Judith Figueroa was once a familiar face in the ED, visiting the hospital almost every month, she says. The 69-year-old New York resident has numerous chronic health problems, including diabetes, a heart condition and a failing liver. She takes multiple medications. But since last year, when Carolyn McCrea, RN, began implementing a series of best practices proven to reduce hospital readmissions, Figueroa’s visits to the ED have dropped considerably.
“She tells me how to take care of myself,” Figueroa says of McCrea, who is a care coordinator for Visiting Nurse Service of New York, the largest not-for-profit home-care agency in the U.S. “She tells me to go to the doctor, and not to wait until I get worse. She makes sure I keep my appointments, and if I’ve having problems, she writes them down to show the doctor.”
The last time she went to the hospital, Figueroa says, was in September to have a pacemaker implanted. “It’s a blessing,” she says. “Because I used to go all the time.”
Keeping patients with multiple chronic conditions out of the hospital has always presented a challenge for healthcare providers, but an increasing awareness of why patients return coupled with a push to reduce healthcare costs has put hospital readmission rates under a national spotlight. A growing number of hospitals, home-health agencies, insurance companies and medical groups are introducing evidence-based pilot programs to improve the transitions of patients discharged from a hospital to community care, and hoping to reduce their chances of returning. Almost all of these programs significantly involve nurses — as coaches, educators, care coordinators and patient advocates.
“Nurses play a central role in the prevention of hospital readmissions. This is well-documented in a number of studies,” says researcher Mary D. Naylor, RN, PhD, FAAN, professor of gerontology and director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing.
A study in the New England Journal of Medicine last April found nearly 20% of Medicare patients discharged from hospitals between 2003 and 2004 were readmitted within 30 days, and about one in three returned to the hospital within 90 days. The government spends an estimated $12 billion a year on “potentially preventable” readmissions for Medicare patients, according to the Medicare Payment Advisory Commission, an independent congressional agency.
In an effort to reduce readmissions, the Centers for Medicare and Medicaid Services have added rehospitalization rates as one measure of hospital performance. Last year, the CMS began publishing 30-day readmission rates for heart failure, pneumonia and heart attack for every hospital in the country. The recently passed healthcare reform legislation includes a provision to cut reimbursements for certain types of readmissions starting in 2012, creating a financial incentive for hospitals to reduce readmission rates.
Transitional-Care Models
Naylor and her colleagues have developed a transitional-care model that uses advance practice nurses to follow high-risk elderly patients from the time they are admitted to the hospital through the day they return home and the weeks beyond.
Nurse care coordinators visit patients in the hospital every day, make follow-up appointments with primary care providers and specialists, and accompany the patients on those visits to hand off information and help them ask questions and understand answers. They teach patients to assess their own symptoms using a traffic light model, with green for feeling fine, yellow for a small weight increase or mild swelling that means calling the nurse practitioner, and red for shortness of breath or other severe symptoms that indicate they should call 911 or go to the ED.
The nurse works with patients for up to 12 weeks if necessary, though six weeks is sufficient for most patients, says M. Brian Bixby, CRNP, MSN, who works with patients at the University of Pennsylvania Health Services, which has incorporated Naylor’s model.
Naylor’s studies have shown an average savings of $5,000 per patient one year after hospitalization.
Naylor’s model is probably the most intensive of readmission prevention projects. At the other end of the spectrum is a four-year, multistate initiative from the Institute for Healthcare Improvement. This project focuses on four “pillars” — enhanced assessment; patient and family education; improved hand-off communication among providers, including medication reconciliation; and scheduling follow-up appointments with primary care providers while the patient is still in the hospital. Higher risk patients receive more intensive follow-up.
At North Shore Medical Center in Salem, Mass., which is participating in the IHI program, nurses receive training in “teach-back” techniques. They ask patients to repeat back information the nurses give them to make sure it is understood. Nurses offer basic “survival skills” patients can use to care for themselves until they can see a primary care provider or visiting nurse, says Carol Pray, RN, MA, director of patient flow and capacity management at North Shore.
One of the biggest changes for nurses at St. Luke’s Hospital in Cedar Rapids, Iowa, was the collaboration involved in working with heart failure patients at discharge, says Peg Bradke, RN, MA, project leader for the hospital’s Transition Home for Patients with Heart Failure program. In 2006, the hospital’s team was expanded to include representatives from patient families, home health, extended care and outpatient clinics.
The program has reduced 30-day hospital readmission rates for patients with heart failure from 14% to 4%, and the hospital is looking at using it for other groups of patients.
The practices visiting nurse McCrea is using to help keep Figueroa out of the hospital are similar to those in other successful care projects, such as helping patients establish health goals, teaching them to recognize and respond to symptoms, and creating personal health records. These practices have been around for a while, McCrea says, “but they haven’t been put into a format where everything was used collaboratively.”
Cathryn Domrose is a staff writer for Nurse.com.
“She tells me how to take care of myself,” Figueroa says of McCrea, who is a care coordinator for Visiting Nurse Service of New York, the largest not-for-profit home-care agency in the U.S. “She tells me to go to the doctor, and not to wait until I get worse. She makes sure I keep my appointments, and if I’ve having problems, she writes them down to show the doctor.”
The last time she went to the hospital, Figueroa says, was in September to have a pacemaker implanted. “It’s a blessing,” she says. “Because I used to go all the time.”
Keeping patients with multiple chronic conditions out of the hospital has always presented a challenge for healthcare providers, but an increasing awareness of why patients return coupled with a push to reduce healthcare costs has put hospital readmission rates under a national spotlight. A growing number of hospitals, home-health agencies, insurance companies and medical groups are introducing evidence-based pilot programs to improve the transitions of patients discharged from a hospital to community care, and hoping to reduce their chances of returning. Almost all of these programs significantly involve nurses — as coaches, educators, care coordinators and patient advocates.
“Nurses play a central role in the prevention of hospital readmissions. This is well-documented in a number of studies,” says researcher Mary D. Naylor, RN, PhD, FAAN, professor of gerontology and director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing.
A study in the New England Journal of Medicine last April found nearly 20% of Medicare patients discharged from hospitals between 2003 and 2004 were readmitted within 30 days, and about one in three returned to the hospital within 90 days. The government spends an estimated $12 billion a year on “potentially preventable” readmissions for Medicare patients, according to the Medicare Payment Advisory Commission, an independent congressional agency.
In an effort to reduce readmissions, the Centers for Medicare and Medicaid Services have added rehospitalization rates as one measure of hospital performance. Last year, the CMS began publishing 30-day readmission rates for heart failure, pneumonia and heart attack for every hospital in the country. The recently passed healthcare reform legislation includes a provision to cut reimbursements for certain types of readmissions starting in 2012, creating a financial incentive for hospitals to reduce readmission rates.
Transitional-Care Models
Naylor and her colleagues have developed a transitional-care model that uses advance practice nurses to follow high-risk elderly patients from the time they are admitted to the hospital through the day they return home and the weeks beyond.
Nurse care coordinators visit patients in the hospital every day, make follow-up appointments with primary care providers and specialists, and accompany the patients on those visits to hand off information and help them ask questions and understand answers. They teach patients to assess their own symptoms using a traffic light model, with green for feeling fine, yellow for a small weight increase or mild swelling that means calling the nurse practitioner, and red for shortness of breath or other severe symptoms that indicate they should call 911 or go to the ED.
The nurse works with patients for up to 12 weeks if necessary, though six weeks is sufficient for most patients, says M. Brian Bixby, CRNP, MSN, who works with patients at the University of Pennsylvania Health Services, which has incorporated Naylor’s model.
Naylor’s studies have shown an average savings of $5,000 per patient one year after hospitalization.
Naylor’s model is probably the most intensive of readmission prevention projects. At the other end of the spectrum is a four-year, multistate initiative from the Institute for Healthcare Improvement. This project focuses on four “pillars” — enhanced assessment; patient and family education; improved hand-off communication among providers, including medication reconciliation; and scheduling follow-up appointments with primary care providers while the patient is still in the hospital. Higher risk patients receive more intensive follow-up.
At North Shore Medical Center in Salem, Mass., which is participating in the IHI program, nurses receive training in “teach-back” techniques. They ask patients to repeat back information the nurses give them to make sure it is understood. Nurses offer basic “survival skills” patients can use to care for themselves until they can see a primary care provider or visiting nurse, says Carol Pray, RN, MA, director of patient flow and capacity management at North Shore.
One of the biggest changes for nurses at St. Luke’s Hospital in Cedar Rapids, Iowa, was the collaboration involved in working with heart failure patients at discharge, says Peg Bradke, RN, MA, project leader for the hospital’s Transition Home for Patients with Heart Failure program. In 2006, the hospital’s team was expanded to include representatives from patient families, home health, extended care and outpatient clinics.
The program has reduced 30-day hospital readmission rates for patients with heart failure from 14% to 4%, and the hospital is looking at using it for other groups of patients.
The practices visiting nurse McCrea is using to help keep Figueroa out of the hospital are similar to those in other successful care projects, such as helping patients establish health goals, teaching them to recognize and respond to symptoms, and creating personal health records. These practices have been around for a while, McCrea says, “but they haven’t been put into a format where everything was used collaboratively.”
Cathryn Domrose is a staff writer for Nurse.com.
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