Sometimes, Namie says, preventing readmissions means doing something for patients that has nothing to do with their physical health but improves their mental outlook so that they work harder to stay out of the hospital.
One of the nurses had a patient with no furniture except a bed, "so she stayed in bed all the time. The nurse arranged for her to get a chair, so now she can sit by her window and see her garden."
When teams analyzed why patients were being readmitted for any reason, it became clear that many were illiterate but had developed great skills at covering it up. "It's hard to adhere to a medication regime if you can't read the bottles," she says. Mercy Health worked with these patients to solve the problem by color-coding bottles in patients' homes, she says. Pills taken once a day were in bottles with one color while those taken twice daily were another color. Diuretic bottles were a third color, so when the physician advised a particular patient to take more diuretics, he would go to the correct container.
The physician's nurse often does the color-coding during office visits, and a Mercy Health "parish nurse" follows up in the patient's home.
Outside the hospitals, Mercy Health's care coordination teams now have a program in which nurses are stationed in physician offices, especially for patients with chronic pain, heart failure, COPD, or uncontrolled diabetes, says Lynne McCabe, director of the community care coordination program.
"The majority of our patients had some sort of financial or social behavioral issue, so we have two social workers that are part of the team."
The teams worked on multiple targets, from lowering hemoglobin A1Cs and lowering cholesterol, compliance with ACE inhibitors, and continued smoking cessation for this especially difficult population.
So far this effort has worked with about 300 patients who had a history of frequent readmissions. In the first year of the program, between June 1, 2011, to May 31, 2012, these patients had 51% fewer admissions, more than 35% fewer readmissions, and more than 35% fewer trips to the emergency department than the same group of patients had during the previous year. In addition, 12% of the patients had stopped smoking.
Namie acknowledges that Mercy Health is ahead of the curve on preventing all-cause readmissions. "I think we're probably a little sooner than the tipping point. But I know there's a high level of interest at other facilities. We get calls all the time from other healthcare systems asking us about what we're doing."
This article appears in the May issue of HealthLeaders magazine.