Mount Sinai, an integrated delivery network in New York City, identified and appropriately treated patients in greatest need of inpatient COVID-19 and non-COVID-19 treatment and services.1
Mount Sinai needed to manage and accommodate the surge of COVID-19-positive cases while also maintaining care for other high-risk or rising-risk patients.2
Partnerships and service-focused care enabled vulnerable patients to receive home-based care 1
1. Holly R. Mount Sinai at home, other hospital-at-home models proving value amid national emergency. Home Health Care News Website. https://homehealthcarenews.com/2020/04/mount-sinaiat-home-other-hospital-at-home-models-proving-value-amid-national-emergency/. Published April 7, 2020. Accessed August 21, 2020. 2. Hostetter M, Klein S. Has the time finally come for hospital at home? The Commonwealth Fund website.\https://www.commonwealthfund.org/publications/newsletter-article/2020/jul/has-time-finally-come-hospital-home. Published July 7, 2020. Accessed August 21, 2020.
An integrated health system serving one of the nation’s largest metropolitan areas empowered respiratory therapists to achieve the systemwide goal of lower COPD readmissions.
The integrated health system wanted to implement a COPD management pathway that spans the continuum of care from initial COPD exacerbation to the home setting.
Respiratory therapists served as COPD navigators, coordinating disease management for the full continuum of care
A care pathway that involved respiratory therapists across the full care continuum, from inpatient to outpatient, resulted in a reduction in COPD readmissions.
COPD=chronic obstructive pulmonary disease.
Data on file. Boehringer Ingelheim Pharmaceuticals, Inc.
Leaders at Partners Healthcare, an integrated delivery system and accountable care organization, developed the Integrated Care Management Program (iCMP) using data from its enterprise data warehouse (EDW) to identify high-risk patients and best focus and optimize efforts.
Partners Healthcare needed a care management program to help with patient identification, improve outcomes, and reduce costs.
– Assessed patient needs and
barriers to care
– Monitored patients during office visits
– Identified gaps in understanding and compliance
– Used phone calls and home visits to monitor patients
– Coordinated care, transportation, and social and specialist services
– Acted as liaisons between the patient and other care team members across settings
HealthCatalyst. Care Management: A Critical Component of Effective Population Health Management. https://downloads.healthcatalyst.com/wp-content/uploads/2016/12/Care-Management-Critical-Component-of-Effective-Population-Health-Management.pdf. Accessed August 3, 2020.
Bon Secours Mercy Health established a systemwide standard of COPD management to incorporate GOLD staging into the approach, ensure that PIF is documented, and operationalize the approach within the EHR.1
Bon Secours Mercy Health needed to reduce 30-day COPD readmissions after identifying several contributing factors such as utilization of triple therapies, utilization of rescue inhalers, and the lack of prompt pulmonary follow-up.1
Incorporated the GOLD Strategy Report COPD recommendations into a standardized care process that facilitates coordination across multiple sites of care
- The HCP receives an EHR alert if the patient with COPD has not had diagnostic pulmonary function testing
- The EHR flowsheet calculates the GOLD grade and GOLD group based on assessment input
- The hospital outpatient pharmacist receives an EHR notification and provides recommendations to the prescribing HCP based on the assessment results
- Pharmacists deliver the filled prescription to the patient in the hospital setting
- Seven-day follow-ups are encouraged
COPD=chronic obstructive pulmonary disease; EHR=electronic health record; GOLD=Global Initiative for Chronic Obstructive Lung Disease; HCP=healthcare provider; PIF=peak inspiratory flow.
1 Data on file. Boehringer lngelheim Pharmaceuticals, Inc. 2. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease; 2020 report. https://goldcopd.org/wp-content/uploads/2019/12/GOLD-2020-FINAL-ver1.2-03Dec19_WMV.pdf. Assessed December 17, 2020.