"We know from experience that these patients are managed badly right now," said Anne Wilkinson, PhD, of RAND's Center to Improve the Care of the Dying (CICD). "Currently, clinicians are reimbursed for procedures, for treatment, and for hospitalizations, but they are not reimbursed for things that make the most difference for these patients, like care coordination and home care." [it's hard to say that it matters more to have prevention than to have one's life saved!]
A health care team from the Veterans Affairs Medical Center (VAMC) in East Orange, NJ, has begun to zero in on ways to better manage the health care needs of patients with chronic obstructive pulmonary disease (COPD). Through a quality improvement program, East Orange patients with emphysema, bronchitis and asthma now enjoy an enhanced quality of life. The medical center has found ways to provide better care at a lower cost.
Getting Started
In January 1999, researchers at East Orange joined professionals from 33 other healthcare organizations to participate in the second Collaborative to Improve End of Life Care, sponsored by the Institute for Health Care Improvement (IHI), the Department of Veterans Affairs, and the Center to Improve Care of the Dying. Participants applied rapid-cycle quality improvement techniques to create model programs that fill the gaps that exist in the traditional health care system for patients with heart and lung disease. (For more on the IHI model, read excerpts from Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians.) The East Orange team focused the efforts of its Pulmonary Department to create a program to improve care for patients with COPD.
The first step was to identify the program's objectives. "We approached our work by trying to answer the simple question: 'What can we do to help these patients?'" said Dr. Maryann Park, a pulmonary specialist at East Orange and medical director of the program. "We wanted to deliver medical care that was more comprehensive, coordinated and complete."
The team chose four target areas for change: advance care planning, continuity of care, pain and symptom management, and support for families and loved ones. In particular, Park and her colleagues concentrated on improving care for patients with dyspnea, the feeling of shortness of breath..
"Their daily life is essentially impaired by their breathlessness which, in turn, makes them disabled and debilitated," said Dr. Park.
The team identified patients and staff with whom to work; the team itself eventually included a pulmonary therapist, chaplain, pharmacists, respiratory therapists, and nutritionists. Patients were selected if they had a diagnosis of end-stage COPD; two hospitalizations or one intensive care hospitalization in six months; had been prescribed oxygen therapy; and had demonstrated poor lung function. "We enrolled the first ten patients to see what our staffing requirements would be," said Dr. Park. Currently, the program has 200 patients, mostly men over the age of 70, and a staff of eight professionals.
At weekly meetings, the team began to identify problem areas and make changes to the program administration and format, when necessary. Using a "plan-do-study-act" model, the team continues to systematically and rapidly evaluate the program and solves problems.
Focusing on Key Changes
To teach patients how to live well with COPD, Park and her colleagues now offer a 3-tiered approach: optimum medical therapy, physical rehabilitation, and patient empowerment. The first two components target the physical well being of the patient. The pulmonary rehabilitation program, a partnership between Dr. Park's group and staff from the departments of physical therapy and rehabilitation, aims to increase patient stamina for physical activity.
The third component - patient education - is designed to empower patients to be able to make the most of every day. During a 6-week course, patients learn about the various aspects of living with COPD. "Education enables the person to make the right choices regarding their disease and treatment and to make changes," said Odarka Mechnycz, a clinical nurse specialist in medical/surgical nursing who directs the course. "The most important way of keeping a person in optimum health is to teach him about his disease and help him apply this knowledge in daily life."
Patients receive information on the physiology of the disease. They learn to recognize different symptoms, their significance, and how to decide when it is appropriate to seek medical help. Another class highlights the importance of medications and how each drug plays a role in the patient's overall treatment. "We want people to stay home as much as possible," said Mechnycz, "We not only explain what the equipment does, but we also watch them use it and teach them how to apply it in everyday life." Additional courses focus on nutrition, advance care planning, smoking cessation, and relaxation and stress management.
A caregiver component is intrinsically woven into every phase of the program. "Family members and friends are incorporated at every level because this illness affects everyone close to the patient," said Mechnycz. Caregivers benefit from meeting others who are facing similar challenges and situations.
Much of the success of the program lies in its "open door" policy to encourage patients to call the doctor any time during the work day to discuss any symptoms they are experiencing. Because the patients are educated about this disease, "when they call me, they are extremely objective about what they are going through," said Park. "They tell me what the color of the sputum is, if they have a fever, how much inhaler they have taken, and what they have done to deal with the shortness of breath." With this information, Park determines whether the patient should come into the office for an evaluation or can manage the symptoms at home. Park receives about two calls daily.
Demonstrating Success
The success of the East Orange COPD program is reverberating on three levels. On the institutional level, the increase in patients' knowledge of their disease and its process has resulted in a tremendous decrease in the numbers of emergency room visits and hospitalization. "Of the 200 people enrolled in the program, less than one percent require hospitalization," said Park. As a result, hospital costs for treating these patients are down. Another benefit lies in the personnel costs required for the program. "We created a successful program without hiring new people," said Park. "We worked with existing staff who were available throughout the VA."
Patients who have become partners in their own care have experienced marked improvements in exercise tolerance and endurance. "Patients are now able to take leisure walks and do household chores, such as getting the mail and taking out the garbage, with greater ease," Park said. Also telling is that most patients who have died in the program were able to live active lives until the day of death. "Most of the deaths are at home," said Park. "They died in their sleep, quietly and peacefully, without any symptoms."
All of this success ultimately rests on the program itself, which recently received the Olin E. Teague Award for "excellence in rehabilitative medicine." This award is one of the highest honors bestowed by the VA on its staff. Plans are underway for the work to continue as a freestanding program that will be expanded to outpatient clinics throughout the state of New Jersey. Using this model, a similar program for patients with congestive heart failure (CHF), called the Heart Failure Empowerment and Learning Program (HELP), is being implemented through the hospital's Cardiology Department.
For more information, contact:
Maryann Park, MD, FCCP
Chief, Pulmonary and Critical Care Medicine
VA New Jersey Healthcare System
East Orange, VA
973-676-1000 ext. 1220
Laura Schmidt is a freelance healthcare writer and an ABCD volunteer.