Integrated uses specialty protocols to clinically manage and oversee the COPD disease management population by their proprietary program called, Carelogics.  Carelogics’ algorithm includes informatics analysis, patient population identification, disease specific risk stratification, RT Led care plan implementation and management, and outcomes and measures reporting focused around clinical care and utilization.  This specialized program works in collaboration with their medical director and clinical implementation team to fully develop this specialty COPD program.

Integrated’s clinical team of respiratory therapists, nurses, and patient care advocates identify patients that are High-Risk and At-Risk by looking at past medical history and examining a variety of key disease factors such as exacerbation history, hospitalizations, CAT, activity level, medication complexities, and current length of stay, etc. to stratify the patients into their specific risk level category. High-Risk, At-Risk and Low Risk patients are assigned to the appropriate 30 day follow up program that will encompass home RT visits, follow up telephone outreach calls, and telehealth devices used to monitor and measure patient health status.  The most important key to the program is to identify the High-Risk/At-Risk patients, most probable to have an event, in the COPD population and designate them for Carelogics specialty care program.   

Building the relationship between the patient and the Integrated care team is the key to the success of the program. Through the process of patient coaching and encouragement, education and oversight, the Respiratory Therapist and/or clinical team member helps empower the patient to self-manage their disease process.  Carelogics is structured around 5 main pillars that focus on overseeing, monitoring, and managing breathing, activity, self-management skills, medication management, patient education and best practice management.

To demonstrate this success, Integrated compiles program data and aggregate results to illustrate the value of his program. The ability to report these outcomes on a regular basis in an easily understandable format allows hospitals and providers to feel confident turning their patients over to Integrated after discharge. Integrated’s Patient Management Program is expanding to include multiple co-morbidities that frequently plague this population.  Additionally, Integrated act as a population health partner to identify any gaps in care and communicate them to the care continuum for better patient management and outcomes.

RESULTS:

Successful Outcomes and Improved Patient Wellbeing and Satisfaction

The program achieved significant reductions in readmission rates for both this program and within the hospital COPD population, in general.  Below is an actual past example of a large hospital that was managed with the Carelogics disease management program.

• Approximately 33% of COPD population were determined to be High-Risk or At-Risk – In a hospital management example this population was approximately 600 patients out of 1800 patients over a 12 month period 
• Readmission rates for the risk populations identified on this program were reduced from 17% to 7.7%; a reduction of 54% over a 6 month time period.
• Readmission rates for the total COPD population were reduced from 25% to 15%; a reduction of 40% over a 6 month time period.

Additionally, patients reported an overall improvement in their wellbeing and were highly satisfied with the program. A wellbeing score between 6 and 10 was report 77.2% of the time over the past six months.  Since the inception of the program, patients report a satisfaction score 8.95 out of 10.

Staying focused on their key commitment to top level patient care has benefited everyone involved.  Please feel free to discuss this program with your Integrated territory representative. They can provide a understanding of the base program, can schedule an assessment and evaluation of your present hospital/facility/population, and can provide a comprehensive program detailing how the program would work, how patients would be identified, how the key stakeholders would collaborate, and what metrics, outcomes, and ROI would be produce.  Let us work with you to keep your patients healthy at home.