Creating a Collaborative Care Model
The changing healthcare landscape and a desire to improve community health compelled
to take a close look at our care delivery systems. Like others, we must find innovative ways to serve our patients and protect reimbursement by improving outcomes, reducing readmissions and better coordinating care. As Albert Einstein said, “We cannot solve our problems with the same thinking we used when we created them.”
As a result, we established a Center for Evidence-Based Medicine to help us adopt and implement standard procedures and tools that would help us follow best practices across the continuum of care. We believed that following the patient as they transition through the settings of care would enable us to better manage population health for a chronic condition.
Our first focus was improving the care of patients with chronic obstructive pulmonary disease (COPD). Although COPD was an organizational priority, there was no evidence-based standard of care in place across our care settings. Only 20% of patients were properly diagnosed with spirometry (pulmonary function testing). Some physicians assumed all smokers had COPD and treated them accordingly. Follow-up – including rehabilitation referrals, management of medication needs and post-discharge care – was lacking.
We implemented an evidence-based standard for our COPD patients across care settings called GOLD (Global Initiative for Chronic Obstructive Lung Disease). GOLD promotes clinical collaboration and coordination. In the process, we created a disease management model that could be replicated for other conditions.
Effective teamwork and interdisciplinary cooperation helped us maximize programs already in place, minimize meeting time and ensure rapid implementation. Rather than mandate adoption, we decided to use the influence of leading caregivers to effect change.
We formed a core group that included a passionate physician champion who is a pulmonologist, an administrative sponsor, representatives from nursing and an evidence-based medicine dyad of a physician and nurse to model best practice behavior. This group in turn worked with subgroups and met daily to move the project forward. A larger group of physicians, nurses, social workers, pharmacists, case managers, and information technology staff, met only three times for final approval of the subgroups’ work. To speed implementation and give a better overall view of the process, care enhancements were submitted for approval as a package versus one at a time.
Improving Care Coordination
With the help of analytics, UnityPoint Health-Methodist has implemented a coordinated care management process for COPD patients that eliminates silos and focuses on transitions of care across the continuum. Organizations outside the health system also are included, such as nursing homes, medical supply companies and long-term, acute-care facilities.
We shared standardized enterprise tools with these entities, including a COPD assessment tool that uses a “stoplight” method (green-yellow-red) of assessing patient status. It enables caregivers and patients to know the proper care action to take for each level, such as calling 911, the home health facility or the primary care physician. Other tools included patient education materials, a dyspnea assessment tool, a hand-off process for care transitions, and a “teach-back” methodology in which the patient repeats back key pieces of care information.
When patients are discharged from the ED or inpatient care, they are referred to homecare, a transition coach, pulmonary rehabilitation or the nurse advisory line as well as their primary care physician. Care is now:
- More effective. From the start, care is evidence-based, with standard order sets used for admission and discharge. Having standard order sets based on best practices helps us provide optimal care.
- More efficient. Care duplication and variation are minimized. Patient education materials are streamlined and standardized.
- Safer. Comprehensive information is available in real-time to all clinicians, linking inpatient, the ED, our medical group’s physician offices, pulmonary rehabilitation, homecare and our Nurse Advisory Line. Care transitions are shared to ensure patients receive appropriate follow-up monitoring and referrals.
With consistent processes and coordination across the continuum of care, we’ve minimized inappropriate variation and duplication – and achieved immediate improvements in COPD care. Within three months, 20 new care measures were in place to help ensure consistent processes. Diagnosis with spirometry increased, home health referrals increased, readmissions decreased for patients seeing a transition coach, and the number of pulmonary rehabilitation patients doubled.
The hospital’s Clinical Excellence Committee monitors all results via a dashboard. If results are below expectations, action plans are developed. We continue to tweak processes to improve results. Initially, readmission rates did not decrease as rapidly as hoped. High-risk patients now see a pulmonologist after discharge before transitioning to their primary care provider to ensure more comprehensive care.
Use of the enterprise model for cross-setting care has enhanced chronic disease management of COPD patients. Most importantly, it has changed the culture at UnityPoint Health-Methodist. With care coordination and collaboration, everyone, including the patient and his or her family, knows the patient status and the standards for treatment – from admission to discharge to referral to follow-up. We designed our model for use with other conditions. Currently, we are replicating the process for our diabetes patient population, and we hope to apply it to our heart failure patients in the near future.
UnityPoint Health-Methodist was a finalist for Web2pro’s 2013 Distinguished Achievement Award for Clinical Excellence. The annual awards program recognizes customers that have achieved notable results in improving healthcare quality and patient safety through the effective deployment of Horizon Clinicals® and Paragon® clinical solutions.
Results of UnityPoint Health-Methodist’s COPD Initiative
A coordinated care process anchored by evidence-based guidelines has helped UnityPoint Health-Methodist improve its care and management of COPD patients, achieving the following results:
- Reduced mortality rate to .89 from 1.2
- Shortened the length of stay (LOS) to .96 from 1.03
- Reduced readmissions through use of a transition coach
- 58% of COPD patients now diagnosed using spirometry
- 50% increase in pulmonary rehabilitation referrals
- 16% increase in home health referrals for COPD