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The Benefits of a Team-Based Approach in Disease Management


How one primary care practice used a team-based approach to reduce readmission rates for COPD patients.

Lung diagram

Chronic obstructive pulmonary disease (COPD) affects 16 million Americans. Millions more people suffer from COPD, but have not been diagnosed and are not being treated. There is no cure for COPD, but it can be treated. Costs attributable to having COPD were $32.1 billion in 2010 with a projected increase to $49.0 billion by 2020, according to the CDC.

Recently, healthcare executives have focused more attention on reducing 30-day COPD readmissions rates and keeping COPD patients healthy at home. Additionally, COPD patients often aren’t on the right medication, don’t take medications properly, or don’t know the signs of a serious exacerbation that could result in an ED visit or hospitalization.

Related article: Six Surprising Ways COPD Can Affect Patient Health

VillageMD, a provider of primary care in eight markets including over 120 physicians in Houston alone, collaborated with an electronic health records (EHR) provider, and introduced a team-based COPD treatment program to focus on those specific problems. Managed Healthcare Executive (MHE) talked with Clive Fields, MD, co-founder and chief medical officer of VillageMD about how Village built the program and how it focuses on specific problems with COPD patients.

MHE: How did the program get started?

Fields: VillageMD is committed to using a primary care-led model to take care of diverse patient populations, including patients suffering from acute and chronic illnesses. Almost 15.7 million Americans have been diagnosed with COPD, the third leading cause of death nationally.

COPD is a disease that is both grossly undertreated and severely underdiagnosed. At VillageMD, we looked at this population and determined it could benefit immensely from a team-based approach driven by analytics.

VillageMD built a team-based COPD treatment program focusing on specific problems with COPD patients, like not taking the right medication, taking medications incorrectly, or not knowing the signs of exacerbations that lead to ED visits or hospitalization. This program involves a primary care physician, clinical support nurse, care manager, social worker, and clinical pharmacist, all following a shared care plan to better treat COPD patients.

MHE: How did the need for this type of program arise?

Fields: Approximately 16% of COPD patients are hospitalized or visit the emergency department each year, with 10 to 20% readmitted within 30 days. One of the advantages of treating the disease is that most exacerbations of the illness are preceded by relatively minor symptoms that when identified and intervened early, can reduce the severity of an exacerbation. The prevalence of the disease and ability of a primary care model to make a significant improvement on patient outcomes and reduce cost made COPD patients the clear group for which to develop a team-based and analytics-driven program.

MHE: How did VillageMD roll out this program? How long did it take to plan, build and implement to healthcare providers and patients?

Fields: The entire process of planning, building, and implementing the VillageMD COPD program took over a year-between 12 and 18 months from conception through implementation. We worked closely with primary care physicians and care teams to develop a best-practice approach and intuitive workflows that could be easily integrated into practices. Implementation began with one Houston practice, expanded to other clinics in the local market, and then grew in VillageMD markets nationally.

MHE: What were the outcomes of the program?

Fields: We are thrilled with the success of our program not only in the management of those patients with COPD but the increase of diagnosis of COPD early on in a patient’s illness. New GOLD guidelines allow us to both risk stratify and initiate appropriate treatment for patients with COPD. 

  • The program has been rolled out to more than 50 primary care physicians at Village Family Practice.

  • An additional 30 to 40 providers partnered with VillageMD have implemented the program nationwide.

  • 55% of COPD visits follow the approved workflow. 

  • Initial results over 12 months indicate a 30% to 40% lower hospitalization rate across the cohort enrolled in this program.

MHE: How have EHR tools assisted in this program?

Fields: EHRs, like athenahealth, are vital to involving the entire care team in patient treatment. Our COPD assessment allows us to determine the severity of the disease and subsequent patient management. The assessment test results are uploaded to the EHR which are then viewable to all members of the care team.

MHE: How does the program address self-management and reducing ED and hospital visits?

Fields: One of the foundations of our program is engagement of patients in the self-management of their own illness. At enrollment in the COPD program, we focus on educating patients on medication adherence, the signs and symptoms of an exacerbation, and what to do when they feel a flareup. We also explain the pathology of the disease and the things that may exacerbate it, including the obvious cigarette smoking, dust and mold exposure, but also education on irritants they may not be aware of, like change in temperature or exposure to perfumes or other pulmonary irritants. There’s nothing more valuable in a disease management program than an engaged and educated patient. 

MHE: Is this specific to COPD? Can it be applied to other disease states?

Fields: A team-based approach to COPD with analytics driven risk stratification and patient identification can be successful across many other disease states, especially those in which avoidable utilization can be predicted early either with a change in objective measures or with subjective complaints from the patients.

MHE: What can other providers/plans do to improve outcomes through team-based programs?

Fields: Team-based programs are essential, but there are three key pieces to a successful COPD program that other providers/plans can implement to help improve patient outcomes. The first is patient engagement, to ensure education and promote self-management of their own illness. Second is team-based care, which in this program involves both physicians, nurses, chronic care managers, and social workers. Third is the use of data and analytics to predict and identify those patients for proactive rather than reactive treatment.  

Related article: Top Barriers to Effective COPD Treatment

MHE: What is the future of the program?

Fields: After successful implementation at our Flagship Village Family Practice, we will continue implementing this program across all eight of our national VillageMD markets and investigate other disease states for implementation of a team-based and analytics-driven program.

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