Effective Discharge of the Oxygen Dependant COPD Patient

1. Effective Discharge of the Oxygen Dependant COPD Patient Bob Messenger BS, RRT Manager, Respiratory Education Invacare Corporation

2. Disclosures • Relevant Disclosures • Employed by the Invacare Corp. • A version of this lecture has been accepted for publication in Professional Case Management

3. 30-Day Readmissions -Hospital Directed Reform • Provision of PPACA (Section 3025) • Penalty for excessive 30-day Potentially Preventable Readmits • Bottom 25th percentile – Penalized on ALL Medicare receipts •  CMS payments (1% in 2012, 2% in 2013, 3% in 2014) • Risk adjustment • Moving target • Diagnosis specific • Effective Oct. 1, 2012 • CHF, AMI, Pneumonia • Effective Oct. 1, 2015 • COPD, Angioplasty, CABG & vascular diseases

4. 30-Day Readmission Rates

5. Readmission Chains • A sequence of readmissions that are all related to a single initial discharge • Essentially an episode of related hospitalizations • Provides a more precise description of the readmission pattern associated with the care given during & after specific types of initial discharges

6. Example of a Readmission Chain Initial Admission: CABG Surgery Readmission: Post-op Wound Infection Readmission: PTCA • Without Readmission Chains: readmission sequence is a CABG discharge with one readmission followed by an unrelated PTCA admission • With Readmission Chains: a CABG discharge and two related readmissions • Post-op infection and PTCA are related to initial CABG surgery

7. Test Your Understanding… • A readmission for diabetes following an initial admission for diabetes • Potentially Preventable Readmission? • YES

8. Test Your Understanding… • An admission for trauma following a discharge for AMI • Potentially Preventable Readmission? • NO (unrelated acute event)

9. Test Your Understanding… • A readmission for diabetes in a patient whose initial admission was for an acute myocardial infarction • Potentially Preventable Readmission? • YES

10. Test Your Understanding… • A readmission for a broken hip in a patient whose initial admission was for an exacerbation for COPD. (NOTE: patient went home on O2 and tripped on the oxygen tubing) • Potentially Preventable Readmission? • ???? Maybe

11. Defining “Readmissions” • Potentially Preventable Readmission (PPR) • Could have been prevented through: • Improved quality of care in the initial hospitalization • Better discharge planning • Improved post-discharge follow-up • Improved coordination inpatient/outpatient health care teams

12. What’s so special about the COPD Patient?

13. US COPD Data • In 2010 COPD costs the US est. $29.5 billion in direct costs & $20.4 billion in indirect costs1 • 14.8 million Americans diagnosed with COPD2 • 150 million days of lost work annually1 • A person with COPD dies every 4-minutes in the US3 • 3rd leading of cause of death4 • 2nd leading cause of disability1 • NHLBI: Morbidity and Mortality: 2007 Chartbook on Cardiovascular, Lung and Blood Diseases. • CDC Fast Facts: COPD. http://www.cdc.gov/nchs/fastats/copd.htm - accessed 3/17/11. • Extrapolated from CDC data: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5745a4.htm - accessed 3/24/11 • National Vital Statistics Reports Volume 59, Number 2. http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_02.pd//f

14. More US COPD Data • COPD ranks #3 in acute hospital admissions (DRG: 088) • 672,000 COPD discharges in 20061 • Avg. annual hospitalized days 8.182 • Avg. LOS 5.1 days3 • Avg. per day cost $2,9594 • Avg. total cost/admission $15,0934 • Avg. payment/admission $19,6355 • There are an est. 1.5 million home oxygen users • CDC. National Hospital Discharge Survey, 1979-2006. 2006 Unpublished Data. • Schneider KM, O’Donnell BE, Dean D. Prevalence of multiple chronic conditions in the United States’ Medicare population. Health Qual Life Outcomes. 2009;7:82. • http://www.health.ny.gov/nysdoh/hospital/drg/2009_siw.pdf • Dalal AA, Christensen L, Liu F, Riedel AA. Direct costs of chronic obstructive pulmonary disease among managed care patients. Int J COPD 2010;5:341-49. • 2007 Medicare PPS Inpatient Hospital Discharge Data.

15. COPD Re-Admission Data • 22.6% of COPD patients are readmitted within 30-days1 • Key readmission predictors2 • Use of long-term oxygen therapy • Low health status • Lack of routine physical activity • Key components to reducing readmissions3-8 • Comprehensive pre-discharge planning • Patient-centric education • Medications and compliance (including LTOT) • AODL • Recognition and response to exacerbation • Education reinforcement • Transportation, medication and nutritional support • Jencks SF. N Eng J Med 2009;360:1418-28. • Bahadori K. Int J COPD 2007;2(3):241-51. • Farrero E. Chest 2001;119(2):364-9. • Bourbeau J. Arch Intern Med 2003;163:585-91. • Ramani AA. J Care Mgmt 2010;11(4):249-53. • Carlin BW. Respir Care 2010; 55(11):1535. • Laher D. Respir Care 2003; 48(11):1116. • Stegmaier J. Respir Care 2006;51(11):1305.

16. COPD Hospitalization Rates Holt JB, et al. Geographic disparities in COPD hospitalization among Medicare beneficiaries in the United States. CDC. Intern J of COPD 2011;6:321-328.

17. Roots of COPD

18. NOTT (Nocturnal Oxygen Therapy Trial)Ann Intern Med 1980;93(3):391-398 • 203 pts. randomized to continuous or nocturnal O2 for 5-years • Enrollment criteria • Continuous Group averaged 17.7  4.8 h/d • Nocturnal Group averaged 12.0  2.5 h/d • After 3½ years the mortality for nocturnal O2 group was 1.94 times that for the continuous O2 group • Continuous O2 therapy reduces mortality • Basis for current LTOT standards

19. NOTT Study (Revisited)Petty TL, Bliss PL. Respir Care 2000;45(2):204-211

20. NOTT Study (Revisited)Petty TL, Bliss PL. Respir Care 2000;45(2):204-211 High Walk COT High Walk NOT Low Walk COT Low Walk NOT

21. NOTT Study (Revisited)Petty TL, Bliss PL. Respir Care 2000;45(2):204-211 Average Per Patient Annual Duration of Hospitalization

22. Since long-term oxygen is so good for COPD patients, they must all be very compliant… Right?

23. Compliance with O2 Prescription • Pepin1 et al. • 930 LTOT patients on O2 for at least 36-mos. • Mean daily duration of O2 prescribed 16±3 hrs. • Only 45% of pts used O2 for 15 hrs or > per day. • Peckham2 et al. • RCT: 86 pts (45 treatment & 41 control) • Treatment group received additional clinician training • Daily O2 use for 15 hrs or more after 6-months: • Treatment group 82% • Control group 44% Long-term oxygen therapy at home: compliance with medical prescription and effective use of therapy. Chest 1996;109:1144-50. Improvement in patient compliance with long-term oxygen therapy following formal assessment and training. Respir Med 1998;92(10):1203-6.

24. Device Related Saturation Shortfalls Uncovered During Rehab Visits Gaps Between Titration Settings at Discharge vs. Titration on Home Device • Premier pulmonary rehab reviewed 65 patients post discharge: • Treadmill test to evaluate ability of home device to meet 90% saturation goal. • 60% did not meet target: 20% needed setting adjusted upward; 40% could not be titrated at any setting (replaced device). Why are patients sent home on sub-standard device? Source: Changes in Supplemental Oxygen Prescription in Pulmonary Rehabilitation, Limberg et al, Resp Care Nov 06; Vol 51 (11), pg 1302.

25. Now let’s get to know our COPD Patients

26. Characteristics of COPD Patients • 80-90% of COPD results from cigarette smoking1 • Prevalence of those who smoke • Education2 • < High school education 32% • High school education 29.3% • College graduates 13.3% • Income2 • Below poverty level 36.5% • At or near poverty level 32.8% • Above poverty level 22.5% • Average age when started on LTOT: 74±8 years3 American Lung Association: http://www.lungusa.org/stop-smoking/about-smoking/facts-figures/general-smoking-facts.html(accessed 2/4/2011). CDC – Morbidity & Mortality Weekly Report. January 14, 2011 / 60(01);109-113. Ekstrom MP, Wagner P, Strom KE. Trends in cause-specific mortality in oxygen-dependent COPD. AJRCCM articles in press. Published 1/7/2011. doi:10.1164/rccm.201010-1704OC.

27. Patients started on oxygen in 2012 • Were born in 1930 – 1946 • Turned 18 yrs old in 1948 – 1964 • 1948: 35% graduated HS, 7% college (4-years) • 1964: 49% graduated HS, 12% college (4-years)

28. Barriers to Teaching Older Adults • Vision Changes • Pupil admits 50% less light for a person of 50 than for someone that is 20. • Hearing Changes • Primarily caused by atrophy of inner ear structures. • Higher frequencies go first. • Effect very prominent in cigarette smokers.

29. Neuropsychologic Impairment and Severity of COPD • 4 groups matched for age & education • Control (n=99) • Mild COPD (n=86) • Moderate COPD (n=155) • Severe COPD (n=99) • Memory and neuro-performance tests compared to control Grant I, et al. Arch Gen Psychiatry 1987;44(11):999-1006

30. Additional Confounding Factors • 17% of Alzheimer’s patients have COPD1. • One in eight people aged 65 and older (13%) has Alzheimer’s disease. • Nearly half of people aged 85 and older (43%) have Alzheimer’s disease. • Smoking almost doubles the risk of Alzheimer’s disease2. • The prevalence of depression in COPD is 26%3. • Racial, ethnic & cultural influences. • Alzheimer’s Association website. Alzheimer’s disease and chronic health conditions: the real challenge for 21st century medicine. www.alz.org/national /documents/report_chroniccare.pdf. Accessed 2/4/2011. • Janine K. Cataldo, Judith J. Prochaska, Stanton A. Glantz. Cigarette Smoking is a Risk Factor for Alzheimer's Disease: An Analysis Controlling for Tobacco Industry Affiliation. Journal of Alzheimer's Disease, 2010;10:2010-40. • Hanania NA, Müllerova H, Locantore NW, et al. Determinants of depression in the ECLIPSE chronic obstructive pulmonary disease cohort. Am J Respir Crit Care Med 2011;183(3):604-611.

31. Can we overcome these training obstacles and improve outcomes? • Absolutely • No freaking way!

32. LTOT Outcome Studies • Ringbaek TJ, Viskum K, Lange P. “Does long-term oxygen therapy reduce hospitalization in hypoxemic chronic obstructive pulmonary disease? Eur Respir J. 2002 • Cohort study; n=246 10-mos. Pre vs. 10-mos. Post LTOT • LTOT period compared with the pre-oxygen period • Hospital admission rate  23.8% • hospital days  43.5% • "ever hospitalized"  31.2% • Author’s conclusion: “This study shows that in hypoxemic chronic obstructive pulmonary disease patients, long-term oxygen therapy is associated with a reduction in hospitalization.”

33. Can Homecare Providers Influence the 30-Day Readmission Rates for COPD? • Retrospective analysis • Regional (Western PA) 30-day COPD readmit rate  25% • 180 pts enrolled in program (10 months) • Referrals from 23 area hospitals • Program components • Pre-discharge assessment • Home RT visits (days 2, 7 and 30) • 12 Care Coordinator phone calls • 30-day readmission rate reduced to 3% BW Carlin, Wiles K, Easley D. Respir Care 2010;55(11):1535 (abstract)

34. Prevalence of HME Provider Programs • Role of the Management Pathway in the Care of Advanced COPD Patient in Their Own Homes. Ramani AA, et al. Care Manag J. 2010;11(4):249-53. • Effect of a Homecare Respiratory Therapist Education Program on 30 Day Hospital Readmissions of COPD Patients. Kaufman LM, Smith AP. Respir Care 2011;56(10):1691 (abstract) • Healthspring Medicare Advantage Plan Comprehensive Case management Respiratory Program. Prince D, Davidson M, Watson F. Respir Care 2011;56(10):1690 (abstract) • 2011 AARC Congress • 5 symposia & 6 abstracts • HME News poll of 120 HME Providers (2011;17(7) (July)) • 97 (81%) Have no program in place to address COPD readmissions! • HME Providers – Opportunity • Acute Care Providers – Need to vet your providers

35. Vetting a Respiratory HME Provider • What is the location of the nearest office? • Is the phone answered locally? • Can I visit the office? • Do they routinely provide OGPE? If yes, • On which patients? • Is it only for travel? • Does it have to be specifically prescribed? • Do they have RTs on staff? If yes, • How many work out of local office? • Do they provide clinical services or marketing? • What is the process for patient education?

36. Questions bmessenger@invacare.com