- By NHRMC President and CEO, Jack Barto
Preventable readmissions to the hospital within 30 days of discharge has been one of the most talked-about metrics in patient care the past couple of years, and it is a centerpiece for savings and quality improvement under the Affordable Care Act. Hospitals that five years ago likely paid little attention to their readmission rate can today quote multiple versions of their rate and what they are doing to lower it.
While we have historically paid attention to preventable readmissions at New Hanover Regional Medical Center, we certainly are in the category of those hospitals that today are very attuned to their 30-day readmission rate. The Affordable Care Act penalizes hospitals with rates the government says are too high. That penalty can be as much as 3% of a hospital’s Medicare inpatient revenue, or several hundred thousand dollars in our case. I am proud to say that we are among the 20% of hospitals in North Carolina that have not been penalized so far.
For the past two years, two of our patient care units have been part of a pilot project, led by the N.C. Quality Center, to reduce readmissions, and we found that some relatively simple interventions can have a profound impact. We believe we can transfer these lessons to the entire hospital and become an industry leader in this field.
And now we have a partner who believes in us as well. The Duke Endowment, a private foundation in Charlotte that strengthens communities in North and South Carolina, has generously awarded NHRMC a two-year, $900,000 grant to expand what we’ve learned throughout the hospital. Our goal is to develop “standard work” on successful tactics that prevent readmissions, then share those with other hospitals and providers.
The primary thrust behind reducing readmissions has been to save healthcare costs, as the average hospital admission costs Medicare about $10,000. Many of these readmissions could have been prevented with better education, better medication management, better follow-up at home or better connection to available community services.
But beyond saving money for the government, the best reason to prevent readmissions is because it’s best for the patient. Hospital stays are often difficult for already-vulnerable patients, as their eating and sleeping rhythms are disrupted, and they are often medicated, disoriented or anxious. Our goal is to get patients well – and have them stay well in the comfort of their home.
With our pilot program, we quickly realized we needed to identify which patients are most likely to readmit and design our interventions for them. We developed a quick assessment to identify “high-risk” patients, basically those who have multiple disease states, multiple medications, multiple admissions to the hospital and - the most accurate readmission predictor – little to no social support at home. We directed these interventions to those “high-risk”patients:
Scheduling patients to follow up with their primary care doctor within five days of leaving the hospital
Installing “road maps” in patients’ rooms to create a dialogue between caregivers, patients and their families about care goals and what to expect after leaving the hospital
Offering to fill prescriptions for patients before they leave the hospital. Too often, patients return home and either don’t have a ride to the drug store or can’t afford the medications. Failure to correctly take prescribed medications is a leading predictor of preventable readmissions
Educating patients on the medications they are taking and “reconciling” all prescriptions to ensure their medicines are working together as they should
Calling patients at home within three days of leaving the hospital to check if they are having signs and symptoms of their disease, understand their care plan, have filled their prescriptions and are scheduled to see their doctor.
This last intervention proved to be most powerful. Skilled nurse case managers at our hospital saved countless readmissions – and vastly improved life quality of our patients – by noticing symptoms that needed to be checked, medication inconsistencies, or other issues of concern in the home.
We found that among our high-risk patients who we were unable to reach by phone, the readmit rate was 17.1%. When a case manager called the patient once, it dropped to 12.5%. When we were able to call on consecutive weeks, the rate dropped to 6%.
For the partnership with The Duke Endowment, we are going to build on these lessons, especially the ones that take place in the home. We intend to add case managers to call all “high-risk” adult patients within three days of discharge, and again the following week.
We are adding a “community pharmacist” to work with patients at home to ensure they have the right medications and are taking them correctly. This project should confirm our belief that the best medication reconciliation takes place at the kitchen table, not the hospital bed.
Finally, we are adding two Community Paramedics, which are specially trained EMS paramedics who can go into patients’ homes and assess their medications, environment and ability to buy food, medicine and other needed supplies – and take immediate action to correct issues that could lead to a readmission.
We are already having outstanding success with our current Community Paramedic program, funded by a prior grant from The Duke Endowment. These paramedics have focused on patients with Congestive Heart Failure, visiting them before they leave the hospital to establish a relationship. So far, they have worked with 31 patients who have been home at least 30 days after leaving the hospital. Just two have readmitted, a rate of 6.5%. Typical hospital readmit rates for CHF patients nationally exceed 20%. This success is what prompted us to ask for more Community Paramedic positions, as we believe this approach is going to have a tremendous impact on hospital readmissions.
As a conservative estimate, we believe if we apply these initiatives consistently, we would save about $2 million annually for the healthcare system. More important, it will save unnecessary hospital trips for our patients, or, to put it another way, patients will spend more time healthy at home with their families - the best healthcare outcome of all.