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Return to Hospital Programs Aim to Reduce Re-admissions Overview

More on Hospital Programs Aim to Reduce Re-admissions

Hospital Programs Aim to Reduce Re-admissions

New York (Jun 15, 2011)

doctors attend to patient in hospital bed, nighttime

Across the country, patients are discharged from the hospital only to be re-admitted shortly after. This problem is an important part of health-care reform as hospital re-admissions are common, costly, and sometimes life-threatening events. In fact, unplanned return visits to hospitals cost as much as $17.4 billion in Medicare costs alone and are associated with longer hospital stays that average admissions. However, many of these re-admissions may be preventable through improved follow-up care and collaboration among health-care providers.

Heart Failure and Pneumonia Are Top Reasons for Re-admission

Congestive heart failure and pneumonia are the two most common reasons for hospital re-admissions. Patients with heart disease "have so much to learn to take better care of themselves including what to eat, what medicines to take, who to call when they have a problem, and what symptoms to look for," explained Beth A. Barron, M.D., Co-director of the Hospitalist Program at NewYork-Presbyterian/The Allen Hospital. "We thought this is a population that we could do a lot of good for."

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Beth Barron, M.D., and colleagues developed a program at NewYork-Presbyterian/The Allen Hospital to help patients with congestive heart failure better manage their disease and ease the transition from hospital to home. The program's goal is to reduce re-admissions by helping patients learn more about managing their disease.

Congestive heart failure occurs when the heart is no longer able to pump blood throughout the body. It can be caused by narrowed arteries, high blood pressure, problems stemming from a heart attack or stroke, infection of the heart, as well as other causes.

Jennifer I. Lee, M.D., the Quality and Patient Safety Officer for the Department of Medicine at NewYork-Presbyterian/Weill Cornell Medical Center and her colleagues at Weill Cornell Internal Medicine Associates are developing a similar program for their campus. This program aims to reduce re-admissions among patients with acute medical conditions, including congestive heart failure, pneumonia, or exacerbation of any chronic condition that will require medical attention within four days of leaving the hospital.

Beth A. Barron, M.D.
Beth A. Barron, M.D.

Among patients with pneumonia, reasons for re-admission to the hospital include failed treatment, lack of clear instruction on use of medications, lack of follow-up with a physician following discharge, and new or worsening co-morbid illness (such as chronic obstructive pulmonary disease or coronary artery disease). The problem involves both community-acquired and hospital-acquired (nosocomial) pneumonia. These re-admissions occur among patients entering the hospital with pneumonia as well as patients treated for other conditions who are later re-hospitalized with nosocomial pneumonia.

"One of the things that we found is that no matter how much preparation we try to put into place in terms of services, when the patient leaves the hospital, it may be a completely different situation that was not anticipated at discharge," said Dr. Lee.

About the Programs

Dr. Barron's team examined the problem from every angle. They found that improving care came down to educating the patient. "It is about giving the patients a better understanding of their disease, better access to care, and someone to talk to," Dr. Barron explained. "The time between when patients leave the hospital and see a doctor again is a vulnerable time. You don't know whom to call and you don't know who is responsible for you.".

Jennifer I. Lee, M.D.
Jennifer I. Lee, M.D.

In Dr. Barron's program all patients with congestive heart failure are now given one-on-one education by congestive heart failure nurse, Mitzy Placencia, R.N., on how to manage their disease and take care of themselves at home. They meet with nutritionists to learn about eating a healthy diet and are invited to take classes on nutrition. They meet daily with the congestive heart failure nurse to be given individualized instructions on their disease and what they can do to help manage it. Each patient is given a handbook to take home with them to remind them of what they learned in the hospital. Counseling and all patient education materials are available in both Spanish and English.

Within 24-48 hours after discharge, the patients are phoned to make sure that they are taking their medications, weighing themselves daily to monitor for water retention, and checking for symptoms. Another key aspect of the program is that patients are given follow-up appointments with primary care providers within one week of hospital discharge, a time frame that is linked with better outcomes. A nurse checks in every two to three days after discharge until patients see their physician and the transition of care is made.

All patients in Dr. Lee's program will be given a follow-up appointment with a primary care physician within four days of discharge. "Arranging a follow-up visit for patients when they leave the hospital is a way to ensure that patients will be seen within four days of discharge rather than four weeks," Dr. Lee explained. Any patient who misses an appointment is contacted to see why.

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"The objective is to help patients feel that they are not being neglected after they leave the hospital," explained Dr. Lee. "They are leaving with the knowledge that they will be seen again and that they will not be lost in the system, but rather are being connected back into the system. We will reach out to them within four days and we will address those issues if there are any."

Preliminary Findings

Early data from NewYork-Presbyterian/The Allen Hospital shows that the program has improved the number of patients who weigh themselves daily and who are able to obtain all of their medications on discharge from the hospital. Likewise, a staff survey showed major improvements in the percentage of patients who received adequate education on their disease, diet, and medications, and who receive a discharge plan that is adequate to prevent hospital re-admission within one month.

"There has been an increase in the quality of care delivered; the hospital is now at or above Medicare targets for all core measures," Dr. Barron said. "The patients seen by the heart failure nurse are much more likely to be able to stay at home and avoid re-admission to the hospital. The re-admission rate for patients not seen by the nurse is nearly 3 times higher than those patients she is able to see," she explained.

Contributing faculty for this article:

Beth A. Barron, M.D. is Co-director of the Hospitalist Program at NewYork-Presbyterian/The Allen Hospital and an Assistant Clinical Professor of Medicine at Columbia University College of Physicians and Surgeons. She is also an Assistant Attending Physician and Assistant Program Director of the Internal Medicine Residency Program at NewYork-Presbyterian/Columbia University Medical Center.

Jennifer I. Lee, M.D. is an Assistant Attending Physician in the Division of Hospital Medicine at NewYork-Presbyterian/Weill Cornell Medical Center and an Assistant Professor of Medicine at Weill Cornell Medical College. She is also the Quality and Patient Safety Officer for the Department of Medicine.

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