Changing reimbursement incentives are forcing hospitals to focus on preventing readmissions. Yet hospitals are stymied when patients fail to take their medications. Adding a home visit from a nurse soon after discharge may provide a beneficial and cost-effective option to keep the most complex patients out of the hospital.

Nurses routinely follow up with discharged patients by telephone to monitor their recovery and ask about medications, but that can be insufficient.

“We couldn’t tell on the telephone that they were not taking medications,” says Linda L. Costa, RN, nurse researcher at The Johns Hopkins Hospital, and assistant professor at Johns Hopkins University School of Nursing.

Increasing nurse involvement to include in-person follow-ups may help patients stay on track, according to a study by an interdisciplinary research team that included two nurses and a pharmacist based at The Johns Hopkins Hospital.

The study, funded by the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative, followed a group of chronically ill patients taking multiple medications and examined whether a simple, early intervention could make a difference in the patients’ post-hospital progress and prevent readmissions. The study sent nurses on home visits to discuss medications and solve problems that prevented patients from sticking to their regimens.

Costa, the lead researcher, says the study’s genesis was calls from patients to nurses after discharge to clarify medication orders.

Many patients with chronic illnesses face complicated medication regimens they may not understand, have prescriptions that need to be filled, or wonder what to do about prescriptions they had been taking before hospitalization.

“We had to go to the home and see it,” Costa says. “It was the only reliable way to really know what [their] medication management is.”

In the home visits, the nurses could determine patients’ understanding about managing their medications. Nurses called the patients two days after discharge to talk about their medications, then visited patients’ homes two weeks after they had left the hospital.

The home visit “was really the way we could see what was going on, as far as medication went,” says Costa. “We could look at the bottles, see how they organized medications [and] filled prescriptions, if they understood what medications they were supposed to be taking.”

The nurses identified discrepancies between treatment plans and what patients were doing post-discharge. “Many discrepancies were not intentional,” says Costa. “Patients were just confused with the instructions.”

Study participants were taking about 10 medications on average, so instructions were plentiful and complicated. The nurses were surprised to learn that money was usually not the barrier to medication adherence. “A lot of patients did have supplemental help because they were lower-income,” Costa says. “The problems were mostly in not understanding or deciding not to take a medication.”

The nurses found that talking with patients and their families improved their understanding of their medication regimen and increased compliance. But the nurses struggled with patients discontinuing medications because of side effects.

The study “confirmed that if they felt a med was not helping them or made them feel worse, they stopped taking it,” Costa says. “How they identified which medication was random. It could be a blood pressure pill or a blood thinner pill. They would select one or two and they would stop taking them if they felt it was affecting them. It wasn’t related to particular side effects and it was pretty random as to which one they didn’t take.”

In some cases, the most important nurse intervention was counseling patients to tell their doctors that they were not taking or had problems with particular medications.

Costa ran the pilot study on a small budget and hopes to examine the larger implications of the findings with further research. She says the initial results indicate that home visits provide a good return on investment.

“If you look at the costs that hospitals will spend to reduce readmissions, the cost of this program is not that significant,” she says. “We’re seeing patients in our local area, so it’s feasible to do. There is value to be had and I don’t think it’s exceedingly costly.” 

Nurses at NYU Langone Medical Center didn't bat an eyelid when Hurricane Irene started barreling toward the northeast last month. The hospital, just steps away from New York's East River was ordered evacuated, along with four others in harm's way, by Mayor Michael Bloomberg.

But NYU-Langone refused to move six of its ICU patients, warning they were so desperately ill that moving them threatened their lives. The ICU's nurses instead opted to stay with their patients through whatever the storm threatened to bring.

After receiving permission for the six patients to remain, Elaine Rowinski, RN, MPS, CCRN, CEN, nurse manager of the medical ICU, found she had no shortage of staff volunteering to stay and care for them.

"Every day we're faced with life and death. Every day my staff are heroes," said Rowinski. "Maybe because we're New Yorkers, we're very resilient. Also we're critical care people. This was nothing unique. Just what they're faced with and you deal with it. I'm very lucky."

The preparations began on Friday, two days before the hurricane was expected to hit. The 18-bed medical ICU immediately made plans to transfer its patients to other hospitals. Transferring critically ill patients is extremely complicated and the staff had to complete a large number in a short time, but it made discharges and handoff transitions smoothly and successfully.

Due to the critical nature of their illnesses, many of the patients had to be accompanied in the ambulance by ICU nurses to ensure they did not crash during transfer. Rowinski says many patients and families didn't want to leave.

"It's a tribute to the medical and nursing care they get here," says Rowinski. "Some patients are with us for a while and they've been very sick for a long period of time. They develop relationships with physicians, nurses, and other members of the healthcare team. They have a comfort level and sending them out would change their comfort level."

Rowinski says the hospital practices patient- and family-centered care. Visiting hours are 24/7 and families are made to feel welcome. When families call for updates on their relatives, they don't have to call the switchboard, they simply dial their family members' nurse's line and speak to him or her directly.

"They talk to nurses constantly," says Rowinski about patient's families. "There's a relationship between families and the healthcare team."

The nurses worked to keep patients and their families informed and Rowinski made rounds to explain what would happen. As the hurricane neared, the staff made preparations in case they were cut off. They collected three days worth of medications for each patient and stocked each room with items such as flashlights and ambu bags.

Mass transit was due to be suspended at noon on Saturday and so nurses brought bags of personal items and prepared to stay at the hospital for an extended period of time.

"On Saturday morning, I had full complement of nurses," says Rowinski. "My whole unit was staffed, everyone came in for their normal shift. I had people who came in 18 hours before their shift so they would be here."

Christine King is a senior staff nurse on the medical ICU who was originally scheduled to work the weekend. After the evacuation notice decreased the need for as many nurses, she was told she didn't need to come in. Instead, she volunteered to stay the entire weekend to care for the handful of patients in the ICU.

"It was important for me to be here because our patients deserve the same quality of care even when times are difficult," says King. "Throughout the weekend the team of nurses and staff reassured patients they would continue to be cared for and were very supportive of the patients and their families who stayed with them. It was a blessing to be here and I would do it all over again."

Rowinski credits the hospital's disaster planning for the smoothness of the experience.

"In every hospital, you have tests and drills. We say sometimes they are stupid to do, but they really do prepare you for things like this," she says.

For example, the hospital's checklist included a provision to check whether patients were on dialysis. A few of the patients who were staying did need dialysis, so they provided the treatment on Friday in case they could not do it after the hurricane.

"It sparked ideas in our minds to get special therapies done early in case we couldn't do it afterwards," says Rowinski. "Teamwork makes all this work. Everyone talking to each other and listening to each other makes it work."

The blood bank made sure the ICU had the blood it needed and respiratory therapists stayed on the unit around the clock. In the end, the hospital evaded any major damage and everything was back to normal within a few days.

The experience has brought the unit closer together.

"I'm very fortunate to have them," Rowinski says of her dedicated nurses. "Everything ran very smoothly. There was a camaraderie we got from working through it together."

When revenues fall, hospitals stop investing in the biggest budget expense: nurses. That's a bad short-term solution to a long-term problem. It's time we change the way we think about hospital staffing.

"When we look at all the problems we have [in healthcare right now], what is the first thing we do? Start slashing nurses," says Kathy Douglas, MHA, RN, president of the Institute for Staffing Excellence and Innovation, CNO of API Healthcare, and a board member of the journal Nursing Economic$, which has devoted a whole issue to examining the evidence around nurse staffing. 

"Healthcare executives and nurse leaders need to be more aware of thinking about staffing and scheduling from a bigger perspective so we understand all of the financial implications," she says. "How do we manage our way effectively through the maze and chaos we are in right now?"

To deal with ongoing challenges presented by value-based purchasing and healthcare reform, executives must acquaint themselves with studies demonstrating how nurse staffing affects a hospital's overall performance and base staffing decisions on evidence.

"What we know from research and experience is that there are very direct links between staffing and length of stay, patient mortality, readmissions, adverse events, fatigue-related errors, patient satisfaction, employee satisfaction, and turnover," says Douglas. "All of these things have studies that directly relate them to staffing. And all have the potential for significant costs. When we don't look at the relationship between our LOS and our unreimbursed never events and our staffing, we're not looking at the whole picture."

Too few hospitals track staffing data in comparison to these big issues.

"Some of these things people might call 'soft costs,' like nurse turnover," says Douglas. "But to me, money is money."

Soft costs have hard financial implications. Value-based purchasing has already put real money behind patient satisfaction. To make the link to staffing research and why it matters, we have to stop looking at staffing numbers in isolation. Until we look at the whole picture, which includes everything associated with staffing, we're not going to understand financial performance.

"Staffing costs sit in one part of the budget, so we think of the results there," says Douglas. "Then the cost of errors sits in another part of the budget. If I could say one thing to healthcare executives it is to make staffing a top strategic priority in your organization. If you look at top priorities—LOS, safety, quality—all of these things have direct links to staffing."

An organization that has cut back on staffing may not notice that it is overusing overtime and not notice that there's a relationship between the overtime and the number of infections on a unit.

Peter I. Buerhaus, PhD, RN, FAAN, chair of the National Health Care Workforce Commission, a 15-member panel composed of distinguished leaders from academia and the healthcare industry created under The Patient Protection and Affordable Care Act, published research in 2008 looking at unreimbursed errors in healthcare, such as catheter-associated urinary tract infections and central line infections.

"I decided to get out my calculator and add them up. When I looked at it in one year the total came to $21 billion in unreimbursable events," says Douglas.

"When hospital executives tell me there's not enough money to staff well, my first thought is 'what about the $21 billion we spend each year on unreimbursed never events?'"

Douglas believes the answers lie in using data and evidence to make effective decisions and utilizing technology in decision making. She is not a fan of blanket ratios.

"It's not that ratios are bad in and of themselves. Ratios happened, in my opinion, because hospital leadership and nursing weren't communicating well," she says. "My issue with ratios is that it assumes [staffing] is about a number. I disagree with that. It's not about a number. It's about the right number with the right qualifications with the right competencies with the right experiences."

Douglas says hospitals need to be free to examine all the factors and design a system that is flexible and allows flexing up and down based on patient needs and professional nurses' best judgment.

To do so, we need a better understanding of what the research shows about nurse staffing. We also need nurses who understand how they contribute to overall performance and who are accountable for that role.

The last thing most hospitals want to do in a time of financial uncertainty is spend money on training and development. We know, however, that poor managers harm retention and productivity and we know that many nurse leaders feel unprepared to manage through the strategic change their organizations need.

Lillee Gelinas, vice president and chief nursing officer at VHA Inc., holds regular CNO group meetings for nurse executives across her health system. At the last one, Gelinas says the group of 100 CNOs decided to focus not on a single topic, such as value-based purchasing, but on innovation and leading change. The group felt they do not possess the skills and competencies to lead an organization through whole-scale transformation.

This is true for many healthcare executives, but the problem is particularly acute for nursing leaders who started out in clinical settings and rose through the ranks with fewer opportunities for formal business training.

Many choose to return to school for MBAs or other degrees that will hone their business acumen. Kim Sharkey, CNO/vice president of medicine at Saint Joseph's Hospital in Atlanta, already held an MBA when she decided to pursue a doctor of nursing practice degree.

"In my role, where I am VP for medicine, I work with doctoral-prepared medical practitioners," says Sharkey. She asked herself, "Do I really want to be the least educated person at the table?"

"I needed to find a program that would allow me to gain that skill and knowledge," she says. "It has really expanded my vision, scope of thinking, my ability to access and use evidence-based practice. It puts me at a more advantageous position at the table negotiating with other people."

Not everyone has the time or inclination to pursue advanced degrees. There are options such as the Robert Wood Johnson Foundation's Executive Nurse Fellows initiative or the American Organization of Nurse Executive's Nurse Manager Fellowship, but these are few and far between.

Some organizations create their own nurse leadership programs, which is what United Healthcare Group has done. The company employs more than 7,000 nurses in 43 states, making it one of the largest employers of nurses in the U.S.

The idea began a couple of years ago, says Dawn Bazarko, senior VP of UnitedHealth's Center for Nursing Advancement. "We observed there were needs around leadership development," she says. "There were not enough nurses at the table and their voices were not being heard. Given changing healthcare and the fact nurses make up the largest portion of it, we saw a missed opportunity and a chance for us to invest in nursing in a different kind of way, for us to prepare leaders to serve in larger roles."

The Center for Nursing Advancement focuses on nurse engagement strategies and training, development, and mentoring for nursing professionals within UnitedHealth. In conjunction with the University of St. Thomas, Bazarko created an executive development program specifically for nurse leaders.

"We could bring out untapped potential," says Bazarko. "Move our nurses into senior leadership roles. Many didn't have the skills and competencies to move into these roles."

"We designed a curriculum based on a number of needs assessments and put together a cohort-based intensive," she says. The program lasted just two weeks and offered a variety of executive leadership development competencies. It provided training about strategy, finances, change management, ethics, and business communication, all centered around the creation of a nurse leader profile.

The attendees were chief nursing officers, VPs and senior director levels, to ensure a peer environment where attendees were on similar levels. The program was so successful that UnitedHealth plans to offer it again.

What's important is that the program meets the unique needs and opportunities nurses face. "It's not a mini MBA, although some courses might resemble it," says Bazarko. "It's business education with a nursing perspective."

Bazarko believes the value to the organization will more than repay the expense of sending the nurse leaders for training. The nurses had to bring an idea for a leadership development project for their home organizations to work on during the course and then apply what they learned when they get home so they can drive a major change initiative.

"Despite pulling senior nursing leaders out of their jobs at very busy time in healthcare in our country, we wanted to provide them with lot of opportunity and enrichment in a short time," she says. "But we're always mindful of need for return. We're fairly confident that one year from now when we've implemented the projects, they will drive both quantitative and qualitative benefits."