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Guest Perspective: Hospitalists’ role in providing high quality care for patients admitted with COPD

Posted on July 19, 2016   |   
16 Comments   |   
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Dr. Valerie Press

Guest author Valerie G. Press, MD, MPH, FHM, FAAP, FACP is Assistant Professor, Internal Medicine-Pediatrics at the University of Chicago and is a member of the PRAXIS Advisory Board. Dr. Press is an active researcher with interests in health literacy, health disparities, adolescent health, women’s health and community outreach. Her current research projects focus on patient self-management education and health literacy in patients with asthma and COPD. She is also an author of one of our most popular Resource Repository items: the Society of Hospital Medicine COPD Implementation Toolkit.

The Centers for Medicare & Medicaid Services’ Hospital Readmission Reduction Program (HRRP) has already had one very important success, which is putting COPD on hospitals’ agendas. Despite being the third leading cause of death and the third leading cause of readmissions among the Medicare population, COPD as a disease had failed to garner the attention that other chronic diseases, such as congestive heart failure, had across the spectrum of care. This attention includes quality improvement initiatives, administrative priorities, pay for performance, among other types of care priorities.

This is not to say work was not being done to understand the current level of care quality across the U.S., as an expert group of researchers and stakeholders had worked for years as part of a multi-stakeholder consortium to understand whether care was consistently being provided at hospitals across the country. Other important research was being done to understand how to improve on the care provided; however, without top-down hospital initiatives, it is difficult to make large-sweeping care transformation changes. Even with this new federal mandate, instant standardization of care or reduction in readmissions will not happen. There simply is not enough evidence to know what elements of a readmission reduction program or quality improvement program will directly lead to improved outcomes. Therefore, it is critical that a wide base of expertise come to the table to develop, implement, study and then improve upon these programs as forward movement takes place.

A key member group of any hospital-based program to improve and standardize the care for patients hospitalized with COPD should be hospitalists. Hospitalists, by definition, are the experts in the hospital at providing care to hospitalized patients. They are physicians on the front line, provide the majority of direct inpatient care, and serve as the care coordinators for hospitalized patients.

This care coordination includes obtaining specialty input from pulmonologists, nurse practitioners, physical therapists, pharmacists, nurses, respiratory therapists, case managers, among others. They are therefore skilled at working with and across medical disciplines and as part of inter-professional teams; however, it is critical to ensure that hospitalists and hospitalists-to-be continue to receive education and training on the existing evidence and best practices to ensure ongoing an improved quality of care for hospitalized patients with COPD. As leaders of or participants on these inter-professional care teams, their expertise can help build and inform improved care quality.

hospitalists

Although the HRRP financial penalty galvanized efforts across the country to improve care and reduce readmissions, we have a ways to go. New financial paradigms, such as bundled care payments, may further help facilitate hospitals’ efforts to improve care, or may serve as barriers, depending on how quickly evidence for best practices on readmissions reduction efforts can be established. Regardless, together, hospitalists and specialists across the wide array of clinical expertise can work with hospital administrators to standardize and transform care to ensure that evidence-based and guideline-informed care is provided and sustained for all COPD patients, in the hospital and as they transition to home after discharge.

16 Comments



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  • Some of the hospitalists in our state are pulmonologists, which should be helpful, since so many who are admitted to the hospital have respiratory infections as a primary or secondary issue in their admission.
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    • Absolutely! The hospitalist field is both inter-disciplinary (pediatrics, internal medicine, family medicine, specialists) and inter-professional (nurse practitioners, physician assistants). Making sure all the expert voices are heard and at the table is critical to helping to improve the care for hospitalized patients.
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  • One of the biggest complaints we see on the many list, boards and forums for folks with COPD regarding hospitalists is that upon admission, they are taken off their regular medications and often put on meds they don't know or understand. When they leave the hospital, no one tries to do a cross-walk between the meds they have at home and the new meds that have been prescribed and many patients then continue to take everything. The alternative is that they go back to their regular doc, dump the hospital meds and go back to their old ones. Neither situation is optimal.

    Many patients are very illiterate regarding meds and what they do and how they do it. Especially with the number of new combination meds and the move toward more personalized medicine, it's really important that meds be discussed with patients or patient reps prior to leaving the hospital. Especially if the patient is being see by someone who is not necessarily skilled in pulmonary medicine, it's important to be sure that the meds are reconciled and that someone, either the patient or the doc and preferably both, understand why various meds are being prescribed.
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    • Agree with Jean that there should be Rxreconcilliation, hopefully at or before discharge so the patient and family understand which meds are being taken for what, which should've continued and which stopped.

      Additionally, the patient needs to be seen by his/her md shortly after discharge--preferably within 72 hours.
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    • This topic is near and dear to me. I study patient medication adherence and inhaler technique assessment and education among hospitalized patients. Critical to these topics are understanding which devices and delivery mechanisms for medications are best for patients. This often includes making sure medications only changed when needed and appropriate. However, it is also critical to ensure that patients can afford the prescribed medications, that they are taught when and how to use them, and are regularly assessed for correct technique and sufficient adherence to the prescribed regimen. This needs to be done at all health encounters including the hospital, but also outpatient and emergency settings. Good and timely communication is needed of any changes, both to patients and their families and to the other care providers.
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  • I have 2 comments. Jean is right all the way, but I need to add that some discharge instructions send the 'hospital' list of meds to the patient's pharmacy. Not all send the hospital meds home with the patient as a continuation of Rx care until they see the next health professional (PCP, clinic or pulmonologist, etc.) This could have been the first COPD event for a patient who was not diagnosed prior to the hospital admission and not on any pre-hospital COPD meds.

    Saying the patient needs to be seen within 72 hours, IMHO, is totally unrealistic. First the patient may be still quite ill, certainly deconditioned, dealing with upset about all that goes with a new diagnosis, concerns of family members, awaiting for oxygen to be delivered and educated about its use, etc.. And may not have transportation to meet this requirement for a variety of reasons (spouse/friend works and can't take time off from work, pt too sick to drive themselves or take public transportation and then sit in a waiting room for hours, etc.) They may not yet been able to find someone to go get their medications that the hospital sent to a pharmacy (or the money to pay for them.) Lastly, their PCP may not even have an available office appt. for many weeks.

    There are many different hospital discharge processes across the nation and now we have just as many different attempts for COPD management teams. We are still in the infant stage of addressing all the COPD management issues but we must first learn what the patient wants.
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    • Sadly, the DME in our state that delivered my O2 just had a technical driver with NO medical training deliver my O2. Because we asked, he demonstrated how to fill an O2 tank and how to see how much is left in the reservoir. He also had us sign papers that he made the delivery.

      We have never had anyone call from the DME to ask us if we have any questions or even tell us how much the monthly charge will be or our share of the monthly charge.

      We got NO booklet or any information about the particular devices that were delivered, so H downloaded and printed the owner's manual off the internet.

      Yes, there are issues in trying to have a patient seen within 72 hours, but often the patient is NOT seen by anyone until after being readmitted, which most will agree is not ideal and probably at least partly why there was a readmission.
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    • What is so magical about 72 hours? All the potential barriers should be identified and solutions found by the case/discharge manager before discharging the patient. But the hospital wants everyone discharged in 4 days - once on oral meds, you are sent home. Great.

      The oxygen issue is a big one and as you learned H, no one gives a darn and you are on your own. If your DME is a Medicare contractor, you might have signed (or should have) a sheet that confirms delivery and instruction, and on the reverse side the conditions of the contract of the DME with Medicare and what are your rights and their responsibilities. Companies today can't bill for the time it would take to do their part so they just don't do it....Hospitalists, physicians (pulmonologists/PCP), nurses, even hospital RTs know nothing about the oxygen systems today being used after the hospital encounter. Everyone leaves it up to the best salesman of a particular DME company. Free lunch anyone?

      As for the particular article here, there have been several recent studies of physicians, hospitalists, hospital aprns, regarding care of the COPD patient and a large number admit to being very lacking in their education and the needs of this group of people. There are online education and one day onsite meetings for them---if they will take the time to do it. COPD is not trendy and the younger ones are just not ready for the chronic patients.....how many of them could even attach a ventilator/BiPap in a crisis. Do any of them know how to instruct a patient about an inhaler? I still urge every one here to please go read the recent Lancet article about the state of COPD care in the USA. It is a real eye opener and those of us that have experienced hospitalization (I had 4 in one year) can attest to the tremendous confusion and lacking in our current culture and can validate almost everything the article talks about.

      Valerie, I don't know where or who you work for, I applaud your goals but the reality is, except perhaps in smaller hospitals, what we 'should' have just doesn't get done in the bigger city hospitals with severe nursing shortages and same with all the necessary other departments - PT, OT, Dietary, including pharmacy. And there are real turf battles between the physicians as to what drugs the patient should receive. Less than half follow recommended guidelines. The patient gets caught in the middle.

      When patients are treated so poorly in the hospital, left to flounder on their own, and discharged with much confusion, why would they want to seek follow-up care.
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    • I'm not on Medicare -- I am BCBS private pay. If I didn't already know how to use the liquid oxygen reservoir and portables, I'd pretty much be SOL. The driver was a nice guy, but didn't have any depth of medical knowledge.

      When you call Apria, you are routed to their toll free national number, consistently. There is really no way for you to contact anyone locally unless you drive over and lie in wait. I happened to get the cell phone number of a local person--have no idea of his position or his long he will remain employed there.

      The problem for many patients is that hospitals and discharges are terribly stressful and confusing. You can think things are perfectly clear, but NOT to the patient and family. If there is no one promptly following them up when they're back in the community, studies have shown likelihood of readmission. Is greatly increased. Their community fm doc is probably the provider they know best and can help with continuity.

      My parents have each been hospitalized recently for non respiratory issues and were seen by their community primary care MD within 72 hours of discharge. He helped them better understand the things the discharge people had also covered. Honestly, the hospitalization and discharge was a blur to the folks hospitalized and relatives, so it was good to have time to review with familiar provider.
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    • Hi MuMarie,

      Thanks for referencing the Lancet article. I am a co-author of this piece. I spend most of my time researching how to better instruct patients on how to use their inhalers, and how to implement hospital-wide programs for COPD that standardizes care and better implements guideline recommended care. COPD as a topic has been ignored until the recent CMS Hospital Readmissions Reduction Program that is a financial penalty for hospitals with excess readmissions for COPD. Therefore, my point is now is the time to try and galvanize all members of the care team to do better for our patients with COPD. Agreed we have a long way to go, but hoping that we get there sooner rather than later.

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  • I would also argue that formalaries are hindering the patient doctor relationship. Hospitalists typically use formalary medications, which leads to prescribing meds that the patient is not already using. Thus adding more confusion and uneccessry medications to an otherwise complicated time at hosp discharge. While reconcilations at discharge are important they would be less needed if physicians could prescribe medications that the patient agrees to use.

    Formalaries benefit the payer, not the doctor / patient relationship. Systems work hard to negotiate the best prices. Then work even harder to defend them. In reality this restricts options for the patient/doctor relationship.

    I would like to see regulation that forbids the practice of formalaries. This would create an open market of competition where prices would be fixed by the industry itself. What I mean by this is that overpriced drugs will not sell and manufactureres would be forced to be more competitive in order to maintain sales of,their products.

    In turn, this is the best scenario for the patient/doctor relationship. It will reduce the complicated discharge process, reduce the need for med reconciliation, reduce the waste produced by prescribing drugs that get thrown away and allow patients to use the,meds that they are well adjusted to amd comfotable in using. We all know the complications with inhaler devices. They are not the same and some patients have difficulty in using some devices because of device design. And if technique is poor, then how would we expect them to do well on that medication.


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    • Formalaries on one hand and on the other is whatever free samples were most recently dropped off by the drug company rep .Damned if they do...


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    • Hi Scott,
      Do you mean the formularies issued by private pay insurance companies? I'm not yet eligible for medicare and have always been covered by an insurance plan with an Rx formulary, whether it was BCBS, Humana or UnitedHealthcare. Therefore, unless I want to pay full price for drugs out of my own pocket, ALL my docs have to adhere to my plan's formulary.

      Not saying that a formulary is good or bad, just that the hospitalist is not the only one locked in. There have been times when I've had to change meds when changing insurance plans because that medication is not on the new plan's formulary...not even at Tier 4. (Daliresp comes to mind.)
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    • I agree with you Scott but that scenario is a long time in the future. We already have new patents with miniscule changes from the original, and the manufacturers that are paying generic manufactures to NOT make the generic version thereby making their high priced trade drug the only one available.

      Patients are always told to bring a list of their current meds with them and then it is ignored. At least then you know what their current insurance (private or Medicare, etc.) is covering. If not on the hospital formulary then at least the hospitalist might be able to provide an equal substitute. No new meds should be sprung on a patient without talking with them. Fortunately when it happened to me, the nurse just said 'you can always refuse them...' and I did.

      Patients who are already on maintenance meds may not have a list with them or remember the name. But many of them do recognize the color and shape of the container. I think it would be extremely helpful for each ER and hospital unit that has COPD patients to have a visual color poster/chart of the current inhalers. Australia and Canada national organizations have them and are online to download. We need one too! I know new meds will be forthcoming, but you can at least put together one that is up to date as of 2016 as the other countries have done. Put it online and it can be downloaded/printed for those that need it.

      If the hospitalist would at least find out from the patient what other meds he has been on or tried in the past (and did not work for him) the hospitalist won't order a drug that is useless to the patient, a waste of money for the hospital and the patient. Hospitalist/patient communication has got to be improved!


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  • Thank you Dr. Press a great summary. I so agree that the multidisciplinary team, including the patient as a key member (and their caregivers) is essential to ensure both care coordination and the development of a personalized plan. As you shared communication is always the key to a safe and timely treatment plan, I have found daily multidisciplinary rounds or huddles to be the best tool to achieve great results. It is where everyone gets on the same page.
    In my experience the use of evidence based guidelines and measurement of their adherence is also critical and having the Hospitalists leading that charge can be very effective, we are fortunate to have that.
    I hope we see your blogs on a regular basis- this is excellent.
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  • Just caught this article and wanted to add it to the discussion -- After 20 years, what's next for hospitalists?

    http://www.modernhealthcare.com/article/20160811/NEWS/160819981?utm_campaign=socialflow&utm_source=twitter&utm_medium=social
    Reply

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