The development of a comprehensive chronic disease management program can significantly improve a patient’s quality of life.
Organization Type: Non-profit
We identified several issues in managing our patients with pulmonary conditions. These included extended ICU stays, long length of stay, frequent readmissions, frequent emergency department visits and emergency medical services (EMS) calls. We wanted a way to manage this population at the hospital as well as in the outpatient setting. We wanted to create a program for our chronic lung disease patients that spans the continuum of care. Education and communication may begin in the hospital setting; however, consistency in messaging is an integral part of caring for patients in transitions.
What We Tried
Implementation of our comprehensive pulmonary program began by working with a multidisciplinary team composed of hospital staff, home health staff, and pulmonology physicians. We created a pulmonary unit in our hospital designed to manage complex chronic lung disease and assist with transitioning patients with respiratory diagnoses out of the ICU sooner. This is a 23 bed unit where nurses are trained to manage complex respiratory patients. The pulmonary unit is able to manage high and low oxygen needs, BIPAPs (Biphasic Intermittent Positive Airway Pressure), and non-invasive ventilator patients as well as manage pneumonia, asthma and respiratory failure patients. Then, we designed consistent education for patients to receive as soon as the patient is diagnosed with a chronic lung disease. The same education is delivered to the patient by the nursing staff, the respiratory therapists, the physicians and their office staff, pulmonary rehabilitation and from community pulmonary staff. By providing the same education from all staff, our team is able to ensure the patient is receiving consistent, accurate messaging. Our education has included the use of the Krames “Living Well with Chronic Lung Disease” pulmonary education book as well as zone tools. The occupational therapists teach energy conservation techniques in the home setting as well. Other components of the patient and family education of disease process include warning signs and exacerbation management, as well as medication reconciliation and adherence.
In collaboration with our system home health agency, we have a nurse assigned to the program. Patients can be referred to the program from the acute care hospital or from a physician’s office; however, a physician’s order is needed to enroll. To quality for program enrollment, the patient must have a chronic respiratory diagnosis. The nurse does follow-up with the patients in their home after discharge, a free service paid for by the hospital. The nurse assesses the patient for signs of distress and serves as a resource if the patient feels ill or has questions and concerns. If the patient has an exacerbation of their symptoms, the nurse calls the physician and has the medications arranged, labs drawn or organizes physician appointments to prevent emergency room admission.
This program was initiated in 2006. The data for the program six months prior to implementation and six months after the program was implemented are indicated below. There were 51 patients included in this data report.
- Admissions: 137
- Length of Stay: 8.82
- ED visits: 14
- Ambulance calls: 51
- Admissions: 21
- Length of stay: 6.05
- ED visits: 4
- Ambulance calls: 8
The program has continued to be successful. In 2011, patients in the pulmonary program had a decrease in length of stay by 1.7 days and experienced a 30 percent decrease in readmission rates compared to before they started in the program. This is for an increase to 54 patients in the program in 2011.
The 2014- 2015 program data is indicated below:
- 38 pulmonary patients total as of September 2015
- 31 patients added during 2014-2015
- 43 admissions for these patients prior to being on the program
- 21 admissions for these patients after program
- 51 percent reduction in admissions for this population
The goals of care continued to improve quality of life, improve patient and family satisfaction, disease education and exacerbation management, medication adherence, advance directive completion and decrease in re-hospitalization and emergency department visits.
The true benefit of this program is that we are able to offer continuity of care for these chronic patients. They can build relationships with staff and have support throughout the disease process, which typically worsens over time. We have the ability to help create individual plans of care based on each individual’s goals and wishes. We can help them transition to palliative care and hospice services as their disease progresses.
Physician buy-in is very important. You must have the support of the physicians to refer patients to the program, offer consistent education in their office and help order treatments in the home rather than just in the hospital or office.
We also made the change from a RN to an APRN. This allows us to have a clinical person evaluate the patient and educate on medications, and we are now able to bill for these services.
Consistency for these patients is really important. Making sure they get the same education and information at the physician office, the hospital and any other outpatient services helps reinforce education and improve quality of care.