Aggressive discharge plan cuts readmissions, costs
Advance practice nurse supervises care
It’s a familiar situation that often becomes a slippery slope: Elderly patients with congestive heart failure (CHF) and other diseases become unable to control their conditions. They end up in the hospital and need intensive treatment to get a better grip on their declining health.
But when these patients are stabilized and ready to be discharged, what happens next? What does it take to make that hospitalization an isolated incident and not the first in a string of admissions?
A new study reports breaking the chain of acute hospital visits requires more than treating immediate conditions during the first hospital stay. An aggressive discharge plan — beginning soon after the patient is admitted, continuing while the patient is in the hospital, and leading to follow-up from a specially trained caregiver — gets more control over chronic diseases. The intense intervention during the month after a hospital stay brings benefits for five more months: a higher quality of life for patients, shorter initial stays, fewer subsequent hospitalizations, and potential savings of thousands of dollars per patient.
Researchers from the University of Pennsylvania in Philadelphia say they used advanced practice nurses (APNs) to track hospital care, to anticipate what patients would need once discharged, and to follow up at their homes. The benefit, besides saving a bundle of money, is establishing a game plan for these fragile patients that can be tailored to fit individual needs.
"It really requires creating systems that traditionally didn’t exist," says lead researcher Mary D. Naylor, PhD, FAAN, RN, an associate professor at Penn’s School of Nursing.
Naylor explains this approach answers two major problems with these types of cases. First, she says, when these patients come into the hospital, there often isn’t a protocol for assessing what it will take to keep them from coming back. And second, after a patient is discharged, the physician often isn’t right at the bedside to watch for problems and treat them. The patient would usually have to get sick enough to warrant another trip to the hospital, where the cycle begins again with the patient losing ground and the meter running.
The study was published in the Feb. 17 issue of the Journal of the American Medical Association.
Naylor and her team studied two groups of these patients. The control group took the traditional route of hospital treatment and follow-up, according to what Medicare would approve. The study group received these special interventions:
• An APN visited the patient within the first 48 hours of hospital admission.
• APN visits were made at least every 48 hours of the stay.
• After discharge, an APN visited within 48 hours, then seven to 10 days later.
• Additional visits could be added without limit.
• APNs were available by telephone seven days a week, 8 a.m. to 10 p.m. during the week and until noon on weekends.
• APNs called patients at least once a week.
Details of the study
Participants of both groups were at least 65 years old and were hospitalized between 1992 and 1996 for CHF, angina, myocardial infarction, respiratory tract infection, coronary artery bypass graft, cardiac valve replacement, a major procedure on either the small or large bowel, or orthopedic procedures of lower extremities.
The two groups of about 200 people each were randomized to this route or the traditional hospitalization and discharge. The savings from keeping the APN group out of the hospital were significant. This group saved about half of the $1.2 million Medicare reimbursements needed to treat the control group in return hospital trips, averaging about $3,000 per patient. The researchers say the intervention group had these benefits up to six months after they first got out of the hospital:
• Patients had 17% fewer single readmissions.
• Multiple readmissions were reduced 8%.
• Length of stay was reduced (1.53 vs. 4.09 days).
• The time between hospitalizations grew longer. (One in four control-group patients was rehospitalized within 48 days of the first stay. It took 133 days for a fourth of the intervention group to require admission.)
The report notes patients without CHF had more success with the intervention than the patients with the disease.
To take part in the study, all participants had to speak English, be alert or oriented at admission time, and be reachable by phone as well as have at least one of these indicators associated with poor discharge outcomes:
• age 80 or older;
• inadequate support systems;
• multiple, active chronic health problems;
• history of depression;
• moderate to severe impairment in function;
• multiple hospitalizations during the prior six months;
• hospitalization in the last 30 days;
• fair or poor self-rating of health;
• history of noncompliance to a treatment plan.
Naylor says the benefits of the intervention did not last beyond six months after discharge. From this point in the study, the numbers in acute trips to the doctor or emergency department were not statistically different between the study and traditional groups.
"What we’ve learned in this trial is the improved outcomes weren’t long-term," Naylor says, noting next she will look at CHF patients by themselves as well as study patients without intact cognitive skills, to determine if such an intervention can be helpful to them.
"I think it will probably work," says Peter A. Boling, MD, associate professor of internal medicine at the division of general medicine at Virginia Commonwealth University’s Medical College of Virginia campus in Richmond. Boling, immediate past president of the American Academy of Home Care Physicians and author of the commentary to the JAMA study, says the key is working with the patients’ support system at home.
By the time these types of patients develop extensive chronic illnesses, chances are good that there are either family members or a nursing home staff caring for the patients on a long-term basis, and they can be the ones who receive instruction, Boling says.
"The patient doesn’t have to be the target with educational materials," he says.
Boling, who has worked with nurse practitioners for 12 years to deliver similar inpatient and outpatient services, contacted Naylor for advice on ways to provide short-term interventions in Virginia. Because both Philadelphia and Richmond are urban areas, Boling says much of Naylor’s techniques are applicable to his practice.
Naylor is now testing outlying areas to see if such follow-up is as helpful to suburban and rural communities. She adds that some people in urban areas have "terrible general health," and much of the work needed to transition patients out of the hospital focuses on helping change the lifelong habits of elderly patients. They may have "fundamentally poor nutrition." Many do not have good sleep habits or know anything about exercise.
Naylor says when the patient is in the hospital, it’s a good time to look at the coordination of care while teaching family members about what they need to do to help keep their loved ones in better condition. But after the patient leaves, the APNs have to make sure patients understand how to stay out of the hospital.
"We do things like go to the patient’s home and go through the medicine cabinet," she says. It will likely contain medications used to treat the patient before the trip to the hospital. But chances are good the situation and treatment strategy has changed since those drugs were prescribed. Here is where the new treatment strategy may begin to break down very quickly.
All involved should know routine
Everyone involved with the patient’s care needs to know the new treatment strategy. Should the patient continue taking all the medicine in the cabinet? Which drugs should be stopped or have a change in dosage? Are there any medications that should be discontinued because a replacement has been prescribed?
The patient needs to be kept on track. In this case, the APNs often know how to advise patients to rectify drug routines or are connected to other team members such as physicians or pharmacists so the program stays on course.
Being able to afford the prescriptions also is an important issue, Naylor notes. Where appropriate, the APN can get patients involved with local programs that offer financial aid.
As the studies continue, Naylor says her team is developing a protocol to help guide caregivers through a hospital discharge and follow-up. The care team has to watch out for situations such as the patient returning to the family physician for treatment and ensuring the patient receives only one set of prescriptions and instructions.
"It’s critical to talk about having one plan before you make changes," she says. "It seems like simple things, but this is where patients can lose continuity." The nurse intervention can find those trigger points and identify when the patient is vulnerable.
Situations can be as straightforward as understanding a particular CHF patient insists on eating a big bowl of soup with Sunday dinner. An intervention in this case would have to take this dietary habit into account and find a way to keep fluids within healthy limits by restricting everything else in the diet on that day.
Being adaptable means having access to a multispecialty team. Beside physicians and nurses, intervention teams include pharmacists, nutritionists, physical therapists, and others. "We think we have an understanding here," Naylor adds. "We can apply it to personal cases."
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