Model of Care in a Comprehensive Sleep Program

Dara Vega, RN, RCP

Project Manager II, Ambulatory program supervisor, Kaiser Permanente Sleep Medicine Department; Fontana, CA

Objectives: • Identify current challenges in sleep medicine and directions for

the future • Discuss methods of utilizing team-based care to improve the ability

to manage sleep disorders • Define the critical role of emerging technologies to enhance the

delivery of sleep medicine care

Sleep LabsMoving Beyond the Basics

Dara T. Vega, RN, CRTT, RPSGTManager Fontana Sleep CenterSCPMG/Kaiser Permanente

Model of Care in a comprehensive Sleep Program

Type of Potential Conflict Details of Potential Conflict

Grant/Research Support

ConsultantSpeakers’ Bureaus

Financial support

Other

2. I wish to disclose the following potential conflicts of interest:

1. I do not have any potential conflicts of interest to disclose, OR

4. This talk presents material that is related to one or more of these potential conflicts, and the following objective references are provided as support for this lecture:

3. The material presented in this lecture has no relationship with any of these potential conflicts, OR

Conflict of Interest DisclosuresSpeaker: Dara Vega

Objectives

During the course of this program you will:

• You will understand the current challenges sleep Technologists and sleep labs are facing.

• Examine how and where to shift areas of focus in treating patients with sleep disordered breathing issues.

• Learn about one model of care practiced at the Kaiser Permanente Fontana Sleep Center

State of Sleep In America

50‐70 million suffer from chronic sleep loss and sleep disorders

80 to 90% of remain unidentified and undiagnosed

Primary Care physicians seldom ask patients about theirsleep

Trends in Sleep Medicine

HEART ATTACK

INCREASED RISK OF EARLY DEATH

Detrimental Health Consequences

STROKEHigh Blood Pressure

Heart Attack

Economic Impact

Increased Public Awareness

AASM Accredited Sleep Labs

Medicare Spending

HSAT Effect

PSG

1. Financial viability of additional growth of attended PSG labs?

2. Alters the expertise required for techs

HSTHST

4X1X

Sleep Lab Closures

•1‐1‐14 Sleepcare Diagnostics Closing: Cincinnati Based Sleep Disorder and CPAP Center

•1‐1‐13 Sleep Health Centers close 39 labs in New England & Arizona

•12/2011 Irving’s Total Sleep shutters testing sites

•1‐14‐2010 UCI to Close Sleep Center

Blue Print for ChangeInstitute of Medicine

“Executive Summary ." Crossing the Quality Chasm: A New Health System for the 21st Century . Washington, DC: The National Academies Press, 2001 .

Supportive payment & regulatory environment

Organizations that facilitatethe work of patient centered teams

High performing patient centered teams

Outcomes:• Safe• Effective• Efficient• Personalized• Timely• Equitable

Care System

Redesign Imperatives: Six Challenges• Reengineer care processes• Effective use of communication technologies• Knowledge & skills management• Development of effective teams• Coordination of care across the patient conditions,

services, sites of care over time

Future of Healthcare

• Outcomes Based Medicine• Team Based Care

Physician

Patient

Physician

PA RNLVN/MA

RCP/ techs

Patient

Office Visit Office Visits

Web encountersText/Email/Phone

Automated mechanisms

Peri‐operative

Clearance of DOT

What is Sleep Medicine?

Insomniapsychiatry

NarcolepsyRLS

Respiratory Failure Pediatrics

Neuro PulmInsomnia

Respiratory Failure

PediatricsNeonates

Non‐PAP Rx

CPAP follow‐upOSASleep labs

In‐Patient

NarcolepsyRLS

OSA

Kaiser Permanente Experience(Fontana Medical Center)

Network of 8+ Sleep Centers in Southern California 

• Serving 800,000+ patients

•Monthly volume:•1000 referrals •3500+ encounters•400 new OSA diagnoses•300 new PAP orders per month

Service Growth

Personnel

Patient Volume (per month)

• 3500+ visits• 5000 telephone• 180 inlab PSG (night)• 20 inlab PSG (day)• 440 HST (diagnostic)• 400+ APAP trials

Personnel• 3 Physicians• 2 Dentist• 1 PA• 1 RN• 7 RPSGT (days)• 9 Rcp (days)• 5 RPSGT/RT (nights)• 1 LVN• 4 medical assistant• 3 Managers (day and night)• 6 Clerical staff• Registry Staff

Ambulatory PSG

Attended PSG

CPAP Follow‐up program

Alternative Therapy Program

Peri‐Operative Program

Insomnia Program

CPAP Clinic

DME Closet

Research

Remote Ambulatory Program

Hypo‐ventilation & Complex sleep disordered breathing  

Follow‐up Program

Commercial Driver 

Pre‐natal OSA 

programProvent

OA Therapy

Dental visits

Winx

Sleep Physician 

Consultation

Case Manager

Weight loss program

Sleep Center Services

Pediatrics

Inpatient Hypercapnic Respiratory Failure 

Program

Reorganize Sleep Labs to Sleep Centers

• Team Based Practice 

• Protocol driven care

• Group appointments

• Using technology to improve efficiencies

Traditional Indications for PSG

OSA(90%)

Pediatric (5%)

Miscellaneous (5%)

Reasons for Attended PSG

OSA(20%)

CSA(15%)

Pediatric(18%)

Hypersomnia(MSLT\MWT)

(8%)

Commercial drivers(6%)

PLMD (4%)

Parasomnias (2%)

Other (2%)

HypoventilationHypoxemia

(25%)

PT SETUP• APPLICATION• IMPEDANCE LEVELS

CollectionTitration

• DIAGNOSTIC• MSLT• MWT• CPAP BIPAP

SCORING• ADULT• PEDIATRICS

PSG

Traditional Technologist Skills

New PSG Technologist Skills

PT SETUP• APPLICATION• IMPEDANCE LEVELS

Enhanced Diagnostics

• Clinical Assessment• Capnography• Transcutaneous Monitoring

Complex Therapy Protocols

• VAPS• ASV• Dead Space Therapy•MATRx / Provent

Role of the Sleep PhysicianTeam Leader

• Interpret Sleep Studies

• Direct consultation for complex patients

• Create a clinical care pathways via protocols for patients to be implemented by case managers

• Build staff capacity

• Build projects often in collaboration with other departments

Roles of Case Management Team

Physician Support• HST Setup• APAP setup• Mask fitting• Remote monitoring• Therapy compliance checks• Maintains equipment• Occasionally communicates physician directed messages to patient (minimal clinical assessment)

Physician Extenders• Patient education (class or individual)• Communicates testing results with patient

• Clinical assessment and clinical decision making

• Referring or triaging to specific services

• Consults directly with sleep physicians

• Communicates directly with referring provider or other non‐sleep dept medical staff.

Task Oriented Clinical Judgment

Team Based Care

• Booking Team• Generalist HSAT Team• Alternative Therapy Team• Insomnia/Shift worker Team• Complex Sleep Disorders Team• In‐Lab Team• Dispensing Team

Complex Sleep Disordered patients

PSG

DX OFCOMPLEX SLEEP 

DISORDER

RN/RCP CASE 

MANAGERMD 

CONSULTMD 

CONSULT

DIAGNOSTIC WORKUPPFT’sABGECHOCXR

FOLLOW‐UP•Labs•Adherence to therapy•Oximetry study

FOLLOW‐UP•Labs•Adherence to therapy•Oximetry study

Protocol Driven Care

HSAT Protocol & Workflow

POSITIVE

CLASS OR INDIVIDAUL APPOINTMENT

NEGATIVE

APAP TRIAL  Insomnia class MD CONSULT

FOLLOW UP PRN

PRELIMINARY RESULTS BY RCP

IN LAB REFERRAL

REPEAT HSAT

APAP TRIAL with O2 probe for ? 

HypoventilationCSA

HSAT Protocol & Workflow

• Patient failed HSAT and strongly request in lab

• Patient on home oxygen and did not disclose 

• Patient lives >40 miles away

• Flow and • Abdominal and 

thoracic belts flat lined during CSA periods

• AutoPAP trial regardless, to check for high residual AHI, about AHI >15 hr

• History of CHF or narcotics predispose to CSA

HYPOVENTILATIONPROTOCOL• Strongly consider if 

initial baseline oxygen saturations are persistently below 90%, look at T90.

• Persistently low saturations during OSA periods with poor recovery (usually below 90%)

• Oximetry probe trial unless on oxygen prior to in‐lab. 

• Cancel in‐lab if oximetry >90%

HYPOXEMIA  ADDITIONAL REASONS

CENTRAL SLEEP APNEA

• Low oxygen saturations noted during the entire sleep study

• History of oxygen supplementation

HSAT to Attended Sleep Studies Referrals

Encounter Efficiency

Insomnia Background

• Cognitive Behavioral Therapy (CBT) is effective in treating individuals with chronic insomnia, typically delivered in multiple sessions and individually (or small groups.)

• Our challenge is to deliver CBT cost‐efficiently given the high prevalence (30%) in the population. 

• Edinger et al (Sleep 2007) revealed 1 session CBT protocol to be reasonably comparable in effectiveness to multi‐session CBT.

• Other studies (Espie, Sleep 2007) showed group format (4‐6 persons) also effective.

• Kaiser Permanente (Fontana MC) – 430K members (129K chronic insomnia)1 Session CBT in Large Group Format

INSOMNIA PROGRAM

BY REFERRAL, SELF REFERRAL  OR CASE MANAGER AFTER REVIEWS 

AMBULATORY STUDY

INDIVIDUAL CONSULTATIONS BY PA

FOR SPANISH SPEAKING OR PEDIATRICS

CBT CLASS 120 MINUTESINSTRUCTED BY THE PHYSICIAN ASSISTANT

FOLLOW UP CALLSBY PA/LVNINDIVIDUAL 

APPOINTMENTS

Technology

Wireless Modem

Fox et al, SLEEP, Vol. 35, No. 4, 2012

CPAP Adherence at 3 months

Outcomes

Impact of case management

• Improved adherence to non‐invasive ventilation from 10% to 90%

• Classroom format for insomnia CBT proven to be cost effective (89% subjective improvement; reduced insomnia medication fills; 25% reduction in primary care office visits 1 yr. after program)

• Primary care physician survey: 100% reported closed‐loop sleep program reduced time spent managing sleep disorders; 88% reported case management program improved care over physician (sleep or primary care physician) management.

Challenges

• Recruiting and training staff

• Quality Improvement

• Continuous education

• Integrating new technologies

• Rapid improvement model

• Patient traffic control

Summary

• Shift Sleep labs to Sleep centers

• Own your own: close looped process

• Move from tasks to care management

• Build skills to partner with patients

Future For Sleep Medicine

Acknowledgements

• Dr. Dennis Hwang, Chief of Service KP Fontana Sleep Center

• Dr. David Quam, Medical Director KP Fontana Medical Center

• KP Fontana Sleep Center

• Rosa Woodrum, RRT, Department administrator

• Julie DeWittte RRT, Assistant Manager

• Cindy Gulley, Physician Assistant

• Jeremiah Chang, Research Associate