Dr. Landon, CATCH Medical Director
COPD Innovative Chronic Care Model Improves Health Outcomes for Patients and Reduces Total Cost of Care CMS Preferred Measure
Introduction The COPD Access to Community Health (CATCH) project is funded by a Health Care Innovations Award (HCIA) through the Centers for Medicaid and Medicare Services (CMS). CATCH is a mobile team of specialists working with a Medical Director and a Pulmonologist to coordinate the care of COPD patients across disparate clinical settings. CATCH activities are focused on engaging beneficiaries, prevention and comprehensive care delivered outside the typical clinical setting. The goals of CATCH are to identify COPD early, improve patient health outcomes and to decrease the overall cost of treating the disease. The CATCH target population is the 10,900 Medicare and/or Medi-Cal beneficiaries in Ventura County diagnosed with COPD. CATCH will enroll and assess 2,500 patients over three years.
Methodology
% Patients receiving influenza vaccine % Patients 65+ receiving pneumonia vaccine % of patients receiving smoking cessation intervention Spirometry Evaluation Inhaled bronchodilator therapy All-cause mortality rate Mental Health Status (PHQ-9)
143. ED/Hospital Visit Rate 149. Total Cost of Care*
Baseline (pre-CATCH)
Year 1 Average
Q5
Q6
31.5% 25.2% 37%
43.45% 49.5% 65.97%
37.93% 41.26% 84.7%
37.5% 39.7% 89.55%
Currently 19% increase over baseline Currently 58% increase over baseline Currently 142% increase over baseline
4.7% 18.1% .033% 26.8% No data on Average Score 5% $1,750 PBPM
45.6% 37.42% .41% 100% 7.76
66.1% 31.83% 0 100% 6.8
73.2% 32.1% .001% 100% 6.8
3.57% N/A
2.97% $1,690
3.65% $1,690
Currently 1,457% increase over baseline Currently 78% increase over baseline 2 Deaths in Q6 74% increase in administration over baseline Nearly 2 point decrease in average score since start of project 27% decrease over baseline (HCA only) *Projected savings is currently 7.94%
90 to 99 80 to 89
Pending
70 to 79
Stage 4
60 to 69
COPD patients face multiple co-morbidities that confound case managers. Chronic hypoxia, cognitive dysfunction, poor nutrition, addiction and economic disadvantage are a few of the challenges requiring creative solutions and ongoing support. Common factors appear among the caseload and, while common, such factors are complex and rarely resolve on their own. The CATCH model provides proactive diagnosis and on-going, multi-factorial disease management that includes smoking cessation, influenza and pneumonia vaccinations, pulmonary rehabilitation and pharmacotherapy.
Conclusions
735 45 112
Stage 3
50 to 59
138
Stage 2
40 to 49
Historically, COPD patients are misdiagnosed. GOLD Guidelines direct treatment based on the severity of disease as determined by medical history, lung function and severity of symptoms. The CATCH nurse case manager conducts extensive patient assessments in the patient’s home. The assessments are presented at weekly conference overseen by the Medical Director and/or Pulmonologist where the team develops an individualized plan of care.
Comments
GOLD Stages of Participants
Age Summary of Participants
The CATCH team implements evidence-based treatment protocol allowing practitioners to identify, treat and manage COPD. The Global Initiative for Lung Disease (GOLD) Guidelines are recommended as the best standard of care. CATCH has purchased mobile spirometers for the family medicine clinics and has provided extensive trainings to clinical staff on performing pulmonary function tests (pft). The CATCH Registered Nurse has developed hand held tools for diagnosing and treating COPD patients on the spot
The team of specialists
30 to 39
Stage 1
20 to 29
Stage 0
33 239
Under 20
Smoker Status of Participants 451 197
Smokers
Non-smokers
474
Genders of Participants
716
586
180
Former Smokers
Unknown
Females
Males
Acknowledgements: Dr. Renee Higgins, Principal Investigator; Dr. Chris Landon, Medical Director; Dr. Ravinder Bajwa, Pulmonologist; Susan White Wood, Project Director; Helen
Further Information
Hansen, RN; Audrey Newman, RRT; Karen Gallardo, RRT; Martha Cervantes, Community Health Worker; Jessica Mabalot, Community Health Worker; Susan Pathman, Medical Office Assistant. The project described is supported by Grant Number 1C1CMS331320 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.
CATCH (805) 677-5162 or
[email protected]
The CATCH program model represents a dynamic hybrid combining screening and prevention efforts with care coordination, provider incentive and payment reform in order to permeate evidence based protocols resulting in overall improvement in health outcomes and reduced cost of care. COPD patients tend to share common social and medical factors. Frequent hospitalizations due to COPD exacerbation stem from a combination of medical-social factors that lead to patient noncompliance including poverty, limited education, inadequate health insurance, transportation challenges and language barriers. Medical factors include multiple comorbidities, use of more than 6 prescription medicines and utilizing the emergency department for primary care. CATCH coordinates the evidence-based treatment of participants and connects patients to community resources such as: In-Home Supportive Services (IHSS), homeless services, Veterans services, mental health resources, health insurance counseling, housing assistance, Adult Protective Services (APS), free transportation, access to durable medical equipment (DME), Meals On Wheels, home modification resources, pulmonary rehabilitation, smoking cessation, crucial access to immunizations, respite and other various support. CATCH works with the patient in their home environment to address issues that may not be apparent to a primary care provider or hospital staff. The CATCH care manager approach is transforming care delivery from a rescue orientated response to a planned-care experience, empowering patients and families to collaborate actively with the health care team. CATCH also establishes relationships with multiple health care organizations, integrating specialty and inpatient care with primary care to achieve the best possible outcomes and cost savings.
