Published in the November 2011 issue of Today’s Hospitalist
LOOKING FOR AN ALMOST SUREFIRE WAY to keep heart failure patients from bouncing back? The key is to keep close tabs on them after discharge “daily, if necessary, and often, in person.
Palo Alto Medical Foundation, a San Francisco Bay-area nonprofit network, took that approach with a group of its Medicare Advantage patients with heart failure, and the effort has paid off in spades. Thirty-day readmissions for patients in the pilot group dropped from 18% in August 2010 to 14% a year later. That reduction is even more impressive given that the control group readmission rate was 25%.
Patients in the pilot made 40% fewer ED visits in the six months after they were enrolled than in the previous six months. And all-cause admissions declined among the group by nearly two-thirds.
But those gains came only after a big commitment to expand the notion of following patients into the outpatient setting. Not only do nurse case managers and social workers make home visits if necessary, but they often put themselves in the office with patients when they visit their primary care physician.
"A no-holds-barred effort"
The intervention was initiated by one of the foundation’s regional managed care medical directors, Timothy Lee, MD, MBA. By any yardstick, it’s comprehensive.
Daily rounds with the hospitalists at El Camino Hospital in Mountain View, Calif., identify eligible heart failure patients. RN case managers and social workers then meet with those patients and families before discharge. They use that opportunity to reinforce education about medications and self-care and to schedule patients’ first primary care appointment within five days of discharge.
The case manager calls patients or caregivers 48 to 72 hours post-discharge to discuss medications, symptoms and the treatment plan. Staff make home visits if needed. Then the case manager and social worker both attend the patient’s first post-discharge doctor visit.
"We wanted a no-holds-barred effort," says Dr. Lee, an internist who maintains a small outpatient practice at Palo Alto Medical Foundation. "We also wanted to determine the resource outlay for this kind of effort, so we started small." The pilot group included 22 patients whose average age was 84.
Prior to enrolling patients, case managers received primary care physicians’ permission to approach patients and got patients’ signed consent. "We emphasized," Dr. Lee says, "that our efforts were under the direct supervision of the patient’s primary care physician." To date, no outpatient physician has declined to have a patient followed; instead, Dr. Lee has had to turn down requests from physicians who wanted their patients enrolled.
"Unfortunately," he says, "we didn’t have the bandwidth to take additional patients."
Surprises at home
House calls are triggered by what nurses hear during the post-discharge phone call. Dr. Lee has made house calls with the RNs, for particularly complicated patients.
And house calls uncover a lot. "Even with decades of effort put into medication reconciliation in the hospital," Dr. Lee says, "I’ve been struck by how often medications were not reconciled from discharge to that phone call in 48 to 72 hours."
Patients at home have trouble figuring out what medications they already had on hand and what are new drugs or doses from their hospital stay.
Nurses may find that patients need more care at home than patients had been willing to admit. They’ve also found situations where patients have no food in the house “or the wrong kinds of food.
"It’s amazing," says case manager Tracey Esparza, RN, "how many patients don’t understand that they can’t eat what they’ve been eating all along." The case manager and social worker work to get patients more on-site assistance, help plan meals or arrange transportation, or find scales for patients who don’t own or can’t afford them.
And they reinforce educational efforts. "Heart failure education usually occurs in the hospital when patients are ill and feeling poorly," Dr. Lee points out. "Teaching is more effective when patients are feeling well."
Patients won’t call physicians
With case managers often making home visits, why do they need to show up at patients’ post-discharge appointments as well? Dr. Lee says he and other team members realized that patients’ confusion about medications “and their social and economic problems “tend to be aired only in conversations that last longer than post-discharge calls or even home visits.
That doesn’t mean, however, that primary care physicians are the ones having those long discussions.
"What I often see when I go on appointments with nurses is that the doctors don’t have the time," says social worker Gwendolyn Smith, MSW. "But nurses are able to give patients unlimited time."
That’s when, Ms. Smith says, problems with transportation and with paying for prescriptions tend to be aired, as well as concerns about caregiver resources. The case manager can also fill in gaps in the discharge summary for the primary care physician.
The RNs have also discovered that patients are unwilling to call their primary care physician or specialist if they feel unstable. They not only assure patients that it’s OK to make the call, but they step in and relay the concern to the doctor. That intervention, both Dr. Lee and Ms. Esparza say, has likely headed off several readmissions.
Without spending this kind of time with patients, Dr. Lee adds, case managers can’t foster the kind of relationship that opens up lines of communication about real-world issues that may cause a patient to stop taking a medication or opt for salty food. Case managers also offload a lot of tough conversations regarding hospice or whether home is really the right living situation for them. Not having those discussions, he points out, "often lands people in the hospital later, when they’re failing."
Clearly, such a comprehensive program costs time and money. For the pilot, the foundation asked three case managers and one social worker to incorporate the additional work into their regular duties. Case managers ended up spending an average of 5.7 hours per patient in the first 30 days post-discharge, while the social worker spent 1.5 hours.
"That’s been the biggest challenge, finding time for our nurses," Dr. Lee says. Still, the foundation is expanding the program to cover the rest of its Medicare Advantage heart failure patients, planning to devote one RN case manager to the effort full-time. (An RN is the minimal level of training for such an intervention, says Dr. Lee, because "both the patients and the medication regimen tend to be complex.")
He admits that the foundation has a huge financial incentive to bolster transitional care because it functions as patients’ insurer. But he is convinced that such programs are in all hospitals’ best interest due to the growing focus on preventable readmissions and looming payment penalties.
"A CHF admission is a signal flare indicating that a higher level of care is required," says Dr. Lee. "Our interventions need to focus on that time when patients are not in the hospital or in the office because that’s where they fall through the cracks."
Bonnie Darves is a freelance health care writer based in Seattle.