Community Collaboration Keeps Chronically Ill Out of Hospital

By J. Duncan Moore Jr./Medicare NewsGroup - June 26, 2013
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The elderly woman was missing her doctor’s visits and was ending up in the hospital every month. The doctor asked Karla Hall, a registered nurse and certified case manager, to find out what was going on.

Hall called the woman first. “I said, ‘Do you have an appointment to see your doctor?’ She said, ‘I do, but I’m too weak to get there’.”

On a home visit a few days later, Hall found that the patient’s regimen was impossibly complicated: she had home oxygen, three different inhalers, a nebulizer machine, pills, injectable medications and a blood thinner that all required daily dosage adjustment.

Once Hall taught the patient how to manage her medications and found her a driver, the trips to the emergency room stopped. “We never saw her back in the hospital for the next two years,” said Hall, a care transition specialist with QualisHealth in Bellingham, Wash. 

This successful patient intervention was part of a demonstration project organized by Medicare in an effort to reduce the high rate of hospital readmissions among the elderly. QualisHealth was one of 14 regional quality improvement organizations paid by Medicare to develop protocols to try to keep elderly patients with multiple chronic conditions out of the emergency room. Those ailments include diabetes, congestive heart failure, kidney disease, and chronic obstructive pulmonary disease.

As a result, the 30-day readmission rate in the Bellingham region dropped from 8.4 per thousand Medicare beneficiaries between 2006 and 2008, before the new protocols, to 7.8 per thousand between 2009 and 2010, during the study period. That is considered a good outcome.

Hospital Readmissions Are an Industry Problem

Needless hospital admissions and readmissions are costing Medicare vast sums of money every year, signaling that patients and their doctors are not managing health care as well as they might. The distinct silos of doctors, hospitals, home health services and nursing homes, experts say, aren’t working together for the benefit of the patient.

Studies have shown that the rate of rehospitalization within 30 days of discharge for Medicare patients with certain common conditions runs nearly 20 percent.

“When we take our car to the shop, if we found that one out of five times we have to bring our car back…we’d be pretty upset,” said Jonathan Sugarman, M.D., president and CEO of QualisHealth.

Often patients and family members don’t understand the hospital discharge instructions, or can’t make a follow-up appointment with the doctor in time, or don’t know when and how to take the various medications. When complicated conditions slip out of control again, the only recourse is to head back to the hospital, usually as an emergency readmission.

“Most of the time the front-line nursing staff and physicians don’t realize that readmission is a problem,” said Robin Jones, a nurse and quality improvement coordinator at Valley Baptist Medical Center in Brownsville, Texas, which participated in the demonstration project. “What are the chances the patient comes back to the same floor and the same nurse? They don’t know the patient is back within 30 days and the problem is more severe (than the last time).”

Indeed, when Hall reported back to the physician in Bellingham what she had found, the doctor was brought up short. She hadn’t realized how complicated the elderly patient’s home treatments were. “I should be addressing that with every patient I see,” she told Hall.

In Jones’s region, the lower Rio Grande Valley, the 30-day readmission rate declined from 18.5 per thousand Medicare beneficiaries to 16.4 per thousand over the four years of the study.

“In a world in which it is very difficult to bend the cost curve and change utilization patterns, (the study) showed some protocols toward better care actually worked,” said Joanne Lynn, M.D., a coauthor of the study published in the Jan. 23–30 issue of the Journal of the American Medical Association.

In the 14 localities that participated in the Medicare demonstration project, hospitalizations and rehospitalizations declined nearly twice as fast as in similarly situated regions where no interventions were conducted. Over two years, both measures declined nearly 6 percent.

The Affordable Care Act (ACA) introduced penalties that went into effect Oct. 1, 2012, for hospitals with poor readmissions rates for three common diagnoses: heart attack, pneumonia and heart failure. Now that real money is at stake, hospitals have started taking the readmissions problem much more seriously.

Improving Care Transitions

The beginning of this study, however, predates the ACA by several years. The study allowed each region to choose its own intervention protocols and to disseminate them among all the providers that have contact with the patient. The goal was to involve doctors, nurses, and social service agencies in communitywide quality improvement programs to keep seniors healthy and at home.

Valley Baptist, in the Rio Grande Valley, started with the diagnosis that had the most readmissions: congestive heart failure. The hospital engaged with nursing homes, home health agencies and the local agency on aging to smooth out the barriers to effective post-hospital care.

They used the Project RED (Re-Engineered Discharge) model, developed at Boston University Medical Center, to make sure each patient understands the discharge instructions and can “teach them back” to the staff.

Patients are asked: Did you receive discharge instructions in a language you could understand? Did nurses teach you the things you didn’t know? Do you have all the equipment you’ll need at home? Do you know why you’re taking these prescriptions?

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