Working together to keep patients out of the hospital
Chronic conditions often force patients into an undesirable cycle of emergency room visits, hospital admissions and brief respites before the pattern repeats itself.
In 2014, Brenda Fayne made six visits to the Barnes-Jewish Hospital emergency department due to chronic obstructive pulmonary disease (COPD), all of which resulted in inpatient admissions. In 2013, Albertina "Tina" Stewart-Walker, who suffers from heart failure and COPD, also was admitted to Barnes-Jewish Hospital six times. She was down to weighing 70 pounds and was taking nearly 30 medications. Both patients needed the help of the Barnes-Jewish Hospital Readmission Prevention Team.
Clinic at Barnes-Jewish Hospital Reducing Readmissions
Patients like Fayne and Stewart-Walker, who are hospitalized due to chronic conditions such as COPD and heart failure, are closely followed by members of the Barnes-Jewish Hospital Readmission Prevention Team. Each day, the team receives a list of all patients admitted within the past 24 hours who are age 65 or older and have traditional Medicare as their primary insurance. Each day, the list of about eight-to-10 patients is reviewed to identify those admitted for management of one of the four conditions monitored by the Centers for Medicare and Medicaid Services:
- COPD – chronic obstructive pulmonary disease
- PN – pneumonia
- CHF – congestive heart failure
- AMI – acute myocardial infarction
The goal: break the hospitalization cycle by ensuring patients have access to the care they need at home.
The readmission prevention team members work closely with the patient, family and multidisciplinary team to develop a safe and effective discharge plan. "It is important that we ensure that patients are discharged to a safe environment and equipped with the medications, supplies, and resources necessary to prevent a readmission," explains Tonya Haynes, DNP, RN. Some patients go home and some are discharged to a skilled nursing facility. "Our goal is to make sure the patient has the support that he or she needs once discharged from the hospital. Otherwise, their health will decline and they will find themselves right back here," says Jill Malen, ACNS-BC, MS, NS.
Stay Healthy Outpatient Program fills gaps for patients at risk
Because regular checkups are key to maintaining health and monitoring these chronic conditions, Fayne and Stewart-Walker both enrolled in the hospital's Stay Healthy Outpatient Program (SHOP). The program is designed to give patients with these chronic conditions a wide range of support, helping them stay healthy and out of the hospital. Fayne now says it was one of the best things she has done for herself.
Brenda Fayne, who suffers from COPD, is able to take short walks with a friend. She hasn't been admitted to the hospital since October 2014.
Most patients with one or more of these diagnoses have other conditions that negatively affect their health. Fayne also has diabetes and high blood pressure; Stewart-Walker has asthma and problems with her esophagus. SHOP has a number of resources in place to guide and support patients with the top four diagnoses and the other conditions that typically accompany them.
For example, before the patient is discharged, an appointment is made for them to visit their primary care physician (PCP) within 7-10 days of discharge. If the patient does not have a PCP, they can utilize the hospital's Stay Healthy Clinic. The clinic is one component of SHOP, which patients may use for a one-time follow-up or they can elect to use the clinic for their primary care, which is what Fayne and Stewart-Walker did.
The Stay Healthy Clinic includes Washington University geriatrician, Lenise Cummings-Vaughn, MD, and nurse practitioner, Kelly Dodds, RN, ANP-BC. About 150 patients currently receive primary care at the Stay Healthy Clinic.
From the clinic, Dr. Cummings-Vaughn and Dodds are able to coordinate a larger team of health care professionals to explore complicated conditions. Stewart-Walker wasn't able to swallow pills so she used liquid prescriptions, making it difficult to know how much she was actually taking. "I've had a lot of problems with my medications and some made me sick," says Stewart-Walker. "I was always tired and in pain, and I would choke when I tried to take my pills."
Dr. Cummings-Vaughn and Dodds coordinated care with a Washington University gastroenterologist to help treat her esophagus. They also discovered that Stewart-Walker was not taking her medicine the way it was prescribed and was doubling her doses.
The Stay Healthy Clinic team provided both women with an Electronic Medication Management Assistant (EMMA), a medicine dispensing machine, to help manage medications at home. Dr. Cummings-Vaughn and Dodds' efforts to coordinate care and build relationships with patients and family members are reasons why EMMA has had success. If patients don't take their medications, EMMA sends a message, which notifies Dodds who in turn calls the patients to help them get back on track. When the physician changes the medications, the machine can be reprogrammed remotely to accommodate the changes. EMMA also helps remind patients of clinic appointments.
Team effort makes it possible
Now, instead of going to the emergency department multiple times each year, Fayne and Stewart-Walker visit the Stay Healthy Clinic once a month. They also have Dodd's cell phone number, as do all of the clinic's patients. "I receive calls 24/7 but the majority of patients who call me just need to talk through what to do if they're feeling bad or anxious about their condition. In the past, they would have called 911, even when it wasn't an emergency," Dodds says.
Rob Hackelman, MSW, LCSW, the social worker with SHOP, says "One of the reasons she (Fayne) has been able to stay out of the hospital is because she's good about keeping her appointments at the clinic." Arranging transportation to those appointments is another part of the program. "We're happy to help her work out transportation," Hackelman says.
With support and regular treatment, patients who have multiple diseases and co-morbidities can manage their conditions to create a calmer, healthier lifestyle. "Staying out of the emergency department and the hospital has meant the world to me and I wouldn't have been able to do it without the help of the Barnes-Jewish Hospital team," says Fayne.