Comedian Tracey Ullman always closed her show by telling her audience: "Go Home." But if she were a hospital provider discharging her patients, she might add, "And we're going to do everything possible to keep you there."
As federal payers consider reducing or eliminating payments to hospitals if their patients must return for care in 30 or 60 days, California researcher Jan Eldred went looking for programs with creative transition solutions, so discharged patients can remain safely out of the hospital.
She found nine, from Boston to San Diego, and chronicled their success in "Homeward Bound: Nine Patient-Centered Programs Cut Readmissions."
The nine projects include:
- Colorado Foundation for Medical Care and Partners in North Denver
- Visiting Nurse Service of New York in New York City
- Boston Medical Centers for Disease Control and Prevention.
- St. Luke's Hospital in Cedar Rapids, IA
- Summa Health System in Akron, OH
- John Muir Health in Walnut Creek and Concord, CA
- HealthCare Partners Medical Group in Torrance, CA
- Sharp Rees-Stealy Medical Group in San Diego, CA
- Blue Shield of California
"Hospital readmissions can be significantly reduced using straightforward strategies that are inexpensive compared to hospital care," says the report. According to findings from some of the demonstration projects she included, up to half of all readmissions can be prevented.
The report was published by the California HealthCare Foundation and was written by Susan Baird Kanaan.
"New Medicare rules are coming, and everyone knows they're coming," which will reduce payments to hospitals whose patients must be readmitted within 30 or 60 days, acknowledges Eldred, the foundation's senior program officer who selected the nine programs from about 20 innovative health system strategies.
"We want organizations to know that there are health systems out there that have figured out how to do this already, and that there are things they know do work. They don't have to come up with something from scratch.
"That's the premise on which this report was prepared. We want organizations to know that there are programs that have figured how to do this, to keep patients from having to return to the hospital," Eldred says.
Eldred's report listed four stages of care that allow for effective intervention to reduce readmission:
- Preparation for discharge, a process that can start even as they are being admitted, to make sure hospital staff is aware of the home environment.
- Hand-off to the outpatient physician.
- Medication reconciliation to make sure new prescriptions are filled and that patients are not falling back on their old medication routines.
- Home visit and/or phone call, daily or weekly for the first 30 days.
Some of the innovative programs were launched as long as four years ago by organizations grappling with capitated rates in their health plans while others tackled the problem as an experiment. In all cases, however, leaders said the most important goal was to improve care.
The strategies used in the study include student nurses who make home visits, discharge planners who text the physician that a patient is returning home and needs an appointment, and electronic talking scales that electronically transmit weight and other information daily back to the provider.
Other creative solutions that keep costs down, as well as keep patients in their homes, use discharge advocates who coordinate home care with the hospital team and arrange for follow-up appointments.
"Our program has shown incredible results," says Jerry Penso MD, associate medical director of the Sharp Rees-Stealy Medical Group in San Diego, which has 150,000 patients. "We reduced heart failure admissions by over 25% for all of Sharp Rees-Stealy, and the return on investment is $7 to $1."
Mike Kern MD, senior vice president and medical director for the John Muir Physician Network in the San Francisco Bay Area, says daily visits to patients' homes each of the four weeks after hospital discharge has reduced readmissions dramatically there as well, from an estimated 25% to 10-13%.
Kern says that often when elderly patients are discharged from the hospital, they go home and feel insecure. "They will call 911 not because they need readmission, but because they're scared. And that's the only thing they know how to do. And I don't blame them.
"And when they get to the emergency department, the ER's gut reaction is to throw the book at them, work them up, and they're on their way to the inpatient ward," Kern says. "That's often an over-the-top, wasteful way to do it" when many of their issues can be so much more effectively managed at home.
In Eldred's report, many of the included programs have common elements. "Medication reconciliation is critical," Eldred says, "because patients may have medicines at home that interact with the ones they received in the hospital. Someone needs to reconcile all those medications so patients know what they should be taking and what they shouldn't."
Another common strategy is to use nurse trainees or other health professionals to make daily visits to the patient's home, at least for the first few days to make sure they are following the prescribed regimen.
And a third effective tool was to make sure hospital staff engages patients and families to play active roles in managing their health needs.
A study published April 2 in the New England Journal of Medicine found that nearly one in five Medicare beneficiaries were re-hospitalized within 30 days, and on the whole, unplanned Medicare readmissions cost the federal government $17.4 billion.