Overview

TOPS utilizes nurse-driven, phone-based outreach to improve transitional care, decrease requirements for in-person follow-up, and decrease readmission among COPD patients.

Organization Name

Pulmonary Clinic at VA Boston

Organization Type

• Integrated healthcare system/network

National/Policy Context

• Chronic obstructive pulmonary disease (COPD) is the fifth most common cause of death in veterans in the United States, likely exacerbated by increased rates of smoking among veterans and risks associated with veteran status. COPD is a key driver of hospitalization and readmission among veterans, and prior studies have demonstrated that nurse-driven outreach can decrease readmission in other diseases.
• While it is known that a nurse-driven telephonic intervention could be beneficial, such programs have yet to be widely implemented.

Local/Organizational Context

• The VA system utilizes numerous quality and performance metrics to compare across their hospitals, and readmission rates are a key metric.
• At the time of conception of this project, the Boston VA had a hospital-wide initiative to decrease readmission rates, and COPD and heart failure were identified as key areas for improvement.

Patient Population Served and Payor Information

• The Veterans Health Administration is a national, single-payer system serving veterans and their families.
• Approximately 9 million veterans are served each year across over 1,000 facilities across the country. The majority of those served have service-related VA insurance, or some combination of VA insurance with private or public (MassHealth) insurance.

Leadership

• • Dr. Syeda provided oversight and clinical support for the pulmonary nurse and other aspects of the program.
  • Team members with both quality improvement backgrounds and public health experience were necessary for crafting the TOPS Tool and structuring the workflow.

Funding

• TOPS was supported through an unrestricted educational grant from AstraZeneca to the Boston University School of Medicine’s Barry M. Manuel Continuing Medical Education Office, primarily funding research assistance for chart review and compiling of the data under the umbrella of performance improvement and quality improvement.

Research + Planning

• Internal planning meetings were required to decide which high-risk patients to target, design the TOPS Tool, and pick outcomes; this work was done simultaneously with rollout.

Tools or Products Developed

• • The TOPS Tool was developed as a comprehensive screener to assess risk of COPD exacerbation and adherence to discharge instructions.
    • The COPD Assessment Test (CAT, ©2009 GlaxoSmithKline group) was used as a part of the tool to assess the patient’s symptoms and look at change over time.
    • The tool also assessed adherence to medication regimens and understanding of the action plan if an exacerbation occurs.
  • A manually-managed, Excel-based patient tracker developed by the Quality Improvement department was utilized to identify the high-risk patients to target.

Training

• • The project required that a research assistant be trained to extract the essential elements of the electronic medical record to assess outcomes. All data were captured in a separate Excel database, managed by the research assistant.
  • A key to the success of TOPS was the engagement of an experienced pulmonary nurse. While no specific training was required for this intervention, experience in navigating the CAT and eliciting symptoms over the phone, providing counseling, and assessing medication adherence was necessary.

Team Members Involved

• Administrator
• Physicians
• Researcher
• RNs

Workflow Steps

• The Quality Improvement Department provided a pulmonary nurse with a manually-managed secure spreadsheet of all patients with COPD who had been discharged from the Boston VA’s inpatient service.
• Pulmonary nurses called the patients on the list and determined risk for readmission.
  • Nurses made a maximum of four attempts to contact the patient before discontinuing further attempts.
  • The COPD Assessment Test was used to determine risk of COPD exacerbation, understanding of and adherence to medication regimens and discharge plans was assessed, and smoking status and physical activity levels were noted.
  • Patients determined to be high-risk at the discretion of the nurse with the above information were scheduled for in-person visits at the pulmonary clinic or referred to the ED.
  • Nurses provided additional counseling and information via telephone in response to any specific concerns raised during the call. The telephone encounter was documented in the medical record.
• A pulmonologist provided oversight and clinical support for the program and expedited appointments for patients as needed.
• Clinic administrators scheduled follow-up appointments as needed.

Budget

• $10K to $25K

Budget Details

• Budget of $25,000 was for 14 months
• This quality improvement project was supported by an unrestricted educational grant from AstraZeneca to the Boston University School of Medicine’s Barry M. Manuel Continuing Medical Education Office.
• The grant from AstraZeneca provided all of the independent funding for this project, which supported chart abstraction and data analysis, accreditation, and project management.
• Additional responsibilities and functions were not covered by the grant and were incorporated into the jobs of individuals involved (e.g. NP, MD time).

Where We Are

• TOPS conducted an eight-month pilot phase from April through December of 2016.
• While the clinic does not currently have the staffing availability to support the project, there is hope that the program will be re-started in the future.

Outcomes

• Patient Outcomes
  • Readmission rates, defined as COPD-related admission to the hospital within 30 days of index COPD admission, were 4% for TOPS participants vs. 17% for unreachable patients (i.e. patients from the same pool who were unreachable when contacted by the TOPS team).
  • Follow-up visit rates within 2 weeks of index COPD admission were 32% for TOPS participants vs. 43% for unreachable patients.
  • Approximately ⅔ of patients enrolled in TOPS required coaching on medication use and discharge orders.

• Process Outcomes
  • Case identification and chart review took 20-30 minutes per case, and calls themselves were 20-25 minutes per call.
  • Altogether, the program required 10-20 hours of nurse time per week, carried out by a single pulmonary nurse.
  • In total, 25 of 48 patients were contacted. Of those who were not contacted, 3 were transferred to another facility, 4 had already been readmitted, and 16 were unreachable after 4 attempts to contact.

Future Outcomes

• Future studies should examine clinical outcomes for a longer period and across the winter months to capture additional causes of exacerbations, incorporate video visits, and expand to primary care settings.

Benefits

• Nurse-directed telephonic outreach to COPD patients decreased their readmission rates and follow-up utilization in comparison to those not enrolled in TOPS.
• Telephonic outreach can aid in clarifying medication and treatment plans for patients following hospital discharge and identify patients in need of follow-up.

Unique Challenges

• The program was limited by small sample size (N=48), and staff were unable to contact ~50% of patients for follow-up.
  • Furthermore, the rate of comorbidities was higher in the group of unreachable patients than in those who were enrolled in TOPS, potentially confounding results.
  • Veterans were most accessible in the morning hours, and attempts to contact patients outside of those hours were less fruitful.
  • For patients who were unreachable, telephonic outreach may be insufficient and home visits or other similar interventions may be necessary.
• The intervention increased the workload for a skilled nurse, though the requirements were manageable within the scope of other job responsibilities.

Glossary

• An IRB exemption for this initiative was provided by VA Boston Healthcare. The VABHS R&D committee reviewed the project and deemed it to be non-research.
• The contents of this article do not represent the views of the U.S. Department of Veterans Affairs or the U.S. Government.
• TOPS Tool (https://s86vkjuqei14qm8e2sawxz2m-wpengine.netdna-ssl.com/wp-content/uploads/Pumonary-Nurse-Post-Discharge-COPD-Follow-Up-Note.pdf)

Sources

• Conversations with Dr. Syeda and team
• Syeda, Sohera N., et al. “TOPS: Telephonic Outreach in the Pulmonary Service at VA Boston Healthcare System.” NEJM Catalyst, 26 Sept. 2018.