Home Discharges Improving post-discharge care for a difficult group

Improving post-discharge care for a difficult group

August 2004

Published in the August 2004 issue of Today’s Hospitalist

Think of people who frequently return to health care wards, and elderly patients suffering from heart failure likely come to mind.

The disease is a problem of staggering proportions in the United States. Elderly Americans with heart failure have the highest rates of hospitalization, with total health care costs that exceed $24 billion annually.

Intensifying this statistic is the fact that for many of these patients, heart failure is just one of many problems. Research shows that four out of 10 hospitalizations for elderly patients with heart failure result from coexisting conditions such as diabetes or coronary artery disease.

A study in the May 2004 issue of the Journal of the American Geriatrics Society examined exactly this group when it looked at more than 200 heart failure patients over age 65. The goal was to find new ways to prevent unnecessary hospital readmissions and other negative outcomes such as death.

Investigators had advanced practice nurses work with heart failure patients both in the hospital and at home for up to three months after discharge. While patients were in the hospital, advanced practice nurses arranged for physical therapy to minimize functional status.

The nurses also helped group members change their diets and adhere to complex medication regimens. They even accompanied patients to their first post-discharge visit to their primary care physician.

After examining the cost-effectiveness of the intervention through one year after initial hospital discharge, researchers found that the results were impressive. While the follow-up care was expensive, it ended up saving nearly $5,000 per patient over the course of a year. Overall, cost of care of these patients in the six participating hospitals was cut by almost 40 percent.

Researchers also found that the interval between discharge and first readmission or death was lengthened for patients in the intervention group. After 52 weeks, patients in the intervention group had fewer readmissions (104 vs. 162) and lower mean total costs ($7,636 vs. $12,481). At 52 weeks, rehospitalizations were decreased in the intervention group (47 percent) compared to the control group (61 percent). The intervention didn’t merely delay readmissions, it reduced them overall.

Such dramatic results reinforce the importance of followup care for high-risk populations such as elders hospitalized with heart failure, according to Mary D. Naylor, PhD, RN, the study’s lead investigator and a University of Pennsylvania professor of nursing. This is the third in a series of randomized, clinical trials funded by the National Institutes of Health in which Dr. Naylor and colleagues have demonstrated the positive effects of comprehensive interventions targeting hospitalized elders.

Today’s Hospitalist talked to Dr. Naylor to find out how advanced practice nurses worked with heart failure patients and their physicians to keep this vulnerable population healthy “and out of the hospital.

What does your latest study add to our understanding of how follow-up care can help sick elderly patients?

Our findings showed that we reduced total readmissions through one year after discharge. That was a longer effect than other trials focusing on this patient group have produced. In addition, our intervention did not just reduce heart failure-related readmissions, but also those due to diabetes, coronary artery disease, and/or other conditions common among these patients.

Among heart failure patients, four out of 10 hospitalizations are for a coexisting condition. We need to use comprehensive approaches that target all of the major conditions resulting in frequent hospitalizations for these patients.

How did the protocol used in the study reduce readmissions and overall costs?

Advanced practice nurses were assigned to care for these patients as soon as possible after their hospital admissions. With short hospital stays, you have limited opportunities to influence the care of these patients. You need to start working with these patients and their family members early in the hospitalization to design their discharge plans.

Nurses made daily visits to identify patients’ and caregivers’ goals to address symptom management issues and to coordinate the care of these patients. Often, the advanced practice nurses brought in physical therapists to help prevent functional decline, something that can happen in even short hospital stays.

The nurses also consulted with pharmacologists to streamline some patients’ very complex medication management plans. Whenever needed, the advanced practice nurses sought expertise from health team members during the patients’ hospitalization. Patients and their families often do not have access to these services after discharge.

Nurses would visit patients within 24 to 48 hours following hospital discharge. Over the many years we have worked with these patients, we have learned that immediate follow up is necessary to identify and intervene in problem areas such as medication management, diet and activity.

What did the protocol call for once the patient was discharged?

By the time they arrive home, patients and their caregivers have often forgotten the instructions they received in the hospital, or there may be unanswered questions or confusion. For example, patients are often unsure if they should continue taking the medications prescribed before they were hospitalized along with their new medicines.

During the first 24 to 48 hours post-discharge, the biggest challenges are adhering to therapies and symptom management. It’s not that these patients aren’t receiving instructions in the hospital, but that their capacity to understand and retain that information in the face of their acute illnesses is seriously diminished.

They come home medically stable, but physically and emotionally depleted. This patient group and their caregivers are especially vulnerable to the breakdowns in care that are common in the transition from hospital to home. That includes poor communication among patients, caregivers or providers.

After their initial visit, the advanced practice nurses, working in collaboration with patients’ physicians, would use their clinical judgment to determine how many visits the patient needs based on the patients’ health requirements and goals. Some patients may need daily visits during that first week after discharge to prevent a visit to the ED or hospital admission.

On average, most of the patients in this study suffered from more than six physical or emotional problems in addition to heart failure. Typically, they were also coping with depression, diabetes and hypertension.

A large part of our emphasis was helping people identify early on that they were running into problems and preparing them to manage these situations. For example, they would learn that eating certain food would cause them to retain fluids. In collaboration with their physicians, nurses taught these patients and their caregivers how to adjust their medications to prevent fluid overload.

We also taught them how to identify when they needed help and how to access services early enough so they could be efficiently and effectively managed in the home without having to return to the ED or hospital.

How did nurses handle the handoff from hospital staff to community-based physicians?

Nurses would accompany patients and family members on the first visits to the primary care physicians to ensure good communication about medical management plans and to help patients and caregivers obtain the answers to questions about their care.

Most patients had multiple physicians involved in their care. They typically did not know who to call when they ran into problems. A major goal of this intervention was to promote continuity of care and enhanced care coordination. As a result, the nurses served as the point person and broker of care among multiple providers.

Why is such extensive follow-up necessary to reduce readmission rates with these patients?

Heart failure and other chronic conditions are common among elders, and they are progressive in nature. Elders coping with multiple complex, chronic problems need the sustained involvement of someone who can help them slow the rate of decline and better manage worsening health problems.

In our current system of care, we do a great job of handling the acute problem, but we return patients home without addressing the issues and problems that result in frequent hospitalizations. Consequentially, 75 cents of every health care dollar is spent on managing chronic health problems.

Our study showed that there are cost-effective alternatives that will enable elders coping with multiple chronic conditions to manage these problems more effectively and lead a much higher quality of life. We need to figure out how to make interventions such as this a part of standard care.