Chronic Obstructive Pulmonary Disease (COPD) is the second-most common reason for hospitalization in Ontario, after childbirth.1 Facilitating effective transitions for patients with COPD into the community is a key step in preventing hospital readmission rates among this population.
Perth and Smith Falls District Hospital has recently shown significant improvements in reducing hospital readmission rates for patients with COPD from 24.53 in 2016/17 to 16.89 in 2017/18 as indicated in their yearly Quality Improvement Plan (QIP).
Health Quality Ontario had a chance to catch up with Michele Bellows, Vice President of Patient Care and Chief Nursing Executive at Perth and Smith Falls District Hospital to learn about how they achieved this success.
Can you describe what led to your recent improvements in reducing COPD hospital readmission rates?
We have a number of strategies in place that have led to our recent improvements.
Participation in Health Care Tomorrow COPD Working Groups
The biggest impact has been our hospital’s active participation in Health Care Tomorrow. This is a South East LHIN broad initiative focused on implementing best practices to improve integrated care across the health care system. Some examples of this work include improving the journey for patients with conditions like COPD and hip fractures. The work is driven by working groups consisting of clinical experts and patient and family representatives.
Although the Health Care Tomorrow project is wrapping up, the South East sub-LHIN regions have all identified COPD as an issue we continue to work on across the health care continuum.
Our ER Manager, Respiratory Therapist and internal medicine physician sit on a working group for COPD. We review the working group’s recommendations with the aim of being early adopters of these recommendations on a regional level.
For example, one of the changes we’re planning on is ensuring that every in-patient who has COPD (or a history of COPD) is seen by a respiratory therapist (RT) during their hospital stay. This referral will be automatically flagged for RTs in our MediTech electronic health record system. In the future, we envision that our RTs will also be able to refer patients to a well-established community-based pulmonary rehab program available in our neighbouring Champlain LHIN upon hospital discharge.
In addition, our hospital physicians are also primary care providers in the community. We are anticipating that providing targeted in-patient care and coordinating this care with our physicians into a community setting will continue to reduce COPD hospital readmission rates. Part of the discussion will also be whether our COPD in-patients require the Health Links approach to care and these supports will be put in place should they be needed.
Finally, our hospital is represented on the LHIN COPD Steering Committee, which has enabled us to leverage the best components of the INSPIRE lung health program and adapt it at a community level.
Transfer of Accountability (TOA)
Transfer of Accountability (TOA) in our hospital is designed to enhance communication between nursing staff, the patient and the family during shift changes to improve patient safety. It is also used to inform primary care providers about the status of their patients when they visit them in-hospital. This occurs at shift change at the patient bedside.
The incoming and outgoing staff involve the patient and family to discuss the keys concerns or achievements.
For example, if patients can’t afford their COPD-related medication upon hospital discharge, they can let the nurse know they would like to speak further about the medications they are going to be discharged with.These concerns will then be part of interdisciplinary rounds which include the HCP. This is a preventative measure where issues are caught before they end up causing a potential emergency department (ED) visit.
TOAs now occur in both our EDs, ICUs and in all inpatient medical/surgical units. This initiative has been extremely successful with positive feedback from both patients and nursing staff.
During discharge planning, we also use a tool called a Patient Oriented Discharge Summary (PODS). It is a hard copy tool with clear instructions to help patients know how to manage at home once discharged.
Home First Refresh
Our hospital completed a Home First refresh which included education to staff and physicians to remind all care providers that home should be considered a first option for all patients who have completed their acute care stay.
In addition, we collaborate with community-based and hospital-based care coordinators during our bi-weekly Home First meetings. This allows us to keep a connection with home and community care partners and encourages supports to be in place at home for complex patients with COPD, which will help decrease the risk of hospital readmission.
Patient- and family-centred care bedside whiteboards
Whiteboards are used throughout the organization to assist patients and their families with goals of care and discharge goals.
Health Quality Ontario has developed a Quality Standard called COPD: Care in the Community for Adults. There are two Quality Statements related to hospital care.
Has your hospital implemented these statements into practice?
QUALITY STATEMENT #11: Follow-Up After Hospitalization for an Acute Exacerbation of COPD:
- People with COPD who have been hospitalized for an acute exacerbation have an in-person follow-up assessment within 7 days after discharge.
As discussed, physicians in our hospital are often the primary care physicians for the patient, thereby allowing continuity of care. Community providers are also able to leverage technology, such as the ConnectingOntario ClinicalViewer portal and South East Health Integrated Information Portal (SHIIP), to see information about patients’ journeys through the health care system.
Post discharge follow-up phone calls are completed within 48 hours of discharge for our patients to help identify any potential issues and to ensure resources that were part of our discharge have been received. In addition our hospital will be implementing a 7-day post discharge call to those patients that have been readmitted within the previous 30 days.
QUALITY STATEMENT #12: Pulmonary Rehabilitation After Hospitalization for an Acute Exacerbation of COPD:
- People who have been admitted to hospital for an acute exacerbation of COPD are considered for pulmonary rehabilitation at the time of discharge. Those who are referred to a pulmonary rehabilitation program start the program within 1 month of hospital discharge.
Our hospital is working collaboratively with Champlain LHIN partners on establishing a robust COPD program, which will allow hospital RTs to directly refer clients to the Champlain LHIN community-based pulmonary rehab program. We continue to explore new and innovative opportunities to facilitate further improvements for post-discharge follow-up care.
What’s your advice for other organizations hoping to reduce COPD hospital readmissions?
All our initiatives have been about making processes more efficient and effective, and working smarter in-house, locally and regionally with all of our community partners. Our COPD initiative is truly both an in-house as well as a ‘hospital without walls’ initiative.
One important thing to note is that our work has not required the investment of additional resources or funds to make these improvements.
Our advice to other organizations would be to establish an automatic referral process for patients with COPD (or a history of COPD) to see a RT in your hospital. This drives best practices for respiratory care. Leverage partnerships and collaborations with home and community care and involve Health Links when needed to ensure optimal patient care continues into the community.
Leverage technology so that community providers are able to see information about patients’ journeys through the health care system. We use the ConnectingOntario ClinicalViewer portal and South East Health Integrated Information Portal (SHIIP), which have helped improve continuity of care.
Ensure there is a physician champion in your hospital to drive your work forward. Having a physician champion involved in our Health Care Tomorrow work was key. This leadership has kept momentum up in our organization.
Do you work on reducing hospital readmission rates? Leave a comment or question below.
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How do you use a regional approach to care to reduce COPD readmission rates?
1. Hospital Morbidity Database and Ontario Mental Health Reporting System, Canadian Institute for Health Information, 2014– 2016.