Home Discharges Doing everything right, but results are elusive

Doing everything right, but results are elusive

March 2012
Doctor Making Notes About His Patient

Published in the March 2012 issue of Today’s Hospitalist

WITH HOSPITALS facing the prospect next year of lower Medicare payments for higher-than-expected readmissions, the hunt is on for ways to effectively keep inpatients from bouncing back after discharge.

Boston’s Massachusetts General Hospital identified one tactic that might help achieve that goal: The hospital embedded a full-time nurse practitioner (NP) within a medical resident team to help team members complete the discharge process.

The NP worked with that team for five months to complete discharge paperwork, including discharge summaries and medication reconciliation; arrange for follow-up appointments and prescriptions; communicate discharge plans to nurses and primary care physicians; and serve as the point-person for questions from all general medical discharged patients.

As described in the November/December 2011 Journal of Hospital Medicine, embedding the NP brought many benefits. Considerably more discharge summaries were completed within 24 hours (67% vs. 47%), and more scheduled follow-up appointments were made (62% vs. 36%). More patients attended those appointments within two weeks (36% vs. 23%), and patient awareness and satisfaction got a major boost (97% vs. 76%).

In the end, however, 30-day readmission rates didn’t budge. The same percentage of patients were readmitted within 30 days (20% vs. 18%), and the same proportion of patients post-discharge ended up back in the ED (9%).

That was a surprise for lead author Kathleen M. Finn, MD, inpatient associate program director for Mass General’s internal medicine residency program. But Dr. Finn points out that other studies targeting the discharge process for all general medical patients have also produced mixed results, at least in terms of readmission rates.

A more effective strategy, she claims, may be to target smaller groups of high-risk patients. Dr. Finn spoke with Today’s Hospitalist about preventing and working with midlevels.

Were the findings on readmissions disappointing?
Yes, in the sense that we did all the things everyone says you should do to improve your discharge process: Make the discharge summaries better, get patients to primary care physicians quicker, make sure patients are communicated with. We were hoping we’d see a dent in our inpatient or ED visits.

Why do you think that didn’t happen?
There is a lot more to readmissions than the job we do at discharge. We didn’t publish this, but we reviewed the readmissions for the study and found that over 50% were psychosocial “homeless alcoholics who keep coming back for a warm bed or elderly patients whose families are not ready to place them in hospice. There are a lot of psychosocial issues that are very hard to deal with in the general medical population.

What do you think works to decrease readmissions?
I think you have to identify the patients who are at the highest risk for readmission. Most hospitals find heart failure and diabetes patients to be at the highest risk, and they focus on the populations who get readmitted over and over again. That doesn’t preclude improving your discharge process, but if you’re really concerned about readmissions, just improving the discharge process for every general medical patient probably won’t help much.

Is your hospital focusing on high-risk patients?
I’m not involved with this, but Partners Healthcare [the integrated system that includes Mass General] started a demonstration project for high-risk Medicare patients with chronic, complicated conditions in three of its hospitals. Nurses call the patients frequently and do what they can to keep them out of the hospital. Over three years, that program has reduced readmissions among those patients by 20% and ED visits by 30%.

Yet your study produced several benefits, such as improved patient satisfaction. What contributed to that?
Because residency teams switch over so frequently, patients aren’t sure who to call if they have a question or things don’t go well after discharge. The NP improved patient satisfaction because she was able to get in touch with a team that may have already gone off service or she would know which consultant or specific doctor to track down.

Did health care reform and possible penalties come into play with this study?
Part of this study was done in 2007, so we weren’t even considering reform. What drove the study was ACGME limits on working hours. Residents and interns limited to 80-hour work weeks can’t possibly do the same amount of work they did before. So NPs have become more vital in helping physicians with the entire process of safely discharging patients.

Do you think this a good role for NPs?
From my understanding of NP training, many NPs want a one-on-one relationship with a patient. This job is very different in that the NP is embedded in a team that has a specific function. So she needs to know about 15 patients and how to put together discharge summaries and plans. She needs to remember such things as the nodules on an X-ray that need follow-up and make sure that’s arranged. It’s a different skill set than planning to see one patient in an outpatient clinic.

How did this innovation help residents?
The future of health care is multidisciplinary teamwork. Having NPs on these teams is a great way for residents to learn how to work with physician extenders. Some residents get on service and immediately know how to start working with extenders, and others really struggle. It sometimes takes training to learn how to delegate and work with somebody else. The NPs also are more experienced in terms of discharging patients, so they provide an educational role.

Do you continue to embed NPs?
We have five medical resident teams. Two have a second junior resident to help with the discharge process. The other three do not, and we have now embedded an NP with each of those teams. We’ve also added NPs on the weekends to reduce late discharges and free up the ED.

What can community programs learn from this study?
We studied one NP in a large academic medical center with housestaff, so it’s hard to generalize to a community hospitalist group that doesn’t have residents. But the discharge process is so complicated and takes so much time away from hospitalists trying to round on other patients and do admissions. Finding a way to work with physician extenders can make a big difference.

Based on your research, what do you think is the best role for midlevels?
I don’t know if anyone has found the perfect niche for midlevels. I think you have to start small and then grow. An NP right out of school doing inpatient medicine would want to get lower acuity patients “but an NP who has five or 10 years of inpatient experience can probably take on more complicated patients than interns. It comes down to adaptability and whom you are working with.

Karen Sandrick is a freelance health care writer based in Chicago.