November 5, 2010
Contact:
Jason Merrill
314-286-0302
[email protected]
ST. LOUIS - A study at Barnes-Jewish Hospital and Washington University School of Medicine examines whether a program aimed at transitioning chronically ill patients from hospital to home through use of a nurse coach could reduce hospital readmissions – a subject of much debate among both hospitals and the federal government.
In 2009, the Centers for Medicare and Medicaid Services (CMS) began publicly reporting data on how many patients suffering from a heart attack, heart failure or pneumonia were readmitted within 30 days of discharge. The information, posted on
hospitalcompare.hhs.gov, was coupled with debate in Washington as to whether Medicare should pay hospitals for readmissions.
The Institute for Healthcare Improvement estimates that 46% of hospital readmissions could be prevented with discharge planning that includes transitional care.
To address the issue of unplanned returns to the hospital, Barnes-Jewish is testing a model of transitions in care that has shown success in other areas of the country to determine its effectiveness in an urban setting such as St. Louis.
“The goal is to see if this intervention impacts readmission rates,” says John Lynch, MD, chief medical officer at Barnes-Jewish and co-principal investigator of the study for Washington University. “We believe our standard of care is excellent for most patients. But some are at higher risk of readmission.”
(Find out more about the "Transition of Care" program by watching this video here.)
“Often patients who don’t qualify for home care services still need assistance in the immediate period following hospital discharge,” says Sandy Graff, RN, who coordinates the study for Washington University. “Our goal is to assist these patients in understanding the actions that are needed to avoid an unnecessary return to the hospital. By providing information, education, and direction to enhance the effectiveness of the health care delivery team, the patient and family can learn the skills to improve self-management, prevent or slow health status decline and interrupt the cycle of frequent acute and emergency care.”
The study randomizes patients discharged from the general medicine service at Barnes-Jewish into two groups. One group receives the usual standard of care and the other receives the services of a nurse transition coach for 30 days following discharge.
The coach meets with chronically ill patients prior to discharge and provides education and direction to support self-management of their chronic diseases. Medication management – ensuring any discrepancies are resolved, the patient understands why and how to take each medication and has the ability to obtain those medications once at home – is an important component of this and every contact with the patient.
Many hospitals listed as having above average readmission rates for heart attack in the St. Louis area are located in regions of socioeconomic distress. For those patients, even buying medications can be difficult, and if a patient isn’t taking the prescribed medications, it increases their chances of falling ill and returning to the hospital.
“Medications are expensive and often there are co-pays involved in obtaining them,” says Dr. Lynch. “Patients experience significant barriers to adherence to the medical regimen when they can’t afford medications or don’t have transportation to and from the pharmacy, even though they want to comply with what has been prescribed.”
The nurse coach makes a home visit 24 to 48 hours after discharge to ensure the patient has obtained the proper medications, understands and can follow all other discharge instructions, has scheduled a follow-up appointment with their medical home provider or primary care office, and understands the signs and symptoms of a worsening condition and how to respond to these changes. Regularly scheduled follow up contacts throughout the remainder of the intervention continue to support patients in avoiding unnecessary returns to the hospital and enable them in developing the skills necessary to self-manage future healthcare needs.
Many of Barnes-Jewish's peer academic medical centers are shown to have readmission rates higher than the national average. Not only do these hospitals see many of the sickest of the sick because of the medical expertise they provide, they are serving populations who struggle with socioeconomic factors, conditions that often impede patients’ ability to follow treatment recommendations. It is during the post-hospital home visit that other barriers to care are frequently identified and addressed.
“Barnes-Jewish is one the largest hospitals in the Midwest, but it also serves a very important role as a large community hospital for the St. Louis region,” says Dr. Lynch. “We have a number of patients living in areas of the city that do not have the type of health care resources that other patients in the region may enjoy.”
If the program proves to lower readmissions, Dr. Lynch hopes Medicare and other payers move to support payment for such a program.
“If it works it will be very important to public policy and we would hope it leads to all patients with chronic medical conditions leaving the hospital with transitional care support,” says Dr. Lynch.
Currently, Christian Hospital is piloting a similar version of the program for patients who do not qualify for home care services. These patients receive a follow up home health care visit ensuring that the patient is on the right medical regimen, that their home is safe and that there are no other issues beginning to develop in the post discharge period. Christian Hospital case management and BJC Home Care are part of the pilot.