Dec 12, 2007

Keeping Patients from Landing Back in Hospital
By Laura Landro
The Wall Street Journal
December 12, 2007

Hospitals are taking steps to prevent the most common risk to patients after discharge: landing back in the hospital due to complications that could have been prevented with better follow-up care.

A revolving door of readmissions is driving up costs for hospitals and causing needless harm to patients, especially elderly people with multiple chronic diseases. Nearly 18% of Medicare patients admitted to a hospital are readmitted within 30 days of discharge, accounting for $15 billion in spending, according to the Medicare Payment Advisory Commission, the independent federal body that advises Congress on Medicare. As a result, readmission rates are coming under increasing scrutiny from regulators, insurers, employers and quality-measurement groups, who are considering methods to tie payment to lower readmissions.

"We have to start paying attention to people's needs beyond the hospital door," says Mary Naylor, a professor at the University of Pennsylvania's School of Nursing. She has conducted a number of clinical trials on a model to help older adults with complex care needs after they are discharged. "The experience of multiple hospitalizations can take a devastating toll on the human psyche and the quality of life for patients and their caregivers," she says.

There are about five million readmissions a year in U.S. hospitals, with approximately a third occurring within 90 days of discharge, according to the Institute for Healthcare Improvement, a Boston-based nonprofit. But with so-called transitional-care programs, which follow patients for varying periods of time at home, as many as 46% of readmissions could be prevented, says Pat Rutherford, an IHI vice president.

The institute is working with hospitals to reduce readmissions. Its programs include: identifying patients at risk for return, scheduling follow-up doctor's appointments before patients are discharged, sending nurses to patients' homes within a few days of discharge, monitoring patients at home, and educating patients and families on how to adhere to medication schedules and self-care regimens.

Still, hospitals often don't provide such services. Even patients who qualify for home care frequently don't get referrals that would help, and in one survey, 64% of patients said no one at the hospital talked to them about managing their care at home.

Part of the problem is that hospitals aren't paid to coordinate care once a patient leaves. But that may change: Large managed-care groups and insurers are now experimenting with programs to cover such services. Both Aetna and Kaiser Permanente, the California-based managed-care giant, are working on pilot programs based on Dr. Naylor's model. Her studies show that discharge planning and home-care services for at-risk hospitalized elderly patients can reduce readmissions, lengthen the time between discharge and readmission, and cut the cost of providing care.

Broad Rollout is Possible

If pilot programs in Chicago and Philadelphia do succeed in reducing readmissions for Aetna's Medicare members, such programs could be rolled out more broadly, says Randall Krakauer, an Aetna medical director. "We believe this can improve the quality of care for members and more than pay for itself by reducing the costs of care by a larger amount than the cost of the home visits," Dr. Krakauer says.

IHI and other groups are focusing in particular on follow-up care for patients with congestive heart failure, the leading cause of hospitalization among older patients. According to Ms. Rutherford, almost a third of heart-failure patients are readmitted within 30 days of discharge with complications from the condition, in which the heart can't pump enough blood to the body's other organs. Changes such as sudden weight gain can signal a crisis, so diet and exercise must be closely monitored, along with adherence to treatments such as blood-pressure medications after a patient leaves the hospital.

St. Luke's Hospital, a Cedar Rapids, Iowa, institution that's affiliated with the Iowa Health System, collaborated with IHI on a program called Ideal Transition Home for Patients with Heart Failure, working with local doctors and an affiliated home-care group to coordinate follow-up care.

Among other things, it uses a method called Teach Back, asking patients and families to restate in their own words what they've been told about how to follow care instructions at home. Patients are sent home with a refrigerator magnet that includes a list of symptoms to watch for and an emergency number to call. Gail Nielsen, Clinical Performance Improvement Education Administrator for Iowa Health System, says the program helped the hospital cut unplanned-readmission rates in half, to 6%, as of last January.

David Dunn, a 69-year-old retired golf-course manager suffering from congestive heart failure, diabetes and kidney disease, was admitted to St. Luke's earlier this year to have three stents placed in blocked arteries; with a history of repeated hospitalizations, he was signed up for the home transition program, which included follow-up visits by home-care nurses and special instructions to help his family monitor his condition.

"The care was so much better than anything we'd experienced," says his daughter, Deb Kacena, who recalls other hospital stays marked by poor communication with doctors and little follow-up care. "It was really crucial, because there were so many things going on with him."

Cutting through Red Tape

After patients who may be at high risk for readmission are discharged from Kaiser's San Francisco Medical Center, nurses visit them -- cutting through red tape, if need be, to get them quickly into doctors' appointments. "We form trusting relationships with the patient, and we know what to look for and what could get them back in the hospital," says Jill Murray, a nurse in the transitional-care program.

One grateful patient is 78-year-old Irwin Goldner, a retired clothing salesman who was hospitalized earlier this year with pneumonia and complications from heart failure and kidney failure. After his discharge, nurses in the program accompanied him to doctor's appointments and followed up with phone calls to make sure he was taking his medication correctly and watching his weight. Mr. Goldner says he follows their instructions to the letter in order to avoid going back in the hospital. "I call it self-preservation," he says. "I like living."