[NYAPRS Enews] VP, AAMC: Innovative Ways to Limit Return Hospital Visits, Promising Value of Peer Coaches

[Harvey Rosenthal]

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.p
df.  

 

 

Hospitals Find Ways to Limit Return Visits

By Amy Jeter <http://hamptonroads.com/2007/10/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

----------------------------------

 

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

 

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