As the fate of the Affordable Care Act volleys about in Congress, hospitals that have seen improvements in reducing COPD readmissions under the ACA plan to continue their work with or without the bill.
Editor’s note: In May 2017, the US House of Representatives passed the American Health Care Act (AHCA), a comprehensive overhaul of the American healthcare system that would effectively repeal and replace 2010’s Affordable Care Act (ACA). Since then, the US Senate has proposed and failed to pass an accompanying bill that would send Republicans’ signature campaign promise to President Donald Trump’s desk.
The mandate from the Affordable Care Act to reduce 30-day hospital readmissions related to chronic obstructive pulmonary disease (COPD) or incur a penalty posed a challenge for hospital systems. But research has found that a multidimensional approach including medication evaluation, patient education and home oxygen or other durable medical equipment (DME) when needed could achieve this goal.1 While the fate of the ACA is uncertain, hospitals that have implemented readmission reduction programs report good outcomes and have no plans to eliminate them.
Coordinated Care Yields Results
Umur Hatipoglu, MD, pulmonary and critical care medicine specialist at the Respiratory Institute at Cleveland Clinic and medical director of the Center for Comprehensive Care in COPD, reported that no specific measures exist that serve the 30-day readmission reduction mandate. “If you look at the literature, there are no published effective strategies for 30 day readmissions in COPD per se. Our data suggests that our post discharge care program may have an impact on a longer term readmission rate of 90 days,” he said, and the Respiratory Institute has implemented several initiatives aimed at providing better coordination of care, ultimately reducing readmissions.
Inpatients receive education on COPD from respiratory therapists and pharmacists who explain the disease, the need for medication and demonstrate the use of inhalers. Case managers and a respiratory therapist also evaluate the patient’s need for durable medical equipment (DME) prior to discharge. “Patients will typically be sent home with home help if they need it and if we feel they should go to long-term care hospitals, we facilitate that,” said Hatipoglu, noting though that in some cases insurance could be an impediment. All patients receive a follow-up appointment at the COPD Exacerbation Clinic post-discharge, he added.
After discharge, patients also receive weekly follow up phone calls for one month. Hatipoglu said, “We go through a template-based evaluation during the phone call as it relates to their disease. For instance, we ask if they are taking their medications, what those medications are, whether they have access to them.”
Another initiative that has been associated with better outcomes for COPD patients is the COPD Exacerbation Clinic, according to Hatipoglu. “The goal is to see them within five to seven days after discharge. Once they come to us we evaluate them in a very systematic, template-driven manner, looking at all aspects of lung disease, comorbidities, whether the patient has access to medications and social support,” he said. Statistical analysis revealed that patients who declined to attend the clinic or receive care coordination with follow-up phone calls had a 90-day readmission rate twice as high when compared to those who received care coordination and/or attended the clinic.
Additionally, the Cleveland Clinic launched an electronic inhaler monitoring program in October 2016. Patients with a history of high healthcare utilization are given sensors to place on their long-acting and rescue inhalers, which allow the physician to monitor adherence and determine if rescue medication use exceeds the patient’s baseline. Physicians receive alerts when necessary, which may prompt a phone call and possible office visit or other intervention, Hatipoglu explained.
Hatipoglu is currently collecting data to determine the impact of these initiatives. “We’ve started the inpatient COPD care path, which identifies patients with COPD while in the hospital who are not part of the Respiratory Institute. Now we are trying to have them go through this program,” he said. “We haven’t added new interventions, but are trying to expand the program to include all patients hospitalized at our Main Campus Hospital. Once we get the data, the goal is to measure the impact and expand the program to our regional hospitals and see whether we can have same impact there.”
Education Key to Reducing Readmissions
West Virginia ranks third or fourth in the country for number of COPD patients per patient population, according to Chuck Menders, RRT-ACCS, AE-C, FAARC, director, Respiratory Care Services, Charleston Area Medical Center (CAMC), Charleston, West Virginia. “The Centers for Disease Control and Prevention predicted in 1990 that COPD would be the third leading cause of death in 2020,” he said. “We hit that in 2010 or 2011.”
So approximately four years ago, CAMC initiated a readmission reduction program targeting COPD patients as well as those with heart failure and pneumonia. The COPD program examines the patient’s progression through the system from preadmission through transition to home and emphasizes education from respiratory therapists and navigators. In addition to providing education, the disease navigators act as a transition coach, make referrals, handle medication issues and make sure patients schedule a follow up visit.
Included in the education piece is guidance using spacers, according to Menders. “We want to make sure the patients are using MDIs correctly. We assess the technique and nursing does follow up,” he said. “We have a bronchodilator program called Onward.” The emphasis is to ensure that patients transition from the hospital with the medications they typically take at home. “We don’t want the patient walking out the door with four nebulizer treatments if they take a controller medication twice a day.”
CAMC also created Cypher voice, a call-back phone system to maintain contact with the patient and invites patients to attend pulmonary rehabilitation, according to Menders. “Patients that go to our pulmonary rehab program have half the chance of coming in to the hospital for exacerbations,” he said, noting though that convincing patients to participate sometimes poses a challenge.
Patients also undergo pulmonary function testing (PFT) to verify a COPD diagnosis. “By assessing and documenting the disease severity, we get the right classification and know what therapy they should be on. We also started Alpha 1 testing recently,” he said. “When we first started, we had a readmit rate near 20 to 30%. This past year the readmit rate was 16.9%. It has gone down significantly, although percentages don’t tell the whole story.”
Giving DME Suppliers a Voice
Kathy Lester, executive director of the Council for Quality Respiratory Care (CQRC), is encouraged that the Centers for Medicare and Medicaid Services (CMS) is addressing the readmission measure for COPD, but is concerned that DME suppliers have not been included in the decision-making process. She pointed out that CQRC, the COPD Foundation and the National Association for Medical Direction of Respiratory Care (NAMDRC) emphasize the importance of home respiratory care in reducing COPD readmissions. “Measuring can be good, but I think successful programs have turned to home respiratory suppliers as a partner,” she said. “There is a lot of potential here, but until suppliers are included, there will continue to be barriers to getting the patient access to home respiratory therapy.”
Since the implementation of the Affordable Care Act, documentation requirements have increased and become more complicated, according to Lester. Prior to the ACA, a certificate of medical need and objective information was required to order a piece of home respiratory therapy equipment, supplies and service. The requirements and “what the contractors see as adequate determination that a patient has a medical need for equipment” have become difficult to understand, according to Lester. “We have tried to understand why the ACA contractors don’t accept a diagnosis of COPD as an ongoing medical condition. It’s clearly defined that way by respiratory therapies and physicians.”
Lester asserted that excessive documentation requirements shifts the focus from patient care to paperwork. “You see this industry having fallen into a game of ‘gotcha’ where the patient is stuck in the middle. It doesn’t make a lot of sense,” she said. “We’ve gotten away from what the patient needs and find ourselves in that part of the care continuum that cannot provide services. We are being excluded at a time when we should all be promoting home care and putting the patient in the most effective and efficient setting they can be in the long-term.”
Steve Griggs, CEO, AeroCare USA, indicated that the “criteria placed on the back of the DME supplier prior to delivering a piece of respiratory equipment” resembles a “paperwork maze” that creates a logjam between the hospital and the home respiratory care supplier. He added that the intent of the ACA is for patients to receive proper equipment as ordered, but in reality, there have been delays in care. “The ACA has a lot of good intentions, but the law needs to be tweaked, re-reviewed. You see a lot of examples of things with inappropriate or unintended consequences when you introduce a massive piece of legislation like this,” he said.
In spite of documentation challenges for DME suppliers, Griggs indicated that the COPD readmission criteria has “some merit to making sure the continuum of care is taken more seriously and making sure the patient is handed off to the proper person.” He added, “But a significant look at the regulations and the requirements ought to be more definitive. There should be more objective reasons to order equipment and get it to the patient in a timely manner.”
Whatever happens with the ACA, Griggs hopes to see more cooperation among agencies. “We need to get real world results and are all working for the same goal – getting patients better care,” he said.
Menders indicated that CAMC’s program was created to improve treatment, cut costs and reduce readmissions and will continue to serve its COPD population. “Our program is not really based on health care laws or saving money for that matter. Our mission statement is to provide the best care to every patient every day. I see us doing that, regardless of how the law is changed.”
Hatipoglu anticipates a shift in focus with changes to the ACA.“I think the current metric got us off on the right foot, but now it needs to consider COPD population management where we look at the number of hospital admissions, average length of stay and total hospital days over a longer period, for that particular population of COPD patients,” he said. “I find that approach a lot more rational and meaningful than just looking at a short-term rate of readmissions.” RT
Phyllis Hanlon is a contributing writer to RT. For more information contact [email protected]
- Coughlin S, Liang WE, Parthasarathy S. “Retrospective assessment of home ventilation to reduce rehospitalization in chronic obstructive pulmonary disease.” Journal of Clinical Sleep Medicine. 2015; 11:6, 663-670.