Using a COPD pathway can improve patient outcomes and boost your standing among referral sources and payors.

Developing and marketing a chronic obstructive pulmonary disease (COPD) pathway can help HME providers differentiate themselves in their local market and position themselves for referrals of new COPD patients. A COPD pathway is based on the premise that certain intervention techniques that are founded on education and therapeutic principles can assist individuals with COPD. It is the thoughtfulness, respect, passion, and competence with which those techniques are conveyed that is at the core of the pathway.

The HME provider is the ideal resource for COPD patients who wish to better manage their disease so they can lead longer and more productive lives. Develop a COPD pathway, measure the results, and visit your outcomes. Consider publishing and marketing the results to demonstrate to payors, referral sources, and Capitol Hill just how home care lowers the burden on health care today.

Direct health care costs related to chronic conditions are responsible for greater than 75% of total health care expenditures. Improved chronic disease care is clearly needed to reduce this burden, yet clinicians alone are not able to improve the health status of their patients.

Individuals with chronic diseases need to make and maintain lifestyle changes to better manage their conditions (in-home testing and monitoring, appropriate medication use, diet, and exercise). For each individual to succeed, they need education, motivation, equipment knowledge, and support to make and maintain these behavior changes.

Defining Disease Management
Disease management (DM) focuses on chronic conditions (diabetes, congestive heart failure, and COPD) that affect large numbers of individuals. DM is defined by the Disease Management Association of America as “a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant.” DM shifts traditional health care’s acute care orientation to patient-supported self-care management. DM programs intervene as early as possible in the course of the disease to prevent increased health care costs.

The basic criteria for DM application to a chronic disease involve:

• potential/proof that beneficiary/provider interventions improve outcomes;
• standardized metrics for treatment care plans and outcome assessment;
• the ability to reconcile baseline and treatment costs;
• economics that permit suitable short-term and sustainable return on investment; and
• a short time to implement with reasonable overhead.

Full-service DM programs include these six components. Programs consisting of fewer components are DM support services:

• population identification processes;
• evidence-based practice guidelines;
• collaborative practice models to include all providers;
• education on patient self-management;
• process and outcomes measurement, evaluation, and management; and
• routine reporting with a feedback loop.

DM: Population Targets
The most common DM programs are population-based, meaning the program is responsible for the health outcomes and utilization of all its members in a targeted group (such as health plan enrollees with a “specific or triggering” diagnosis), not just those individuals who might seek treatment during a given period. Different interventions become directed to the different types or categories of patients, depending on the severity of the condition and other risk factors.

Population-based disease management (PDM) typically interfaces with one primary physician per patient and relies on clinical evidence related to a particular condition or set of conditions. It focuses on patient symptom assessment and monitoring, physician/patient education, and adherence to a care plan. ¹

Currently, most health plans lean toward a system of coordinated health care interventions and communications for populations that have the potential for improvements in DM with patient self-care efforts. These interventions:

• can support the physician-patient relationship and plan of care;
• emphasize prevention of exacerbations and complications using evidence-based practice guidelines and patient-empowerment strategies; and
• evaluate clinical, humanistic, and economic outcomes with the goal of improving overall health.

Evidence that PDM can save money is most often presented in the form of reduced costs through prevention of hospitalization, emergency care, and unscheduled physician visits. While not much public attention has been paid to total savings netted from PDM intervention, total savings are a vital element that needs further research, documentation, and promotion.

COPD and DM/PDM
In the United States, COPD is the fourth leading cause of death and it is projected to be number three by 2020. It is a rapidly growing chronic health condition. While COPD is commonly perceived as a disease of the elderly and of limited impact to the working population, 70% of COPD patients are under the age of 65 and account for a large portion of acute care hospital emergency department visits.

COPD impairs the ability to carry out the activities of daily living, thus adversely affecting quality of life. It is the 12th leading cause of disability-adjusted life years, which is a measure of the years lost because of premature mortality and years of life lived with disability adjusted for the severity of disability.

To follow a DM program or pathway of management, an individual with COPD requires a correct and early diagnosis. Unfortunately, that diagnosis is frequently missed due to the disease being in such an early stage. With this lack of diagnosis in mind, it is important to promote awareness among clinicians of the causes, prevalence, and burden of COPD so that patients with COPD are diagnosed sooner. Since delays in diagnosis are usually associated with more progressive destruction of the lungs and loss of functionality, a COPD pathway can promote awareness.

Studies show that several factors cause the under-reporting and incorrect early diagnosis:

• the diagnosis is misconstrued as a health condition of the elderly;
• the diagnosis process is simplified by telling patients they have asthma (more socially acceptable); and
• many physicians do not perform or order spirometry testing.

It is important while developing a disease management program to use a well-designed pathway that is able to be implemented as a step-wise approach to managing COPD according to the severity of the disease. Outcome measurement is vital to demonstrating effectiveness and success.

The GOLD Standard
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) is standards that were designed and published in 2001, and updated in 2004. Their intent was to guide health care providers in effective identification and management of patients with COPD.

It was the intent of the standards to prevent the progress of the disease; relieve symptoms; improve exercise tolerance; improve health status; prevent and treat complications; and reduce mortality.

The GOLD standards were designed to highlight patient education and treatment pharmaceutically and nonpharmaceutically according to severity of the disease process to increase effective patient care. There are five stages of COPD according to the GOLD standards² (Figure 1).

Role of the HME
It may be difficult for HME providers to conduct a “true-to-form” PDM program because they do not have access to enough population claims data to go “at risk” with a payor. They can, however, develop a COPD pathway that can be marketed to hospitals, physicians, and payors. The components of a COPD pathway encompass the key recommendations of the GOLD standards as follows:

• a clearer definition of the patient’s condition;
• triggers/risk factors to avoid;
• self-management skills to manage their condition;
• signs and symptoms of exacerbation;
• strategies to safely manage worsening of symptoms (in a timely manner);
• factors to determine when to seek medical attention; and
• updates on medical treatments.

The ultimate intent of the GOLD standards and a COPD pathway is to actively involve patients in their own health care decisions and increase their participation in managing and controlling their health. An initiative for COPD disease management by a home care company comprises three key components: 1) identifying the population; 2) implementing a program; and 3) measuring outcomes.

Identification
For an HME provider, it is relatively easy to identify those individuals already receiving respiratory services. These are the patients already on your service receiving aerosol therapy and home oxygen. It is a bit more difficult to identify potential patients who present with a milder level of disease severity but who are candidates for additional services in the future. These are the currently undiagnosed patients that are being seen daily by primary care physicians.

For existing patients, a proactive approach is to introduce appropriate action plans and lifestyle modifications to slow the progression of COPD. For example, an HME provider can start with three to five existing COPD patients who are on home oxygen. These individuals are usually at stage three or four of the GOLD Standards.

Identifying potential new patients requires working closely with the discharge planners of a hospital or the primary care physician. This requires a respiratory therapist who can conduct chart audits with the permission, of course, of the referral source. The RT starts by reviewing ICD-9 codes.

The primary ICD-9 codes for COPD are 490, 491, 492, 493, and 496. Looking at these codes will help identify the “most-at-risk” patients with a primary or secondary diagnosis of COPD.

Pay special attention to those patients who are over the age of 50 with a new primary diagnosis of asthma (ICD-9 code 493) because these patients may be classified as having asthma when it is really early stage COPD. In addition, patients who have been to the emergency department for pneumonia or chronic bronchitis two or more times in a 6-month period should be assessed because they are also high-risk individuals.

When reviewing the patient’s chart, the RT should also review the prescriptions used and the pulmonary function test results to help make the correct decision in referring a patient for DM.

An effective program begins by taking the results and stratifying each individual for severity using the stages of the GOLD standards system. The severity indicates when to introduce the pathway into the patient’s disease process. Using this approach allows HME providers to act as a clinical consultant and resource to their referral sources. A good program helps primary care physicians to quickly identify those patients with COPD, educate them about their disease, and keep them out of the hospital.

Forging a relationship to collect this type of information will require some effort. Discharge planners or physicians will need to be contacted and educated using GOLD standard materials. HME providers should package all of these materials and include specific referral information. One popular technique for introducing a COPD pathway program is to coordinate a “luncheon topic seminar” for the discharge planners and physicians to educate them regarding your COPD home care pathway and use that opportunity to distribute educational and identification materials.

Implementation
Once the patients are identified, the concept of a pathway would include the initial steps to help set the stage for documentation and to keep a time schedule. Documentation is vital because it provides the foundation for outcomes measurement.

Look at Figure 2 to see how a COPD pathway might work. At Visit #1, the RT sets the stage with the patient. At this step, he must explain the entire program and get the patient’s consent to participate in the pathway. This takes a minimum of 30 minutes. It is during this first visit that the assessment and survey information is documented.

This survey and assessment will have more information added during the subsequent visits and phone calls. If Visit #1 results in a patient who does not wish to be involved in this pathway, the materials should be left for the patient to read. At the very least, these patients will learn about their disease and why they were placed on oxygen. HME providers should be sure to leave contact information in case they change their mind and wish to enter the pathway at a later date. The referring physician should be notified and told which of their patients will be participating and those who will not. For those patients who decide not to participate, HME providers should provide the patient’s stated reason for nonparticipation. If Visit #1 results in consent, the pathway progression is halfway there.

Visit #2 takes place at a predetermined time after the initial visit and reinforces the previous visit by reviewing the informational booklet the patient received during the first visit—and the survey and assessment is once again completed and returned to the home care provider. This visit is important because the patient has had time to look over the program and begin to understand their role in their disease process.

The time frame between Visit #2 and Visit #3 is to be determined by the provider, so during this time the RT/pathway coordinator needs to “visit” with the patient by telephone two different times. This phone call again reinforces the value of the pathway and permits the home care company to gather information about compliance and adherence. The assessment is not used during these “visits” because the visit does not occur in person. These visits provide information about progression or regression of the disease state.

Visit #3 will complete the original cycle for the pathway. Information should be complete and statistics should begin to be completed for the individual to demonstrate compliance and adherence to the pathway

After the results from the initial months are compiled and readied for a final report, the pathway coordinator and the RT schedule an appointment to present and review the patient with the physician. This meeting can determine if you would care to re-enroll the patient or continue with therapy as is. The physician is required to continue the order for the pathway after Visit #3. A suggestion would be to have this order include specific outcomes according to the severity and progression of the disease process.

Impact
Outcomes reveal the impact of the COPD pathway. Without the ability to analyze outcomes, a pathway will not provide an impartial, independent evaluation of its clinical and financial effectiveness. The evaluations carry greater weight and give validity to a pathway for COPD and demonstrate the success of the patient having their COPD managed without a great deal of time and effort from the referral source.

Jacquelyn M. McClure, RRT, directs the National Respiratory Network and orchestrates government relations for The MED Group, Lubbock, Tex. She can be reached via e-mail: jmcclure@medgroup.com.
Gail Watkins Varcelotti, RRT, is president of Education on the GO in Pittsburgh. Varcelotti can be reached via e-mail: varcelotti@yahoo.com.
Thomas J. Williams, MBA, RRT, is managing director of Strategic Dynamics, Scottsdale, Ariz. He can be reached via e-mail: twilliams@strategicdynamicsfirm.com.