Hospital drops readmission rate for HF patients by 10%
Patients not forgotten post-discharge
It's going to hurt at first. Financially, from both the cost side and the revenue side. The investment is huge. And it's a lot of work — a lot of starts and stops, says Gray Ellrodt, MD.
With the Centers for Medicare & Medicaid Services beginning to publicly report readmission rates, reducing them is becoming ever more important. But the problem and the improvement process aren't easy.
"This is as complicated as it gets because you're worrying about everything from hot dogs to telemedicine to as sophisticated care as you can imagine with resynchronization therapy, etc. all the way down to don't drink that Campbell's soup," says Ellrodt, chief and chair of medicine at Berkshire Medical Center (BMC) in Pittsfield, MA, and professor of medicine at the University of Massachusetts Medical School.
Targeting your readmission rates, though it may not be financially rewarding up front, will likely save you money in the long run.
Ellrodt says Berkshire had always tracked its overall admission rate, but once it homed in on the rates associated with certain populations, especially heart failure, with a rate as high as 27% within 30 days in 2007, "the bells and whistles went off" and the hospital decided it had to do something.
Alicia Ferrarin, FNP-C, cardiology nurse practitioner, clinical manager, BMC heart failure program, joined the forces in 2007, when BMC initiated a comprehensive inpatient program. As part of this were multidisciplinary rounds and a more in-depth review of patients throughout their hospital stay, paired with a home-based program in which nurses from the health system's Visiting Nurse Association (VNA) were charged with patients' care post-discharge. In the fall, BMC brought in a heart failure specialist from Baystate Health and opened an outpatient clinic.
"So now we had a process in which we followed patients in the hospital, at home, and then they were hooked into the outpatient clinic," Ferrarin says. "So we were able to close the loop."
In 2008, the program began following up with discharged heart failure patients by phone 24 to 48 hours after discharge to check on their status, that they had all their necessary medications, and that they had received all the services they needed. "We also used that opportunity to use some of the teach-back methods for education to make sure that they understood what they were taught while they were here," she says.
Beginning in 2008, a pre-discharge time out was implemented before heart failure patients were sent home. For each patient, Ferrarin meets with all the physicians involved with the case, the primary nurse, and the patient's case manager to review the chart in depth to ascertain whether everything is ready for the patient to go home.
The team discusses any potential future barriers — "whether it be financial issues and having medications taken care of or safety issues at home," Ferrarin says.
Telemedicine and real-time monitoring
A nurse visits each patient usually within 24 hours of discharge. The in-home visit includes "a full evaluation including safety assessments. [The nurses] go through the cabinets. They do diet education, medication education, reconciliation, a physical assessment, and then usually they will certify the patient for a 60-day period," Ferrarin says.
Eligible patients also participate in the hospital's telemedicine program. The patient is given an electronic scale, blood pressure cuffs, and an SPO2 monitor to assess his or her oxygen saturation. All the data obtained from these are uploaded to a web site for daily monitoring of weight, blood pressure, and oxygen level.
The data are transferred to the VNA and reviewed by a triage nurse. If he or she sees a problem, the patient's physician is contacted. "Generally, the physician's office will get back to the VNA as to what the plan is, and then the VNA with either contact the patient for medication changes or make an extra visit," Ferrarin says.
Patients are given a number to reach either the visiting nurse or Ferrarin herself if complications or problems arise.
For those who are readmitted, each is "completely dissected to figure out what actually was the cause of their readmission so we can take it from there, whether it was a medication issue, a compliance issue, whether they needed more services at home, whether they didn't get in to see their physician," she says. "For all readmissions, we pull the charts and try to come up with a reason for the readmission so that we can fix it and do it better the next time."
About the same time the hospital began its heart failure readmission charge, it also began implementing a hospitalist program. Ellrodt points to that program as having given the hospital "a much tighter relationship between the hospital care and the outpatient care." Within that program, the hospital began to make follow-up appointments with patients' primary care physician or subspecialist.
"I think having a comprehensive inpatient hospitalist program with a mandate to communicate effectively with primary care physicians and the rest of the caregivers across the continuum was absolutely essential" to the program's success, he says.
Beginning in July, the hospital developed what it calls a geographic hospitalist program with one or two hospitalist teams per floor per unit based on the size of the unit. "We think this makes it a whole lot easier," he says. "Almost all of the heart failure patients — 95% — are basically on one unit, our telemetry unit."
He says this has made it easier for Ferrarin to locate patient-specific physicians. And as department chair, he says "having to manage 125 physicians vs. 16, guess which is easier? So you can very easily get protocols in place if we decide to look at BNP levels on discharge [which the hospital has been doing] and trying to predict high-risk patients."
The alignment between the hospitalist and the primary care physicians, he says, has been a big part of improving communication. Representatives from skilled nursing facilities are on BMC's transitions committee, and now it is mandated that discharge summaries be dictated on the day the patient is discharged. Physicians also have home access to the system's electronic medical record system if problems arise.
Downward trend
The hospital continues to see a downward trend in readmissions for heart failure patients (see graph) and has gone from a 27% 30-day rate in 2007 to a current rate of about 15-16%. Ellrodt says the team will see a few bumps in certain months. "What Alicia did with her team was go back in and look at every one of those readmissions. What she found basically was the difference was two patients were readmitted multiple times during that time frame. What we did was we then developed for those two patients a custom-tailored strategy that basically changed our approach to those patients."
What's made the biggest difference? Ellrodt thinks it's the outpatient clinic, which takes the highest-risk patients. The readmission rate there, among the sickest patients, is down to 3% now. "I think the large part of the impact is the heart failure clinic's ability to intensively monitor the highest-risk patients. I think this has had a huge impact, along with all of the other things we've done."
Ellrodt acknowledges the program has been an expensive one — one that is not currently in the financial interest of the hospital. Readmissions get reimbursed at a significant amount, but seeing the tide changing in the near term, even though you may "by preventing readmissions, decreasing your revenue" you're doing the right thing.
It's going to hurt at first. Financially, from both the cost side and the revenue side. The investment is huge. And it's a lot of work a lot of starts and stops, says Gray Ellrodt, MD.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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