By RENEE STOVSKY
According to data released in July by the Centers for Medicare & Medicaid Services, preventable hospital readmission rates have not dropped significantly, despite years of determination and the overhang of financial penalties. Nearly 10 million — or one in five — Medicare beneficiaries are still readmitted within 30 days of discharge, costing the government an additional $17.5 billion in inpatient spending per year.
The CMS study of 4,000 hospitals showed that only 23 had better than average rates for two out of the three most common conditions leading to readmissions — heart attack, pneumonia and congestive heart failure. One of those top-performing hospitals is Bon Secours Health System's
St. Francis – Downtown, in Greenville, S.C., which had lower than average readmission rates for congestive heart failure and pneumonia.
Dr. Frank Smeeks, St. Francis' chief medical officer, says the hospital's performance was not always so strong. "At one point our data showed we were actually above our peer group in readmission rates," he says. "As part of a clinical transformation steering team, we studied chronic disease management, concentrating on congestive heart failure, to see where we could make interventions to provide the most efficient care from a quality, cost and outcome standpoint. Each piece we added and tweaked resulted in incremental improvements until we finally wound up at our present rates."
Staying connected
Ron Spencer, director of quality outcomes at St. Francis, says his team began its work three years ago, looking hard at both the inpatient setting and discharge procedures. "We discovered that our patients were receiving excellent care while they were here, but we needed to improve our 'patient touch' from discharge to follow-ups with physicians," he says.
To that end, in 2010 St. Francis first designated a pharmacist to meet patients in the hospital, go over their medications before discharge, and then call their home health nurse once they arrived back home to help supervise an extensive teaching program. That program involves easy-to-understand instructions such as cleaning out medicine cabinets according to a red bag/green bag approach, with out-of-date or inappropriate medications being sorted into a sealed, red bag while current prescriptions are placed in the green bag.
"We found that many patients really didn't understand our directions, or refused to throw away expired medications they thought they 'might need' in the future. Before long, they would mix up bottles and start taking antibiotics from 1972. So this was an easy way to segregate things," Spencer explains.
In addition, the patient now receives the pharmacist's direct number to call with any questions any time of day. The pharmacist, using electronic records, can look up the patient's background and provide detailed information when necessary.
Information in doses
Next, St. Francis took a hard look at its patient education process. The hospital's standard operating procedure had been to provide an average of 60 minutes or more of teaching about a patient's specific medical condition — in this case congestive heart failure — during the hospital stay. Through interviews, however, the nursing staff learned that most patients were too sick, too anxious and too focused on going home to absorb most of that information.
"The staff decided to change strategies and teach patients in detail after discharge," explains Spencer. "In the hospital, we focused on 'survival skills' — important issues like weight gain, sodium intake and diuretics. Then we made a follow-up call within 48 hours of discharge to make sure they comprehended the bullet points. Only then did we present them with a full program on the best care for their condition."
In 2011, St. Francis added yet another component to its model of care for late-stage congestive heart failure patients. It began talking to patients about what kind of care they really want — including end-of-life treatment such as at home, palliative care or hospice care. "Of course, in those cases we also assist with family meetings prior to discharge so that everyone — caregivers, home health nurses, the pharmacist — understands the patient's preference," says Spencer.
High 'touch'
Recently, St. Francis also began working on a model of care for moderate-risk congestive heart failure patients — one that includes an agreement that all patients admitted with a primary diagnosis of heart failure will receive a cardiac consultation within seven days of discharge.
"We found that many of these patients had no access to a cardiologist," says Smeeks. "Yet we know that the more times we can 'touch' a patient within a week of discharge, the more likely we can decrease the chance of readmission. Patients need an entire support group — pharmacists, home health nurses, dieticians, physicians — to provide the knowledge and encouragement to treat the disease."
Now that the hospital has shaped a successful model of congestive heart failure care, the staff is working to expand and apply it to other chronic conditions, from pneumonia and diabetes to chronic obstructive pulmonary disease. Though treatments vary according to disease, some innovations are universal. Among them:
- Refine discharge instructions.
Clinicians need to adapt their word choices to fit the educational level of their patients, says Spencer. "If you tell a patient he needs a CT scan, or that his diagnosis is hypertrophic cardiomyopathy, chances are likely he has no idea what you are talking about, but he'll nod so as not to look stupid. Then he'll go home and try to Google the procedure or condition," he says. "It's much better to find a sweet spot for communication and be certain the patient understands the conversation."
- Be involved with care that extends beyond the hospital.
"We have frequent conversations with health care providers and nursing homes in our area in order to promote better partnerships with them," says Smeeks. "If medical directors and nurse practitioners understand treatment plans, they are more likely to call us to help with an evaluation or change in medications instead of simply sending a patient back to the emergency room for any change in condition."
St. Francis staff also learned to pay careful attention to the competency of family caregivers. "We had assumed that patients who were married would have lower rates of readmissions when cared for by a loving spouse at home," says Spencer. "Yet we found that to be absolutely incorrect. Family members are often working or have chronic health issues of their own. It is extremely important to educate those caregivers as well as the patients."
- Make certain patients have access to medications.
"Here in the South, pride prevents many patients from admitting that they cannot afford to purchase medicine. But no patient should be at risk of dying because he or she is too poor to pay for something like an oral antibiotic," says Spencer. "We make sure we determine any financial challenge at discharge and use monies from our mission or operating fund to buy medications if need be with accounts we maintain at Kmart, CVS and other stores. And if patients are noncompliant, we extend hospital stays to combat both readmissions and mortality risks."
- Promote a collaborative approach with hospital staff.
Turf wars and defensive attitudes among medical directors, nursing directors and physicians with various specialties do not lead to exceptional care for patients in the community. "When we began our initiative to reduce readmission rates, we really needed all parties to buy in to establish protocols and help set up hardwired processes to reach our goals," says Smeeks. "Working in partnership, we've been able to become a better hospital, and in the end, that has been gratifying for everyone."