The PRAXIS Nexus The PRAXIS Nexus

Cone Health: Improving Outcomes for their Gold COPD Patients

Posted on August 18, 2016   |   

the revolving door of hospital readmissions

Cone Health, an integrated, not-for-profit health system headquartered in Greensboro, N.C, has more than 100 regional locations and employs 11,000 staff. The week before this post was first published, four of their five hospitals earned five-star ratings in CMS’s new Star Ratings listing, and their quality accolades do not stop there. An ever-evolving ACO network with a commitment to quality improvement, Cone Health has implemented a variety of care delivery initiatives intended to improve health outcomes and reduce readmissions. In 2012, they realized there was a patient group that could benefit substantially from these focused efforts: COPD patients with multiple readmissions.

In that year, the Cone Health team, under the leadership of Chronic Disease Project Manager Elvin Perkins, III set out to improve the lives of these patients. The group analyzed their existing electronic health records data: who were the COPD patients who might benefit the most? These analyses revealed that 65 of Cone Health’s COPD inpatients had experienced three or more hospital admissions in the last six months. They also identified these patients presented with a variety of serious comorbidities: CHF, diabetes and renal failure were just a few. They knew action needed to be taken – and these 65 patients were a great place to start. In response, the Cone Health team developed the Gold Card Program.

Components of the Gold Card Program

A systematic quality improvement approach – Before beginning to implement any changes to their approach, Cone Health took a long look at their data. What days and time of day were most of these patients coming to the ED? What was their average length of stay? What percentage had received the recommended, routine vaccinations? What was the cost of this care to the patient and the health system? What were the critical care points at which their processes could be improved (e.g., triage, handoffs, scheduling, follow up)? A steering committee and three clinical teams developed objectives, processes and metrics before moving forward.

Multidisciplinary teams – Cone Health recognized that it takes a village to reach successful outcomes. All staff touching these patients during their time in the health system were considered part of the team. This included nurses, social workers, case managers, pharmacists and exercise, respiratory and occupational therapists. Physicians included pulmonologists, hospitalists, primary care and emergency department MDs – the ED was a particularly important partner in this work given the frequency with which they encountered Gold Card patients and their potential impact at a critical point in the care continuum. Teams were process focused, empowered to make change, and accountable for their goals. The buy-in and participation of all providers, the steering committee and the health system’s administration was central to success.

Order sets – The team hard wired evidence-based order sets -- based upon the GOLD guidelines for prevention, diagnosis and treatment – into Cone Health’s EMR. They engaged in a campaign to ensure pneumococcal and influenza vaccines were recommended and administered according to guidelines. Pulmonary rehabilitation, an important component not only for exercise training but for patient education, was encouraged and prescribed as appropriate.

multidisciplinary care team

Staff education – Cone Health then embarked on a self-described “system-wide educational blitz.” The team worked to ensure all system staff were aware of the program and how to address these patients’ unique needs. For example, the program’s project managers attended hospitalists’ monthly meetings to educate them on the program and answer individual questions. They extended their efforts into the community, as well, providing primary care physicians with information about the program, reminders about the importance of spirometry as the gold standard diagnostic tool and encouragement to refer at-risk patients for a Cone Health critical care consult to prevent hospitalization.

Patient education – Cone Health also conducted focus groups with patients as part of this quality improvement initiative. One of the things they learned was that patients were reluctant to go to their doctors for fear of being readmitted to the hospital. The team crafted their educational approach to help patients understand that identifying and addressing the signs of an exacerbation early were keys to preventing the hospitalizations and rehospitalizations they feared. Patient education also included basics about COPD and repeated instruction on medication and device use, often administered by RTs. They also used COPD action plans to improve communication and to equip patients to more readily identify and respond to signs of an exacerbation.

Patient empowerment – It was important to the Cone Health team that patients be actively involved in and empowered by their care. For this reason, the group abandoned terms like “frequent flier” in exchange for “Gold Card members.” They provided each patient with his or her own credit card-sized gold card, which included program information and a unique ID for their reference.

Community partnerships – Cone Health recognized that the support of their community physicians, pharmacies and other partners was essential to the successful outcomes they sought. To that end, Perkins and his colleagues engaged with a variety of community partners. For example, local pharmacies with delivery services waived the delivery fee for Gold Card patients. This was a win for those with COPD, who gained access to their much-needed medications; this was also a win for the participating pharmacies, as they then had a dedicated referral and repeat client base boosting their business. Pharmacies in turn provided Cone Health with data helpful in determining medication compliance outcomes.

Psychosocial determinants of health – Team social workers partnered with patients and families to address often-overlooked psychosocial determinants of health. Did the patient have a way to get her medications? Did she have access to proper nutrition at home? What is the relationship like with her DME provider? Her PCP? Given the high prevalence of mental health comorbidities in this population, Cone Health also conducted essential inpatient screening for depression and anxiety.

Timely follow up – Case managers were instrumental in ensuring that before discharge, patients had follow-up visits scheduled with their primary care physicians. These were scheduled within seven days of a patient’s discharge date (within 48 hours, if possible). Case managers also conducted ongoing telephonic or home-visit follow up with all patients to gauge their symptom management and any remaining educational or resource needs.

Two-year results of the program demonstrated a sizable impact. In 2013, Cone Health’s average COPD Gold Card patient readmissions rate was 87 percent; by 2015, this had dropped to 36 percent (a total reduction of 70 percent). Importantly, the approach did not require significant additionagardenerl funding to implement. The organization assigned two existing staff project directors to lead the program’s development and implementation; educational initiatives were incorporated into the existing staff professional development structure. Resource investment beyond person power was minimal – and the cost savings to the health system considerable. The team estimated that they avoided $14 million in healthcare costs as a result of the program’s implementation.

But the real achievement? “It’s what we’ve done for the patients,” Perkins says. Getting them back home to living their lives and returning to the activities that made them happiest, like mowing their lawn or being outside to enjoy the day.

Sounds like a winning program for all.

This page was reviewed on March 3, 2020 by the COPD Foundation Content Review and Evaluation Committee


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  • Thank you, Kristen, for sharing this article. Sounds like an excellent program and definitely a win for all!