Background: COPD is the third leading cause of death and hospital readmissions. Inpatient care for patients with COPD exacerbations varies widely across the US which can lead to patients failing to receive recommended evaluation, treatment, education, and follow-up to reduce the likelihood of recurrent exacerbations and unnecessary acute care utilization. In an effort to innovate and address this care variation, the Centers for Medicare and Medicaid (CMS) offered a voluntary Bundled Payment Care Initiative to hospitals that aims to reward high value care and reduce unnecessary and preventable readmissions. We extended our existing COPD readmissions reduction program initially focused on 30-day readmissions to extend through 90-days post readmissions. Our inter-professional team aimed to provide evidence-based, high quality care, to patients hospitalized with acute exacerbations of COPD to reduce care variation, improve the transition of care process, and reduce acute care utilization. Specifically, we provided COPD-specific expert care in the hospital and the clinic across 90 days, including Advanced Nurse Practionner evaluations, pharmacy based education and medication management, and nursing phone calls.
Purpose: From October 2015 through September 2018 we sought to reduce 90-day all-cause readmissions in an effort to maintain average 90-day patient episode costs below target. Due to fluctuations in staffing, we also sought to determine whether the program running fully (APN and pharmacy coverage inpatient and outpatient), partially (APN and pharmacy coverage inpatient only), or not at all (no APN or pharmacy coverage) impacted readmission rates and/or our reconciliation price-target price. The primary outcome was reconciliation price-target price. Our process measures included: BPCI patients identified and seen by program while hospitalized, outpatient visits scheduled and completed, and acute care utilization (ED and hospital readmissions).
Description: Our program targeted all patients admitted with COPD exacerbations. They received APN and pharmacy COPD specific care and education while hospitalized, prior to discharge. After discharge the patients were called by our patient experience nurse within 48 hours after discharge and then were seen by our APN and PharmD providers at 1 week, 30 days, and 60 days after discharge. Our team consists of 1-2 Advanced Practice Nurses, a PharmD and team of pharmacy students, a patient experience RN, as well as hospital leadership.
Conclusions: We found that readmission rates went down at 30, 60, and 90 days , though our sample size was underpowered to show statistically significant differences compared to our pre-program comparison year (2013-2104). Overall, our median costs were below target every quarter except one. However, we found significant fluctuations in costs/savings that were correlated with staffing levels. When the program was fully staffed, the program met or exceeded the target in all but one quarter, and the one quarter where there was a loss, it was minimal. However, when there was no APN coverage (and therefore, no pharmacy coverage), the losses increased 10 times the worst quarter with full coverage. Therefore, the program not only appears to improve readmission rates but also reflects positive value in terms of savings when it is running fully compared to when it was not running fully or at all.