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Looking at COPD Hospitalization/Re-admission from Outside the Hospital Walls: My Experience

By Thomas Mayer posted 05-30-2015 20:54

  
Fifteen years ago, I started a lung health clinic within the context of a primary care physicians group in rural Missouri. The plan? Enhance the practice reputation for quality care by utilizing a respiratory therapist to perform simple pulmonary diagnostics in conjunction with office visits. The objective? Employ pulmonary rehabilitation concepts in the doctors’ office by using simple diagnostics during visits to enable early disease diagnosis, improve disease management through objective verification of intervention efficacy, and improve differential diagnoses. Accidental outcome? Our hospitalized patients became healthier as a whole because the ratio of hospitalization by necessity to hospitalization by emergency improved.

We had a unique program design for our situation, and it worked well for over nine years. Given the heightened vigilance toward disease management that has risen from in-patient reimbursement concerns, disease managers outside the hospital walls might play important roles on the disease management teams that are springing up in hospitals everywhere. Perhaps my story of nearly decade long success can stimulate a few new ideas.

The Fallow Soil of No-Show

The group of physicians for whom I worked served patients in an almost completely rural, nine county area. Farmers made up much of the demographic, and there was not a practicing pulmonologist in the whole region. As the “PFT guy” in the local hospital, I saw the chronic lung disease patients pass through my lab once a year for a complete PFT…if I was lucky. (There was a nearly 30% no-show rate in the lab.) As the “pulmonary rehab guy,” I met a few of the COPD patients on a more personal basis, which gave me a chance to see the benefit of pulmonary function re-evaluation following a good disease management process filled with medication modification and exercise.

My PFT lab had a no-show problem, and I know that many of those same patients skipped out on their visits with specialists in cities far away. The PFT lab was not the only service suffering. There were not enough participants in the pulmonary rehabilitation program either. It turned out that these two problems, mixed with some old-fashioned stubbornness, equaled an ironic recipe for success.

Fertilizer for a Stubborn Crop

In rural America, farmers are prime candidates for developing COPD. They work from sun up to sun down, often with cigarettes for companionship—especially during planting and harvest seasons. Self-reliant farmers can cultivate a good crop of stubborn during life. Our general internists treated COPD sufferers all across the area, and farmers were the number one patient demographic. (Truckers were the second.) Generally, the farmers would not agree to travel 90 to 120 miles to see a specialist, and they often refused to travel 25 miles back to the PFT lab for testing just two days after seeing the doctor.

The market seemed ripe for simple testing at the point of contact. For me, it seemed obvious that, if I were going to sell my idea to the doctors, I had to know the circumstances that supported the idea. The demographics of the region and the evidence base for simple pulmonary testing spoke for themselves. After some careful preparation and an impassioned presentation, the physicians opened the lung health clinic under a one-year probationary period that turned into more than nine years of lung and sleep disease management in the adult primary care setting.

A Few Lessons

We learned a lot over those nine years. Even in this very good practice, situations that called for simple spirometry as a preliminary diagnostic tool usually prompted orders for complete pulmonary function testing. As we began to test our established patients, and when new patients came into the practice, COPD diagnoses often turned out to be life-long, untreated asthma. Diagnosed asthmatics frequently proved to have COPD. Asthma-type medication regimens ruled the day for the majority of COPD sufferers, not just the ones who had severe disease, and shortness of breath usually resulted in more medicine versus an evaluation of O2 status. With once-a-year testing as the norm, symptoms frequently over ruled objective measures the rest of the year. Simple spirometry, nocturnal oximetry, and simple pulmonary stress testing in the office played an important role in turning these types of problems around within just a few years.

A Surprise Finding

In the days before hospitalists came to our small regional hospital, the physicians in the practice rotated on-call for their patients who entered the hospital emergently. That one undesirable task, more than any other, became the impetus for dropping the yearly re-evaluation of my contract. For the first three years, I worked hard to keep a statistical finger on the pulse of chronic pulmonary diseases via simple pulmonary diagnostics—primarily spirometry testing. Our disease management techniques within the practice greatly reduced unnecessary ER entry into the hospital, which meant fewer late night calls and runs to the hospital for our doctors. It did not reduce hospital admissions. What it did was ensure that patients who needed hospitalization got there in time, usually through a physician office visit as opposed to three days later through the ER. After just two years, the crazy idea of hiring a respiratory therapist in a large primary care practice became the norm for this practice and remained so until the fated economic crash of 2008.  

Does Any of this Translate?

Would this exact model work today? Probably not. I was lucky. It was the right time. It was the right group of risk-taking, mostly non-specialist physicians. (We did have a cardiologist in the practice.) Our patient base was ready for something different, and they paid the physicians back with incredible loyalty as the practice grew. Today, however, as the plow blade of reimbursement-cuts for re-admission tears through the fallow ground of old hospital practices, things are changing.

Hospitals are now employing disease management teams that target the most vulnerable patients by disease groupings, COPD being a prime example. These teams introduce chronic disease management tools and techniques prior to dismissal and build a bridge for care beyond the hospital stay—all with a view toward reducing re-hospitalization within 30 days of dismissal. It is a good first step into disease management for organizations that specialize in acute and crisis healthcare intervention. These programs are getting the attention, time, and money for which starving pulmonary rehab programs have begged over the past two decades.

Comparisons, Contrasts, and Summary Questions

When I started my lung health clinic and sleep lab in an adult primary care practice, physician practices were tiny worlds of their own. The underlying tensions between large practices like ours and hospitals rose from competition in the area of common simple testing services, and my lung health clinic definitely posed a perceived threat to the hospital. These days, however, hospital organizations employ hospitalists, own their own physician groups, and tout all players as partners in care. Reimbursement sources slap these partnerships on the hand when they fail, e.g. hospital re-admissions within 30 days. Have reimbursement cuts, and threatened future cuts, changed the way these “partners” handle their patients when they go from one care station to the next?

Today, on a much broader scale than what we faced fifteen years ago in rural Missouri, the time has come for change. Perhaps the seed for innovative changes will come as we search for the answers to a few simple questions. Will hospital outpatient and diagnostic services—such as PFT labs and pulmonary rehab programs—continue to operate on a business as usual platform, or will they move beyond the hospital campus confines? Will the job options in those important services proliferate, drawing new ancillary clinicians into the fold of chronic disease diagnosis and care? Will pulmonary rehab clinicians who care so much about managing the health of their clients be included as players in dismissal management? We must plant before we harvest, and perhaps disease management at the physician practice level plays at least a part in avoiding re-hospitalizations down the row…I mean…road.

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08-06-2015 11:56

I also started up a Cardiac and Pulm rehab in a small rural clinic. Did PFT's event and holtor monitors. Did a lot of patient education and help pt get meds they needed. It seemed to me that pt's listened and was more into what to do as an out pt vs when getting DM and all they want is out the door. That clinic is no longer open. I really miss it, I felt I did a lot for the patients and the Dr by making sure they were taking meds and using equipment properly. I also worked closely with the DME companys.

05-31-2015 14:16

In an effort to give credit where credit is due, I must mention two people. Dr. Thomas Petty, a major player in arterial blood gas sampling, oxygen therapy concepts, pulmonary rehabilitation, and the use of simple spirometry, was a key player in my decision to get into simple testing at the physician practice level. In January of 1998 I was in his office with my then boss, Greg Spratt BS RRT CPFT, as an editor for some educational texts that Greg was writing. We were using Dr. Petty's work in many of our pamphlets and newsletters. I didn't speak much--just took notes. However, before we left Dr. Petty looked at me and asked about my professional endeavors. We got onto the topic of how difficult it was to run a PFT lab in a rural setting. He then asked me what I wished I could do about it, and I said that I'd like to do simple spirometry in physician offices. His response: "Then why don't you do it?" A year and a half later I gave my first pitch to the doctors of the practice I speak of in the article. I probably would not have done it except for that piercing encouragement from Dr. Petty. Further, Greg Spratt encouraged my every wild dream, even when he knew it would take me from the company for which we worked. Dreams and encouragement. I have lived on both.