Hospital visits for acute episodes of COPD fall after Joseph Brant Hospital educates patients, healthcare providers and the community

The Challenge

Across Canada, an estimated 800,000 Canadians live with chronic obstructive pulmonary disease (COPD), a progressive disease characterized by debilitating breathlessness. This population is among the highest users of hospital care. Of all chronic diseases, COPD is the number one reason for hospitalizations, accounting for the largest number of return visits to emergency departments (EDs) and the highest volume of hospital readmissions. Often, patients end up seeking care in the ED to manage their chronic illnesses because more appropriate care isn’t available in the community. The situation is expected to worsen as one-infour Canadians is set to develop the disease in their lifetime.

In 2014, the Canadian Foundation for Healthcare Improvement partnered with Boehringer Ingelheim (Canada) Ltd. on INSPIRED Approaches to COPD, a pan-Canadian quality improvement collaborative that provided funding, training, coaching and resources for a network of 19 interprofessional teams from healthcare organization across Canada. Through this collaborative, the teams adapted, adopted and evaluated the INSPIRED COPD Outreach Program™, a coordinated, proactive approach to improving care for people with COPD and supporting their caregivers.

The INSPIRED COPD Outreach Program™ was developed by respirologist Dr. Graeme Rocker and his team at Capital Health (now Nova Scotia Health Authority) in Halifax. CFHI set out to spread this comprehensive approach to COPD care across Canada.

Burlington’s Joseph Brant Hospital is located in a region with a significant population of senior citizens, where serious episodes of COPD (“acute exacerbation”) are the third most common reason for admission to the hospital. In 2013-14, 27 percent of COPD patients were re-admitted to Joseph Brant Hospital within 30 days after they were discharged.

The team at Joseph Brant Hospital was one of the 19 teams that joined the collaborative. Leadership at the hospital recognized that better post-discharge planning could improve the transition to home, support optimal health management and reduce the frequency of emergency department visits and hospital readmissions.

The team consisted of: Lily Spanjevic, Clinical Nurse Specialist; Melanie Potvin, Project Lead; Kathy Theroux, RN-COPD Educator; Jennifer Kemp, Respiratory Therapist-VitalAire; Dr. Patrick Killorn-Respirologist, and Dale Massender, Psychosocial/Spiritual Care/Bereavement Clinician, HNHB CCAC.

When the hospital partnered with CFHI to implement the INSPIRED approach, for the enrolled participants it aimed to reduce: readmission rates and length of stay in hospital by five percent; and emergency department visits by 10 percent.

These goals would be achieved primarily by increasing patient and provider knowledge about COPD, thus improving care, patient experience, navigation of the healthcare system and patient self-management.

The Solution

Teams participating in the INSPIRED collaborative identified patients who visited the ED or were hospitalized with advanced COPD, and then invited them into a supportive program that provided them with: a written action plan for managing their disease; a phone call after they were discharged home; at-home self-management education and psychosocial support; and advance care planning when needed. Patients in the program were also given a telephone number to call for support.

The hospital spent the first six months of the 18-month initiative, which began September 2014, assembling a team to lead the project and engaging stakeholders. Supported by CFHI’s quality improvement collaborative, hospital staff were familiarized with the INSPIRED program, which incorporates Living Well with COPD education. The hospital also hired a COPD educator to engage patients, hospital staff, physicians, and community partners on the INSPIRED approach to COPD management.

The COPD educator reached out to the community and held one-on-one sessions to explain the INSPIRED program to 85 local primary care doctors. Because a significant portion of people with COPD in the hospital’s catchment area live in retirement homes, the educator also held sessions for retirement home staff, educating them about COPD – for example showing them how to help a resident use a puffer properly – and alerting them to when medical help would be required.

The first patient was enrolled in early March 2015 and 41 people were enrolled by September 2015. “They had to have a diagnosis of moderate to severe COPD and be willing to have someone come to them for a home visit,” explained clinical lead Lily Spanjevic. “A person with this stage of COPD could be quite debilitated without proper supports and knowledge,” she said. For example, these patients often experience breathlessness and fatigue after walking 100 yards on level ground is and this leads to reduced activity, engagement in community and quality of life.

Although not everyone in the cohort was ready to actively manage their own condition, the team thought eventually they would “accept an action plan, which would reduce theirs and their family’s anxiety. The main goal was to help them at their comfort level.” An action plan helps patients understand their symptoms, be aware of changes in their condition, and then take appropriate action (e.g. taking antibiotics or calling 911).

The average age of participants was 76, slightly more women than men were enrolled, and approximately 30 percent identified themselves as active smokers.

Participants had to have their diagnosis of COPD confirmed. This was achieved with a combination of test indicators – a spirometry or a lung function test was administered (as appropriate) for those who hadn’t had one. Also, patients had to have either been admitted to hospital more than once in past year, or been admitted to the Intensive Care Unit (ICU), or frequently visited of ED for an acute exacerbation of their COPD.

Participants received education in hospital and at home, delivered by the COPD educator. Respiratory therapists and other team members also made home visits and participants had their medications reviewed. Those most at risk (e.g. living alone and housebound) received repeat visits and also had phone access to team support during working hours. A smoking cessation program was offered to participants.

The Results

By early Oct. 2015 (only three months into the program), 80 percent of patients reported having a positive experience and better managed care. With the action plan they learned when they could self-manage and hence avoid unnecessary hospital visits. With the help of a respiratory therapist, some participants were able to be weaned off supplementary oxygen and become more mobile.

Tom had been a smoker for 43 years and frequented the emergency department before he enrolled in the INSPIRED program. He created an action plan, quit smoking (thanks to a referral to a government-sponsored smoking cessation program) and attended the hospital’s Breathe Easy Wellness group program. He now co-facilitates the group and has not returned to the emergency ward.

“Before INSPIRED I lost hope about ever managing my COPD symptoms, but the INSPIRED team has helped me get back into the ‘driver’s seat’ again…my family can’t get over the change in me.”

There were no unplanned hospital readmissions among participants and for those who were admitted, their length of stay was shorter – 5.7 days, compared to the average of 7.5 days before the program began. The program continues to demonstrate very positive results for patients and the healthcare system.

Sustainability and Spread

As a result of the COPD educator’s work with local primary care doctors, more of them are more involved in active management of COPD patients, including discussing and completing action plans.

About 82 percent of people who come to the hospital with moderate to severe COPD enrolled in the INSPIRED program. By July 2016, 76 people had been enrolled. Of the 76, 12 died with their end of life wishes supported, most of them at home or in the community. Because the 12 had filled out advance care directives, families indicated that they experienced “less anxiety and felt confident that their loved one’s wishes were fulfilled,” Spanjevic said.

As a result of the CFHI supported initiative, hospital staff obtain diagnoses sooner and are able to begin appropriate education and care earlier. That’s because of changes to the hospital’s charting system and improved access to spirometry (a lung function test). After an acute episode of breathlessness is resolved, patients, who haven’t already had one, are given the test to confirm a COPD diagnosis.

The COPD program at Joseph Brant Hospital has since been enhanced thanks to a Local Health Integrated Network (LHIN) wide project, “Integrated Comprehensive Care for COPD and Congestive Heart Failure.” This program complements INSPIRED by offering supports for patients who don’t meet the INSPIRED program criteria (e.g. haven’t been diagnosed with moderate to severe COPD) but who benefit from continued support in the community to manage their COPD and other chronic health conditions.

The combined programs are making a difference for the health system by creating a better patient experience and providing increased access to care and system capacity – important achievements which align with the Ontario Ministry of Health and Long Term Care’s “Patients First: Action Plan for Healthcare.”