At first blush, one might think Mary Schlitter's job title could be "professional nag." But her relentless pursuit of patients recently discharged from Our Lady of Resurrection Medical Center is designed to keep them healthy and out of the hospital.
Schlitter, a registered nurse with a 32-year tenure at the Chicago hospital, is a discharge advocate, a new role created to help reduce the number of preventable readmissions among heart failure patients. She works with a caregiving team that includes the patients' physicians, nurses, case managers and family, to make sure that patients remain on the road to recovery after leaving the hospital.
She discusses their medications and other therapies, making sure the patient and the family caregivers understand the post-discharge instructions. She might help the family arrange placement in a rehabilitation center. She'll call the outpatient physician to arrange the follow-up appointment. Or call the patient's home the next day, and the next week, and the next month, to ask whether that patient is sticking to the prescribed diet and taking medications as instructed.
"A lot of people say they understand everything when they leave (the hospital), but then when they get home they realize that there are a lot of things they don't understand," explained Schlitter.
For example, she said, patients told to weigh themselves daily might have misunderstood the reasons why, and might fail to report an additional pound or two, even though sudden weight gain can be a sign of potentially threatening fluid retention and should trigger a call to their doctor.
The hospital identifies the patients who might be at increased risk for relapse and hospital readmission. When Schlitter follows up on "those who maybe need a little extra encouragement," she sometimes hears, "'Oh yeah, I was doing good for two weeks but then I went to the doctor and things were okay, so I am sliding a bit.' Most of them seem to appreciate the call."
An incentive to change
Schlitter's work is one reason that Our Lady of Resurrection's 30-day post-hospital discharge readmission rate for heart failure patients has been cut by two-thirds, dropping to around 9 percent or lower for the past several months, from a peak of 28.4 percent. Our Lady of Resurrection's success in lowering its rate of avoidable readmissions for its heart failure population will be featured in an Innovation Forum session at the Catholic Health Assembly in Philadelphia June 3 to 5.
That peak rate, in December 2010, placed Our Lady of Resurrection in an uncomfortable national spotlight. At the time, the hospital ranked fourth in the nation for preventable readmissions for heart failure patients — an unwelcome recognition, said Dr. Scott Betzelos, senior vice president for performance distinction for Chicago-based Presence Health. That system was created through the November merger of Resurrection Health Care and Provena Health. Prior to that merger, Betzelos was chief quality officer for Resurrection Health Care.
At about the same time that Our Lady of Resurrection reached its readmissions nadir, the federal government was shaping incentives for all hospitals to lower their 30-day avoidable readmission rates for Medicare patients. Beginning this October, hospitals with higher than average readmission rates for Medicare patients with specific conditions will see a reduction in federal reimbursement. This change in reimbursement is an effort by the federal government to address the issue of preventable hospital readmissions, which some studies suggest waste $25 billion annually.
"Not only did we have a public relations challenge but a financial challenge, and we knew that the solution was to break down the silos, develop systems of care and standardized processes," Betzelos said. "We knew we needed to manage care and value at the same time."
A path after discharge
To be successful required a change in thinking, said Betsy Pankau, director of performance improvement for Our Lady of Resurrection.
"In the hospital, we generally thought that if we sent patients home with instructions and prescriptions and they had a doctor, that the hospital episode had ended," Pankau explained. "It's kind of a new day when we realized we had to step beyond that and work together so we could prevent these readmissions."
The immediate response to the problem was a "Heart Failure Summit," an all-day session that involved representatives from all six hospitals with what was formerly Resurrection Health Care and other stakeholders throughout the system including rehabilitation units and home health care units. The summit eventually led to a more collaborative approach to managing treatment from the moment the patient enters the system, Betzelos said.
"We plan for discharge on the day of admission," he said.
The approach is twofold: the focus on in-hospital patient education and expanded post-discharge care coordination (accomplished by Schlitter and the rest of the care team) is combined with extensive patient assessment when recently discharged patients come back through the hospital doors.
For example, Betzelos said, patients discharged to Our Lady of Resurrection's rehabilitation unit (which is located in the same building as the hospital) were routinely moved back to acute care for issues that might have been dealt with in rehab. And patients who come in through the emergency department might simply need a change in medicines or additional education on the impact of smoking or high-salt diets on their conditions. Those patients might experience equal or better outcomes if they are treated in the emergency room and then sent home, rather than being readmitted to the hospital, he said.
The new system was put in place without hiring new people, Betzelos said. "We really didn't add additional resources. We redirected people's ability to provide care in a more strategic fashion."
The improved readmission rates should benefit patient health and Our Lady of Resurrection's reimbursement rate from Medicare, Betzelos said. At the same time, the improved outcomes will enhance the reputation of the health system.
"We hope to position ourselves with third-party payers as the health care provider in the Chicagoland area that provides high-quality and high-value health care at a reduced cost," he said.
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