s multidisciplinary team which includes Care Managers, Pharmacist, Social worker, and Respiratory therapist partnered with Christiana Care’s Pulmonologists, the COPD clinical inpatient pathway team and eBrightHealth ACO providers, to establish evidence based best practice standards of care for COPD patients. CLCN developed a Care Management COPD program that is focused on driving evidence-based best practice COPD standards of care to achieve improved outcomes for members with COPD and which include: • Pulmonary Function Testing or Spirometry • Global Initiative for Chronic Obstructive Lung Disease (GOLD) disease staging • Short term and Long term Plans of Care based on GOLD staging • Standard Dyspnea tool CAT- COPD Assessment Tool-baseline and ongoing scores • Medication Optimization • Standard Education COPD self-management Tool • Smoking cessation • Standarized Communication Checklist with Providers Carelink’s COPD Care Management Program was implemented in June 2017
CONCLUSION Enrolling members with COPD into a CarelinkCarenow care management program, whose focus is driving evidenced based best practice, improved clinical outcomes for members with COPD in the eBrightHealth ACO. Consistent application of COPD evidence-based standards of care, while standardizing our self- management education tool, our communication with providers template, and our assessment to detect COPD exacerbations, proved successful in improving quality of care, and reducing unplanned hospitalization, and 30 day readmissions, particularly for the most severely ill participating members with COPD in the eBrightHealth ACO. E
Implemented plans of care based on staging showed: 95% of participants received a seasonal influenza vaccine 97% of participants received a pneumococcal vaccine, with 88% within 5 years COPD Assessment Tool (CAT) scores were obtained periodically for members (more frequently for more severe members). Average scores were 15-20 points. Score changes identified 28 instances of COPD exacerbation for early intervention and utilization avoidance (5+ point increase) 15% of members in stages 3 or 4 participated in Pulmonary Rehabilitation
Launching clinical best practices and care standardization across 300 participating providers in numerous primary care practices is challenging; but standardizing care management processes that drive short term and long term goals, based on COPD evidence standards of best practice, has helped to engage both providers and members, and has produced improved clinical outcomes.
EVIDENCE BASED BEST PRACTICE STANDARDS OF CARE FOR COPD GOLD Global Initiative for Chronic Obstructive Lung Disease Staging
IMPLICATIONS
RESULTS: OUTCOMES
Based on our experiences with COPD, programs for other high risk populations, including heart failure and diabetes are being initiated
COPD BUNDLE: CareLinkCareNow for another health system over a 90 day period using the same care management COPD methodology
CAT- COPD Assessment Tool
30-Day Readmissions (unplanned inpatient admission within 30 days of discharge, for any reason) decreased by 12.6% (from 25.6% to 22.4%, p=0.67) in the 90-day period following engagement with Carelink. Members in GOLD Stage 3 (Severe) or Stage 4 (Very Severe) had a reduction of 54.3% (from 31.3% to 14.3%, p=0.09). 30-Day Returns (unplanned hospital encounter within 30 days of an inpatient, emergency room or observation discharge, for any reason) decreased by 16.6% (from 39.3% to 32.8%, p=0.38). Members in COPD GOLD Stage 3 (Severe) or Stage 4 (Very Severe) had a reduction of 11.7% (from 39.3% to 34.7%, p=0.59)
DISCLOSURES: There are no financial conflicts for any of the authors. © 2019 Christiana Care Health Services, Inc., All rights reserved