Research provides ideas to improve discharges
Nurses provide transition support
Evidence is growing to show how specific hospital interventions at discharge can improve outcomes for patients and reduce health care costs - two goals that likely will be at the centerpiece of any new national health care legislation.
For instance, one recent study of a reengineered hospital discharge program (Project RED) found that the intervention significantly reduced hospital utilization, increased primary care physician (PCP) follow-up, and improved patient self-perceived preparation for discharge.
The study also found that the actual cost of emergency department visits totaled $21,389 for the usual care group and $11,285 for the intervention group. And actual hospital visit costs were $412,544 for the usual care group and $268,942 for the intervention group. When outpatient visits are included - which were higher for the intervention group - the total health care costs were about 34% lower for the intervention group.1
"Our study showed a 30% reduction in hospital utilization, including both emergency room visits and rehospitalization," says Brian Jack, MD, an associate professor and vice chair of the department of family medicine at Boston University School of Medicine and Boston Medical Center in Boston.
"That's very important, because in the past year, President Obama's administration has been saying they're going to pay for health care reform by changing the payment mechanisms to hospitals," Jack says. "And they have been specifically saying the 30-day rehospitalization rates will not be paid for to save $13 billion in public and private sectors to pay for health care reform."
Projects directed at improving patient safety at hospital discharge are the low-hanging fruit in reforming health care, Jack notes.
"There are 38 million discharges a year, so there are a whole lot of them and a whole lot of problems," he adds. "It's something that needs to be fixed."
The health care system from payers to providers needs to focus on improving the discharge process, and this means transforming its current culture, suggests Jeff Critchfield, MD, an associate professor of medicine in the department of medicine at the University of California - San Francisco. Critchfield also is chief of the division of hospital medicine at San Francisco General Hospital.
"We're trained to think about what happens in the hospital," Critchfield says. "Even though nursing as a profession has led the way by developing systems like home health care and home nursing, these systems nowhere meet the need of every patient discharged from the hospital."
Jack and Critchfield offer these examples of ways hospital discharges can be improved:
Support from Hospital to Home for Elders (SHHE) program: "We've set out to develop a model that would address the relatively challenging needs of our patients at San Francisco General, which is the only trauma center in San Francisco," Critchfield explains. "We care for patients who are 35% Asian, 25% Latin American, 20% Caucasian, and 15 to 20% African-American."
Hospital-to-community transitions are particularly challenging for elderly patients who have a non-English first language, he notes.
"We wanted to put into place a system that meets their needs in a cross-cultural way," Critchfield says.
The result is the SHHE program, which includes a primary team that helps patients and their families prepare for discharge from the beginning of their hospital stay.
SHHE nurses are multicultural and multilingual, and they provide patients with support from the hospital to home.
"They meet with patients within the first day or two of their hospital stay and touch base every day patients are in the hospital," Critchfield says. "They educate them about their medications, helping them understand why they're taking these medicines, and stay in contact with the caregiving team."
SHHE nurses interact with families and community providers to facilitate follow-up care, he adds.
They give patients written materials that are literacy-level appropriate and that clearly describe all follow-up appointments.
"We recognize that it's challenging for patients to see their primary care providers, and we think that's a really important element," Critchfield says. "Delays in seeing your doctor or nurse practitioner lead to increased readmissions."
So, patients discharged via the SHHE program are contacted by nurse practitioners (NPs), who call them on the third day and 10th day post-discharge from the hospital, Critchfield says.
The hospital also gives patients medications to take home with them, which helps to eliminate the problems of patients becoming ill because they forget or cannot fill their prescriptions immediately after discharge.
The NPs ask them these specific questions to screen for potential problems:
- Do you understand your medicines?
- How are things working out at your home?
- Do you have caregivers in your home?
If there are caregivers, the NPs speak with them, as well.
"We're experimenting with doing this by telephone, because we've decided it's too cost-prohibitive to send nurse practitioners to patients' homes," Critchfield says.
The SHHE project will be the intervention arm of a randomized, controlled trial that over a two-to-three year period enrolls about 700 patients, who speak English, Spanish, or Cantonese, and who are able to consent to the study he adds.
One goal of the program is to improve care coordination.
"One of the problems of health care is that it's so fragmented," Critchfield says. "So, the next step is to have someone coordinate and integrate the fragments, and that's what we'll have our nurse practitioners do."
Like the SHHE nurses, the nurse practitioners are multicultural and multilingual, so there are no language or cultural barriers to their interactions with patients and families.
"We see ourselves as integrators, coordinators, who bring the primary care provider into the picture," Critchfield says. "The nurse practitioners will call patients' doctors and say, 'I was on the phone with your patient today, and it sounds like they have these needs, so I'm passing this information to you and your clinic so you can start taking care of it."
Reengineered hospital discharge program (Project RED):
Jack and co-investigators used patient safety techniques borrowed from engineering processes, such as nuclear power plants, and studied the discharge process to identify the principles of best practices at discharge.
Once they identified 10 items that should be a part of a reengineered discharge process, they sought funding for a study to show how it might impact the process, and this led to the clinical trial with its recently published positive results.
"We randomized patients between the usual discharge and the reengineered discharge group," Jack says. "Nurses collected the appropriate discharge information and packaged it into the hospital care plan with operationalized material we used to teach patients what to do."
Graphic designers and health literacy experts helped to develop the materials that were clear and easy-to-read visually.
One key to the discharge program's success was its emphasis on making appointments for patients for follow-up care.
"It just makes sense to have some sort of follow-up," Jack says.
Reference
1. Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization. Ann Int Med. 2009;150(3):178-187.
Evidence is growing to show how specific hospital interventions at discharge can improve outcomes for patients and reduce health care costs - two goals that likely will be at the centerpiece of any new national health care legislation.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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