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Evaluation of Post-discharge Telephone follow-up call with Patients Diagnosed with COPD

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Evaluation of Post-discharge Telephone follow-up call with Patients Diagnosed with COPD

Problem Statement

Congestive Obstructive Pulmonary Disease (COPD) exacerbation is a common cause for hospital admission and readmission. Hospital admissions and readmissions negatively impact the cost of care, costing approximately 924 million per year (GOLD, 2017; Liu, Zhang, Li & Sun 2017). Hospital admission and readmission costs prompted the Center for Medicare and Medicaid to include COPD as a new readmission measure in 2015 (Hospital Readmission Reduction Program, FY 2015). COPD readmission measure as recent new measure create in the healthcare system the necessity to analyze what are some of the reason that lead the patient back to the hospital. GOLD, 2017 identify that COPD exacerbation is the most common cause of hospital admission or readmission. According to patients, some of the reasons they visit the emergency room including fear of disease prognosis, and lack of skills to manage disease symptoms (Rising et al. 2015). This evidence show that effort should be prioritizing to enhance patient education integrating physical, psychological and psychosocial dimension. In most of cases patients experiencing a COPD exacerbation is impacting more than physical symptoms; they also experience psychological symptoms such as anxiety and panic affecting resulting in activity reduction that end to self-isolation involving psychosocial dimension (Spathis, et al. 2017). Is at this point that the primary care should focus effort to improve and use standardizing approach to improve the patient education and the support given to patients during the first month after hospital discharge.

The Viera VA outpatient clinic is part of the Orlando Veterans Administration Medical Center (OVAMC), but it is approximately sixty miles away from Brevard County. Therefore, patients often remain in Brevard hospitals. The Viera outpatient clinic to support better the patient recently they established a rapport with three community hospital systems by improving the communication process. Now, three healthcare system in Brevard county are sending a daily list of patients discharged their hospitals. This improving in communication between VA and Non-VA facilities help because nurses can initiate coordination of care with post-discharge telephone follow up calls to support better the patient when they are at home after been hospital discharged.

Although the telephone follow-up call is an effective strategy, additional efforts are needed to effect change in the patient's self-management to decrease hospital readmission (Ko, Ngai & Ng, 2014). The management of patient with COPD using telephone follow up call should have a standardized approach specific to the patient's disease (Jayakody, et al. 2016; Ko, et al 2014). However, the management of patients with COPD require a combination of interventions because, no single intervention is superior than other (Jayakody, et al. 2016). This project aim to identify areas to improve, because according with the nursing administration of the clinic there is not standardizing process to follow-up after the patient with COPD get hospital discharged. Post discharge follow-up should be specific to patient's disease ( Liu, et al 2017; Jayakody, et al. 2016; Ko, et al 2014 ). For example, lack of specific educational activities related to disease management is to supporting patient self-management contributing to poor patient outcomes, such as hospital admission or readmission (Misky, Burke, Jonson, Jones, Hanson and Reid, 2018 ). Another are to explore is the topic of the patient education because non-pharmacological management of Dyspnea symptoms will impact self-management and quality of life (Spathis, et al. 2017). Lack of education content focusing on the management of COPD resulting in poor quality of care and satisfaction, both are associated with lack of follow up after discharge (Coleman, 2006; Burke et al 2013; Kripalani et al. 2014; Liu et al. 2017).

The purpose of these project is evaluate post-discharge telephone follow-up calls activities within the first month after hospital discharged because the identification of areas to improve lead to provide specific interventions according to the patient's diseases and needs (Jayakody et al. 2016; Ko et al. 2014).The goal with the post-discharge telephone follow-up call is better support the patient by providing patient education plan and support their with coordination of care in the use of different resources. For example, support the patient education will enhance self-management skills, and while monitoring their warning symptoms during the weekly follow-up call, at this point nurses enhancing educational material that may impact patient's self-management skills to better management a COPD exacerbation crisis.

Practice-Focused Question

or Comment by user: The question should be focus on the VA intervention to improve readmission(green) or in my propose intervention (red) to improve readmission?.

During the first 30 days post discharge, would using a standard approach of education during telephone follow-up by the primary care nurse for care of patients over 65 years of age who have been diagnosed with COPD improve increasing in a 100% of patient education giving weekly?

Social Change

The use of a standardized approach to guide nursing activities with the patient discharge from non-VA hospitals allows the opportunity to assess efforts made in the primary care setting to improve the quality of care provided to the patient diagnosed with COPD. The telephone follow-up can improve patient outcome and satisfaction (Burke et al. 2018; Jayakody et al 2016). The use of standardized approach will help to overcome the patient's stigma, because most of the time they denied of having problem with disease management Kirkpatrick, 2012).

The use Breathing-Thinking-Functioning (BTF) model for patient education and telephone follow-up will helps to design an individualized plan of education specific to the patient's interest and needs. Also, the BFT model support coordination of care activities improving the use of existing resources (Spathis et al. 2017). The use of existing resources will support educational material resulting in risk reduction of hospital admission or readmission throughout the post discharge education plan include non-pharmacological and pharmacological management (GOLD, 2017; Ko et al. 2014). Nursing will support better the patient helping monitoring warning symptoms during the first months after hospital discharge. The weekly monitoring will be part of educational reinforcement and discussion.

This project by identifying areas to improve during post-discharge telephone follow-up call and standardized patient education according to the patient diseases, interests and needs will impact other Ambulatory Care Sensitive Conditions (ACSC) such congestive Heart failure. Also, will increase patient's satisfaction motivating the patient to become an active participant (Lippincott, 2017).

The Viera VA is one of nine satellite outpatient clinic branches of the Orlando Veterans Administration Medical Center (OVAMC). Annually, the Viera Clinic provides multidisciplinary services to the veteran population who reside in Brevard County. The Brevard County veteran population continues to engage in a staggering number of hospital admission/readmission. Patient education after been discharge from Brevard hospitals will support patients by establishing the standardizing approach for education. At the same time will facilitate the coordination of care and the telephone follow-up call.

The telephone follow-up call is highly recommended as a proven strategy to use during the transition of care (Burke et al. 2018; Jayakody et al. 2016). The telephone follow-up call will enhancing communication with patients and also with the interdisciplinary team to include in the educational reinforcement of educational material receiving and also to follow up recommendations provided by the interdisciplinary team. Evaluate the educational topic delivered by nurses and by interdisciplinary team during the first month after the patient have been discharged will help to justify the improvement in the patient education is an essential part of the interventions received after discharge.

The Viera clinic has the opportunities to improve the telephone follow up call using BTF model. The clinic has resources to support the patient such as mental health services, Telehealth program, Move 101, palliative, home-based, pulmonary rehabilitation, social services, pharmacy, among other. The Breathing, Thinking, Functioning (BTF) model to provide education and care coordination enhancing self-management skill to manage a COPD exacerbation or crisis (Spathis et al. 2017) .

Source of Evidence

COPD is one of the most costly chronic diseases in the VA health care system. Untreated COPD exacerbations are often the cause for admission and readmission (GOLD, 2017). The staggering readmission rate of patients with COPD relates to poor post-discharge follow-ups and the lack of standardization of process ( Coleman, 2006; Burke et al 2013; Kripalani et al. 2014; Shah, Churpek, Coca Perraillon, & Konetzka, 2015, Liu, Zhang, Li and Sun 2017). The need for a standardized process to guide the management of patients with COPD is clear evidence of the inconsistency in practice.

The Breathing, Thinking, Functioning (BTF) Model model focuses on increasing self-management support by educating veteran about COPD including non-pharmacological skills to assist them in managing their care in special and dyspnea crisis. The BTF Model encompasses cognitive and behavioral techniques during an exacerbation or crisis as the method to alleviate the disease symptoms. The BTF model focuses on engaging the patient in the breath, think and function while living with a chronic illness (Bausewein et al., 2018). This model conceptualizes breathing, thinking and functioning as a cognitive and behavioral reaction to dyspnea during a COPD exacerbation.

Approach

The best strategy for a program evaluation is by gathering the existing data related to the current program and identifying areas for improvement to ensure better outcomes (Nieswiadomy, 2012). Nieswiadomy (2012) stated that the program evaluation approach is the fifth level of evidence. Patton (1987) declared that evaluation is the critical process of examining a program. Program evaluation involves the collection of information related to the program and outcomes. The intention of completing this process is to obtain accurate information to produce effective decisions (Patton, 1987, p. 21). The proposed project aims to apply the Kellogg Basic Logic model as a systematic and visual process to collect the post-hospital discharges follow up data.

The Kellogg Basic Logic model uses a systemative five-step process. The first step in the model is gather information of current practice using nurses, physicians, and other team members. The second step is to explore the activities involving the existing program and evaluate if the program is effective by auditing existing. The study targets Quality Management post-discharge performance measurements to monitor the COPD patient population. The project attempts to collect performance measure standards like timeframes and documentation of the post-disharge call and weekly follow-up, timeframe of medical follow-up appointment, patient education and the used of resources.

Ethical Considerations

The Veterans Administration Central Institutional Review Board (IRB) complies with the “Common Rule” for the protection of human subjects. Although, the proposed project does not aim to use the human subjects as part of the program evaluation, the improvement measure will impact the services provided to patients with COPD.

The data collection will start after the IRB approval. To protect the patient’s privacy and avoid duplication of patients a code will be assigned. Any data collected will be saved using an electronic file password protected by VA computers. The proposed project will follow the structured step process to ensure that the study complies with Walden University’s Ethical Standards and U.S Federal regulations. This proposed project will conduct a program evaluation using patient’s information, which is protected data within the VA research process. The program evaluation in this project targets the second fold of the VA Central IRB process, which explicitly specifies the enhancement to review program process across participant sites (VA Central Institutional Review Board (IRB), 2017).

Alignment

The proposed program evaluation project aligns with the VA priority that includes improving the transition of care and the standardization of care management (VA, 2018). This intended program evaluation project targets to enhanced and standardization of current process in the Viera clinic. The efficiency of the proposed program will impact the services and the support needed by patients with COPD post-discharge by improving the quality of nursing care. Commonly, a structured follow-up coordination of care covers the first 30 days of high risk for hospital readmission period. A standardized care coordination process will improve the communication and the plan of care for patients with COPD. The use of standardized approach guides nurses and promotes consistency in intervention between patients. The provision of a patient's education with a weekly follow up aims to improve outcomes. The use of a standardized approach helps to increase the use of existing community resources available (Zurlo and Zuliani, 2018). The evaluation of the telephone follow-up call helps to identify area of oportunities for improvements (Siriwardena 2009).

References

Ayele, R. A., Lawrence, E., McCreight, M., Fehling, K., Peterson, J., Glasgow, R. E., … Battaglia, C. (2017). Study protocol: improving the transition of care from a non-network hospital back to the patient’s medical home. BMC Health Services Research, 17(1), 123. https://doi.org/10.1186/s12913-017-2048-z

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