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Reducing Admissions and Readmissions in the COPD Patient Population

Reducing Admissions and Readmissions in the COPD Patient Population

At a recent MVC chronic obstructive pulmonary disease (COPD) workgroup, representatives from McLaren Physician Partners presented on their recent quality improvement initiative involving their COPD patient population. McLaren Physician Partners worked to identify areas for improvement within this specific patient population and found some common patient struggles consisted of higher utilization of the emergency department and in-patient settings, as well as higher readmission rates, specifically among their Medicare patients (38%). Five nurse managers were tasked with doing case reviews in order to identify possible areas for improvement. Five to ten patients that had three or more encounters in the last six months were taken from each nurse managers case load. Around 83% of those patients had other significant comorbidities (e.g. Diabetes Mellitus, Congestive Heart Failure, Hypertension.) Additionally, the reason for readmission was most often related to either respiratory insufficiency or a cancer treatment side effect.

Care managers then engaged the patients and went over a questionnaire with them. Approximately 68% of these patients had a misunderstanding of their medication, 26% had environmental barriers, 14% were not compliant with medication, and less than 15% reported an inability to afford medication/devices. Readmissions related to disease progression and inappropriate medication use were the major contributing factor to higher utilization of the in-patient setting and emergency department. Additionally, all admissions and readmissions were related to some form of respiratory insufficiency or a cancer treatment side effect.

Due to the time of implementation, COVID-19 impacted the type of intervention that could be put into place. McLaren Physician Partners opted to adopt a telephonic intervention in order to address education needs and remove barriers. Specific needs related to managing medications and compliance, triggers that led to an exacerbation, and developing a plan of action at the onset of first symptom were addressed. Additionally, the intervention sought to minimize and remove barriers where possible (e.g. cost of medications, transportation issues for visits). Lastly, a consideration was made if a patient was a candidate for palliative care.

Nurse navigators looked into possible ways to engage patients differently in order to hopefully prevent an exacerbation that caused an admission or a readmission. They were aware that what they were doing wasn't working, and needed some sort of upgrade. A toolkit was developed that was sent to the patient prior to a one to two-hour phone call scheduled in order to  help the patient understand this toolkit. The kit requires active participation and helps the patient develop specific goals and actions to take when they see signs of a potential exacerbation.

After implementation of this pilot program, all navigators came together to discuss their findings. Many things were noted, including the fact that patients did not know the difference between their inhalers (long-acting vs. rescue). Additionally, patients often didn't know that by identifying certain triggers, some symptoms may have been preventable. Of the patients who received and engaged in this telephonic intervention, the readmission rate for those who had been recently discharged decreased by more than 20%. Overall, McLaren Physician Partners saw a decrease in their hospitalizations due to the implementation of this program.

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Michigan Value Collaborative: Sepsis Reports

Michigan Value Collaborative: Sepsis Reports

In early 2020, the Michigan Value Collaborative (MVC) Coordinating Center created a new sepsis service line with the help of the Michigan Michigan Hospital Medicine Safety Consortium (HMS). Initially the service line began with 215,447 episodes and has since grown to 229,673 episodes. In conjunction with the creation of the sepsis service line, reports customized to each collaborative member hospital were developed. The most recent iteration of these, shared in two volumes, were disseminated to members in February 2021.

Each volume of the sepsis reports serves their own unique purpose. The first volume provides a detailed review into specific components of a sepsis episode with the ability for each member to compare individualized information to regional and statewide averages. These metrics help members garner a better understanding of the sepsis patient population from admission to 90-days post discharge with data on length of stay, causes for readmission, and post-acute care utilization. Figure 1 shares information on length of stay, and this example shows Hospital A’s (a fictional institution) average length of stay to be higher than both the regional and collaborative-wide average. Additionally, metrics such as total episode payment and readmission rates are displayed as trends over time as shown in Figure 2 and Figure 3.

Figure One.

Figure Two.

Figure 3 shows that the individual hospital trend for the 90-day readmission rate is higher than both the regional and MVC averages which mirror each other closely. Initially, the overall hospital trend decreases towards the regional average, but climbs again in 2019. MVC members may wish to use this information to investigate the root causes leading to increased readmissions.

Figure Three.

The second volume of MVC’s sepsis reports provides benchmarking for members to identify how they compare to all other MVC hospitals. Figure 4 shows information on a hospital’s total episode payment compared to the regional and MVC averages. In addition, it shows the range of the average total episode payments across the collaborative. By using previously sent reports, hospitals can compare how the metrics have changed - such as an increase or decrease in collaborative-wide or individualized total episode payments. As these reports are disseminated every six months, when comparing, it is important to take notice of the reporting period covered in each report which can be located in the associated cover letter and footnotes. Members can also access their own sepsis related data on the MVC registry.

Figure Four.

If you have any suggestions on how these reports can be improved or the data made more actionable, we would love to hear from you. We are also seeking feedback on how collaborative members are using this information in their quality improvement projects. Please reach out to the Coordinating Center at michiganvaluecollaborative@gmail.com to share your story. If you have any questions or are interested in custom data for your facility, contact us at the aforementioned email address.

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Henry Ford Health System – Cardiac Rehab

Henry Ford Health System – Cardiac Rehab

At the most recent congestive heart failure MVC workgroup, Dr. Steven Keteyian, Section Head of the Cardiac Rehabilitation/Preventive Cardiology Unit at Henry Ford Medical Group, presented on exercise-based cardiac rehabilitation in patients with heart failure. Dr. Keteyian started out by discussing the importance of cardiac rehabilitation and adhering to a program in order to improve exercise tolerance and disease-specific outcomes. Exercise intolerance is measured and the information gathered can be used to stratify a patient’s future risk. If the measurement improves over time, Dr. Keteyian discussed the potential for a decrease in risk of death and re-hospitalization. This shows a tie to directly improving outcomes and symptoms in cardiac rehabilitation. Also, in the words of Dr. Keteyian, “functionally, the more they don’t do, the less they can do.”

Cardiac rehab is a Class I recommendation from The American College of Cardiology for all of the traditional cardiac disorders. Henry Ford has a 36-visit program that is anchored on exercise training. Between four and fifteen people are in each class and each person receives an individual treatment plan with a focus on bio-behavioral components. Six core components make up the program which include outcome assessments, supervised exercise, dietary/weight management, tobacco abuse, psychological support, and medication adherence. All participants participate in 30-minute behavioral education sessions which cover topics such as nutrition, dining out, proper exercise, medication compliance, and other relevant disease-management self-care activities. These same topics are also available on YouTube and can be found here, all of which are available for use in your cardiac rehab program. Currently, Henry Ford is working on bringing their time to enrollment after hospital discharge to less than 21 days and increasing adherence to the 36-visit program. The goal is to achieve a participation rate of 70% or more in cardiac rehab for Henry Ford’s patient population.

After discussing the program specifics at Henry Ford, Dr. Keteyian discussed the barriers that one may face in relation to participation in cardiac rehab. These barriers include:

  • Demographic
  • Difficulty contacting patient after hospitalization
  • Return to work demands
  • Transportation
  • Co-payment obligations
  • Dependent care responsibilities

Henry Ford is working at a system level in order to increase the percent of patients who gain access to cardiac rehab. This includes increasing the use of electronic medical record (EMR) driven automatic referrals, with an option for users to opt-out if necessary. Additionally, a member of the cardiac rehab team goes to the inpatient setting and talks to patients to establish a touchpoint before they leave the hospital. This five-minute conversation is all some patients need in order to see the importance and benefits of rehab. Lastly, Henry Ford is working to shorten the discharge to start time. Each day after discharge, the chance of getting patients started in rehab decreases by 1% for each day that passes. Henry Ford is working diligently in order to help decrease this risk.

In 2016, Henry Ford launched a hybrid home-based cardiac rehabilitation service. This includes some visits at the clinic and other virtual sessions. Previously being tied to a single visit at a time on their current streaming platform, Henry Ford will roll out a WebEx model in February 2021 that will allow up to six cardiac rehab appointments to occur at one time. This will provide more of a group setting. Currently, a randomized controlled trial is being done on center based cardiac rehab versus hybrid cardiac rehab. Improvements in fitness and the number of sessions attended are being assessed.

If you are interested in watching the entire workgroup, please click here.  If interested in any information about this workgroup, or other MVC workgroups please email michiganvaluecollaborative@gmail.com

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Healthcare Burnout and Possible Solutions

Healthcare Burnout and Possible Solutions

More recently than ever, healthcare workers may be faced with the potential for burnout and a decreased quality of life. The Agency for Healthcare Research and Quality defines burnout as “a long-term stress reaction marked by emotional exhaustion, depersonalization, and a lack of sense of personal accomplishment”. From the busy work days, to the intense pace and time sensitive pressures, the healthcare environment places individuals at a high risk. All of this has the potential to impact the delivery of high-quality, compassionate care within an institution. The risk for staff to develop burnout may increase as changes to the work environment result in a poor fit for healthcare workers. :

  • Technological advances
  • Compliance with regulatory measures
  • Difficult electronic medical records (EMRs)
  • Issues with insurance coverage and reimbursement
  • Increased volume and patient acuity

In order to help decrease the risk of burnout, a quality improvement project was put into place in a 37-bed ICU between February and June 2019. Registered nurses, medical assistants, and physician assistants were the targeted population. The Mini-Z Burnout survey was given to those participating in the study to assess for factors contributing to burnout, as well as job related stress and job satisfaction. After completing the survey, interventions were put into place in order to address such risks. These interventions included:

  • Identifying scheduling opportunities (e.g. stacking days when possible)
  • Determining special needs for patients while in the ICU setting
  • Identifying staff backup based on acuity of assignments
  • Staff events to foster a positive team culture and increase collaboration

After three months of applying the above interventions, the Mini-Z Burnout survey was administered again. The findings revealed a higher percentage of staff reporting no burnout after the intervention (57.7% vs. 75%). Additionally, “satisfaction with current job” went from 70.6% pre-intervention to 82.8% post intervention. Finally, open ended questions revealed that stressors that still remained focused heavily on staffing and patient ratios. The sustainability and long-term impact of these interventions on preventing burnout continue to be monitored.

Overall, implementing quality improvement initiatives in order to promote staff wellbeing has the potential to impact the delivery of high quality and compassionate care. The Michigan Value Collaborative (MVC) is committed to helping our collaborative members implement quality improvement projects in order to increase patient and provider satisfaction. If you have any questions or wish to learn more, please reach out to the collaborative at michiganvaluecollaborative@gmail.com