NYAPRS Note: Last week, we ran sobering new findings that premature death rates have been rising for people with major psychiatric diagnoses (http://www.nyaprs.org/e-news-bulletins/2012/2012-02-29-Study-Premature.cfm). Several of our readers wrote appropriately tying these trends to the use/overuse of psychiatric medications. There’s also lots of evidence to show that our community is dying earlier because of significantly high prevalence of smoking-related COPD and numerous other conditions that have required more connection to and follow up with medical and other treatments.
The following pieces underscore the value and effectiveness of approaches that quickly link people with unusually high hospital and ER use (often from our community) to the appropriate outpatient care after a recent admission. One looks at a Virginia initiative and one provides an update on a prominently covered New Jersey model that was highlighted in the ‘Hotspots’ New Yorker piece (http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande).
Central to these kinds of approaches is often the use of health or life coaches, an increasing number of which are peers (people with mental health histories).
For a recent review of “Peer Support Whole Health and Resiliency” by Dr. Judith Cook, go to http://www.cmhsrp.uic.edu/download/PeerSupportWholeHealthAndResiliency.pdf.
Hospitals Find Ways to Limit Return Visits
By Amy Jeter The Virginian-Pilot March 1, 2012
Yvette Greaves pulled a chair up to the examination table and fired off questions to her patient, an uninsured 36-year-old woman with dangerously high blood pressure.
Does she smoke? Does she feel safe in her home? Has she recently suffered from fever, chills, skin problems, a cough, shortness of breath, chest pain, depression, anxiety?
After a physical exam, the nurse practitioner made plans for a stress test, prescribed a new blood pressure medicine and an electrocardiogram, and scheduled a follow-up appointment two weeks out.
If all goes well, it will be Nicole Gamble’s last visit to Chesapeake Regional Medical Center’s transitional care clinic. She also won’t need to go back to the hospital.
The clinic is among several efforts by South Hampton Roads hospitals to help patients stay healthy enough to avoid return visits.
In recent years, preventable hospital readmissions have been spotlighted as an area for potential health care savings. About $25 billion is wasted annually on such rehospitalizations, according to a study by PricewaterhouseCoopers’ Health Research Institute.
When the returning patients are uninsured – like those served by Chesapeake’s new clinic – the hospital isn’t paid for some or all of the cost of the readmissions.
Starting this fall, hospitals also can lose money if they readmit too many Medicare patients.
In 2005, the government insurance program for seniors and the disabled spent about $12 billion on potentially preventable readmissions within 30 days of hospitalization, according to the Medicare Payment Advisory Commission, an independent congressional agency.
Beginning in October, Medicare will reduce inpatient payments for hospitals with 30-day readmission rates considered too high for pneumonia, heart attack or heart failure patients.
The rates already are publicly reported. For admissions between July 2007 and June 2010, two local hospitals performed better than the national average: Bon Secours DePaul Medical Center in Norfolk for heart attack patients and Sentara Bayside Hospital in Virginia Beach – which is now an outpatient center – for heart failure patients. All other Hampton Roads hospitals met national averages.
“The federal government is putting hospitals on notice that readmissions aren’t going to get reimbursed, and that we need to get better about controlling length of stay and keeping people out of the hospital,” said Elaine Griffiths, Chesapeake Regional’s vice president of patient care services and chief nursing officer.
Researchers have pinpointed characteristics of patients most likely to be rehospitalized – people with two or more chronic conditions, who have been hospitalized at least twice in the past year, who are low-income, who consider themselves in poor health.
They also have identified which conditions typically can be controlled outside of a hospital setting – including those targeted by Medicare. Still, determining which patients will return is no easy matter.
“There’s no sure-fire way to predict who is going to be readmitted and which readmissions were preventable,” said Dr. Ann O’Malley, senior researcher at the Center for Studying Health System Change. “But there are general things we know we can do to avoid readmissions.”
That includes educating patients and family members about their conditions and medications before discharge and scheduling follow-up appointments. After patients leave the hospital, they benefit from follow-up phone calls and home visits.
Most important, O’Malley said, patients should see a health provider soon after they leave the hospital.
“Most readmissions occur in the first 12 to 14 days after discharge,” O’Malley said. “A lot of these conditions, if you don’t keep a really close eye on them, minor things can kind of blow up and push the patient over that edge where they have to get readmitted.”
Medicare’s new practice creates a small risk that hospitals will refuse to readmit patients to avoid losing money over unflattering rates, O’Malley said. However, many hospitals are responding by strengthening the bridge to outpatient care.
South Hampton Roads hospitals aim for patients to visit a physician within a week of discharge.
For those who see Sentara Medical Group primary care doctors, an alert is programmed in their electronic medical record after their hospitalization, prompting the doctor’s office to schedule an appointment.
Nurses at Bon Secours Hampton Roads Health System hospitals personally call patients after discharge – sometimes more than once – to check on them and remind them about follow-ups.
“It’s being relentless in a compassionate way,” said Lynne Zultanky, a spokeswoman.
Chesapeake Regional uses similar practices.
Additionally, local hospitals are trying out new ways to reduce readmissions, such as assigning nurses to monitor heart-failure patients after discharge and using a scoring tool to determine which patients are most likely to be rehospitalized.
So far, at least one program has documented monetary savings. Bon Secours “life coaches” link uninsured emergency room patients with free or reduced-price primary care at nearby clinics. Only 12 of 1,000 patients seen by DePaul Medical Center’s two life coaches in 2010 returned to the emergency department for the same complaint that year, and the Norfolk hospital saved an estimated $150,000.
Chesapeake Regional is hoping for similar results with its transitional care clinic.
Greaves sees uninsured patients with chronic illnesses within two weeks of their hospital visits. She assesses their progress, adjusts medications and orders lab tests, as needed. Within two months, she sets them up with primary care for the long haul, often at a free clinic.
Last year, $64.3 million in inpatient and emergency treatment at the hospital was classified either as charity care or written off to bad debt – up 15.2 percent from the year before, said Michael Corcoran, Chesapeake Regional’s chief financial officer.
Running the clinic costs about $102,000. According to an analysis of the first seven months, it could save the hospital around $400,000 a year by preventing 30-day readmissions and repeat emergency room visits.
But there is still room to improve.
Open just four hours a day, Greaves and her small staff sometimes struggles with a backlog of referrals and with no-shows.
If the clinic continues to be effective, Chesapeake Regional will consider expanding it, Griffiths said.
Meanwhile, people like Gamble have the chance for more complete health care than they’ve had in years.
She lost her job and insurance more than two years ago and has only sporadically been able to take care of her high blood pressure.
An inflamed bug bite brought her to Chesapeake Regional’s emergency room early last month, and doctors referred her to Greaves’ clinic.
“I said, ‘Thank you, Jesus,’ ” Gamble said. “I could finally see a doctor.”
http://hamptonroads.com/2012/02/hospitals-find-ways-limit-return-visits
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Innovations in Clinical Care: Improving Care From the Bottom Up
by Sarah Mann AAMC (American Association of American Medical Colleges) Reporter: February 2012
Just over a decade ago, Jeffrey Brenner, M.D., was frustrated with the state of primary care in Camden, N.J., where he had practiced for 10 years. During a monthly breakfast group with local providers, Brenner realized he was not the only frustrated doctor in Camden. Patients with chronic conditions like diabetes often bounced between hospitals, with little improvement. There were high rates of asthma and obesity. In many cases, patients had problems like poverty that went beyond the traditional health system and required coordination with social workers and other health professionals.
“We realized that we had a lot of concerns in common and needed to work together to start fixing the system from the bottom up,” said Brenner, a faculty member at the University of Medicine and Dentistry of New Jersey Robert Wood Johnson School of Medicine. “We were going to have to start working in brand new ways. We didn’t even know each other’s languages. The delivery systems, whether behavioral health, housing, or medical care all have their own culture and their own way of solving problems.”
The breakfast group evolved into the Camden Coalition of Healthcare Providers, a nonprofit group that creates innovations from the perspective of providers to increase health care quality and access. The coalition’s approach is unique because it begins with frontline primary care providers rather than starting with policymakers or hospital administrators.
“I think the people who are closest to the problem have the most to offer to solve it, and they are often the last people who are asked. They also have the most interest in collaborating and working together,” said Brenner, who is also executive director of the coalition.
One of the coalition’s first projects was to analyze patient-level insurance claims data from the city’s hospitals and emergency departments (EDs). The data showed pockets of the city that had particularly high health care utilization. In a single apartment building, 615 residents had gone to the hospital 3,901 times between 2002 and 2008, resulting in $83 million in charges. In another nearby building, 332 residents visited the hospital 1,414 times at a cost of $65,000 per visit.
The coalition members focused on these specific “hot spots” to determine why utilization was so high. They involved building residents to develop solutions. Today, the building has two patient exam rooms on-site and offers a diabetic support group and a yoga class. Other programs focus on reducing unnecessary ED visits by working with patients who have a history of multiple ED visits to find housing, apply for government assistance programs, and address other barriers to care.
One of the coalition’s newest projects, the Care Transitions Program, which started last November, works with patients, health providers, and social workers to prevent hospital readmissions. Jason Turi, clinical manager for the program, receives a daily list of admissions to Camden’s two hospitals that shows the number of times each patient has been admitted to the hospital and visited the ED over the past year.
“We have a conversation with the patient, the social workers, and doctors, and ask if these admissions are preventable,” Turi said. “We’ll ask if the patient needs case management or if the admissions are related to an ongoing treatment.”
In the case of a 52-year-old tracheotomy patient who had been in the hospital eight times over the last 12 months, Turi met with the patient and her family at the hospital and developed a plan with social workers and home care workers. The patient spent time in a long-term acute care facility, where she transitioned to a vent, before going home. Once she was back home, Turi and a care team visited her weekly, reviewing her medications, following up with her doctors, and educating her family. The team ensured she visited her primary care physician within a few days after leaving the acute care facility, which is key. According to Turi, research has shown that about 50 percent of readmissions can be prevented if the patient follows up with a primary care doctor soon after leaving the hospital. She doesn’t remember being out of the hospital this long, Turi said.
“Not only is she more motivated, but her family is more motivated. Now that she is stable at home, over the next few weeks we might engage her with some of our health coaches around goals she has set related to her health. Then we’ll slowly hand her back to her primary care office,” Turi said. “This goes a little bit beyond case management. We really help these individuals and families figure out how to navigate a system, which a lot of times is extremely frustrating even for us. We’re in the middle of this complicated matrix of providers, and just by being there, it makes a huge impact.”
The coalition is making an impact in other ways. With the help of the coalition’s several programs, Brenner predicts Camden will be the first city in the country to reverse the upward trend in health care costs. And, people are healthier.
“We have great stories of people who are starting to get better care and feeling cared about rather than rejected by the delivery system. When health care doesn’t work well, it’s really disempowering to people,” Brenner said. “One of the most exciting things is that we are beginning to see patients feel like they’re part of the solution. Our primary care providers have been really discouraged, but I think we’re starting to see them get more excited.
https://www.aamc.org/newsroom/reporter/feb2012/273810/innovations.html