With continued scrutiny from the Centers for Medicare & Medicaid Services (CMS) of hospital readmission rates after post-acute care, long term/post-acute care providers have an opportunity to use data, analyze trends, and pioneer new patient-focused programs and systems.
At Maine Veterans’ Homes – Scarborough, Maine, a new Respiratory Niche Program is already seeing success after drilling down into the data and taking the time for extensive research and development. Furthermore, the program’s development process led to a standardized system for developing future niche programs.

Addressing a Common Trend

Development of the Respiratory Niche Program at Maine Veterans’ Homes began after data from internal reviews showed a common trend in patients with respiratory illness and hospital readmissions. Data from CMS validated this was an issue across the state of Maine and that there was a need for this program.
The program provides a personalized and comprehensive approach to the care, therapy, and follow-up each patient needs to successfully transition at all levels of recovery, from hospital to post-acute care to home.

Still in its infancy starting just eight months ago, initial numbers already point toward a decrease in hospital readmissions. A key to the program’s success has been the time invested up front in research, strategy, and development to ensure it was implemented as an excellence in clinical care program.

The Development Process

By looking at the data of the veterans currently served and the future customer base, specifically veterans who served in Vietnam and the Middle East where they may have inhaled dangerous chemicals and sand, Maine Veterans’ Homes narrowed in on developing the program for its post-acute care residents with chronic obstructive pulmonary disease (COPD).

Veterans are especially vulnerable. They are three times more likely to develop COPD due to service exposure, statistics from the Chronic Obstructive Pulmonary Disease Foundation show. COPD currently has no cure, and, therefore, it is vital that patients continue proper treatment to slow the disease progression.

With a targeted focus, a year-long research and strategic development process began that included deep dives into the following questions:
  • What should the program look like?
  • Who will it best serve now? Will it serve future residents?
  • Have the residents been asked what they want?
  • What will the program need?
  • What are the needed staff components?
  • What equipment and supplies will be needed?
  • What partnerships would be beneficial or needed?
  • What are current best practices nationally and internationally?
  • What standards should be set?
  • What outcome measures will be used to know if success is achieved?

Partnerships Play an Important Role

Research by the Maine Veterans Homes’ clinical and administrative teams also involved focus groups with current respiratory patients and families on what they needed and wanted from a follow-up program.
Clinical partners, including Maine Health Care and other local providers, were asked how a program at Maine Veterans’ Homes could support their care. Data were gathered on successful programs already in place, including one in Canada, and their best practices.

A partnership was formed with the local senior living collaborative to provide respiratory therapists five days per week. An advanced practice registered nurse with geriatric and pulmonary certifications was brought into the team. Staff training began as the program was defined.

The Components

The main components of Maine Veterans’ Respiratory Niche Program now include:
1. Care Paths. Individualized care plans are developed for each patient with COPD based on his or her needs. The Care Path allows for a comprehensive approach that brings together all support needed, which may include a care transition coordinator (CTC), nurses, physical therapists, occupational therapists, respiratory therapists, speech therapists, dietitians, social workers, and pharmacists.
2. A PAM (Patient Activation Measure)® score. While still in the hospital, the patient is asked a series of questions to determine a PAM score that shows how engaged the patient is in his or her own health. By knowing the patient’s level of motivation at that time, the team can adjust and target education that best suits the patient.
3. A CTC. The CTC helps patients transition from hospital to Maine Veterans’ Homes and then to home or another discharge location. The CTC meets with the patient while still in the hospital to discuss goals and expectations during the rehab stay. The CTC coordinates all services during the rehab stay, attends the discharge meeting, and continues with follow-up support at home.
4. A Home Follow-up Program. Patients are called within 24 hours of leaving the skilled care center, and a home visit is made within 72 hours. The CTC may continue follow-up calls for two to three weeks, if that is what the patient needs.
5. Branded Nebulizers. Maine Veterans’ Homes discovered several patients were not doing prescribed treatments due to Medicare reimbursement being low for nebulizers or patients not knowing how to use the machine at home. Maine Veterans’ Homes purchased the equipment and now teaches patients how to use the nebulizer and then sends that exact nebulizer home with the patient. A branded sticker is placed on each piece of equipment going home with a patient.
6. Patient-Specific Follow-up Letters. A patient-specific letter is sent back to the patient’s primary care physician and/or pulmonologist to summarize the patient’s stay and help keep the lines of communication open between all care providers.

Implementation, with Adjustments

When the program launched, Maine Veterans’ Homes reached out to hospital emergency teams to educate them on the niche program and the support the center could provide for respiratory patients. A simple conversation was arranged to ensure all parties knew what situations could be diverted back to Maine Veterans’ Homes versus a hospital readmission.

The team also took time at the beginning to evaluate and adjust as needed.

For example, the time frame for the first home call after dismissal was changed from the initial plan of 48 to 72 hours to within 24 hours. 

The team found some patients needed immediate assistance, whether it was confusion over the use of an inhaler or a home health agency not arriving as planned. It was better to offer assistance early to all than risk having a patient not call and end up in the emergency room.

Expansion Ahead

Maine Veterans’ Homes plans to expand the program, now targeted at COPD patients at its Scarborough, Bangor, and Augusta locations and at pneumonia-specific patients in all six of its Maine locations. And, with the groundwork already laid for how to develop such a program, the team can replicate the development process to create additional niche programs, such as one for cardiac patients transitioning from the hospital to post-acute care to home. 

Maureen Carland, MA, RN-BSN, NHA, is administrator of Maine Veterans’ Home – Scarborough, Maine. She can be reached at (207) 883-7184. The extensive efforts in developing the program led to Maine Veterans’ Home – Scarborough receiving the American Health Care Association/National Center for Assisted Living 2016 Gold – Excellence in Quality Award for meeting the standards of the Baldrige Criteria in the areas of leadership, strategic planning, customer and workforce focus, and operations and knowledge management.