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Nurse-Led Efforts Aim to Reduce Hospital Readmissions

Monday April 19, 2010
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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.


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Three Models for Reducing Readmissions

These three models use evidence-based practices to successfully reduce hospital readmissions. Some hospitals and healthcare groups have incorporated elements of all three, or use different models for different risk groups of patients. Costs of the models and use of resources vary, but researchers say all have proven more cost-effective and resulted in higher patient satisfaction than rehospitalization.

• Transitional Care Model, developed by Mary Naylor, RN, PhD, and colleagues at the University of Pennsylvania:

The Transitional Care Model uses transitional care nurses — advance practice nurses who follow patients identified as being high risk for readmission, from the time they enter the hospital until they are completely transitioned into community care, which usually spans two months. The nurses use their time in the hospital to work with all providers caring for the patient, including attending rounds, talking to the patient and family members, and working with discharge planners. The nurses make follow-up appointments with specialists and primary care providers, visit the patient within 24 hours of returning home to assess conditions there, reconcile medications, make regular home visits and phone calls, and accompany the patient to medical appointments to assure a proper handoff.

• Care Transitions Intervention Model developed by Eric Coleman, MD, MPH, and colleagues at the University of Colorado Health Sciences Center:

This model focuses on teaching patients and families how to continue care once the patient leaves the hospital. For four weeks, a trained transition coach works with patients, visiting them at least once in the hospital and once at home, and making at least three follow-up phone calls. The transition coach helps manage and reconcile medications, schedules appointments with specialists and primary care providers, helps create and maintain a personal health record the patient can share with providers, and teaches the patient and family members how to identify serious and lesser symptoms of his or her condition, and how to respond to each type. A study by the Centers for Medicare and Medicaid Services showed this model cut 60-day readmissions in half.

• Project RED Model developed by Brian Jack, MD, and colleagues at Boston Medical Center:

Project Re-Engineered Discharge uses an 11-point checklist for hospital staff to follow during discharge, and is coordinated by a nurse trained as a discharge advocate and a pharmacist, both employed by the hospital. The list includes educating patients about their diagnoses, confirming medications, creating a personal health record, making follow-up appointments with primary care providers, and giving patients a written discharge plan. A recent randomized study showed a 30% decrease in readmission when all steps were followed, says Jack.