Can a virtual nurse named Louise help keep patients from landing back in the hospital after they are discharged? The animated character on...
The animated character on a computer screen, who explains medical instructions, is one of several new strategies hospitals are using to help patients make the transition to home, including sending patients off with a "Home with Meds" packet of medications and having real-life case managers and nurses monitor patients by phone.
It's part of a push to reduce the 4.4 million hospital stays that are a result of potentially preventable re-admissions, which add more than $30 billion a year to the nation's health-care tab, or $1 of every $10 spent on hospital care, according to the federal Agency for Healthcare Research and Quality.
With hospital stays shorter than they used to be, patients may be sent home in frailer states. They may not understand instructions on how to take care of themselves and face unexpected medical problems after leaving the hospital. More than a third of patients don't get the lab tests, specialist referrals or follow-up care they need.
With one in five of its elderly hospital patients re-admitted within a month of discharge, the federal Medicare program plans next year to reduce how much it will pay hospitals for certain preventable re-admissions. In April, MedicarIndependence Blue Cross has supported pilot programs covering about 25 different conditions with a re-admission risk, Dr. Caraballo says. Discharged patients may experience side effects with new prescriptions because they resume medication that they'd stopped while in the hospital. Or they may fail to fill new prescriptions, such as antibiotics to combat a surgical site infection that was under control when they left the hospital. Patients also frequently fail to keep a follow-up appointment, says Dr. Caraballo, "because the last thing they want to do is see a doctor after they come home."
Grove City Hospital in western Pennsylvania sends patients home with a printout of instructions and information from their electronic medical record. It also assigns transition coaches to call patients two to three days later to discuss medications and appointments and link them with outpatient and community programs, says Brad VanSickles, vice president of operations. In its "Home with Meds" program, discharged patients leave with a month's worth of medications arranged by morning, noon and bedtime; a local pharmacist visits the hospital to counsel patients on medications and makes house calls if concerns arise with home-bound patients.
Gertrude Staab, 87, was admitted through the emergency room last month with a heart irregularity related to congestive heart failure and discharged after 14 days. The medication pack has made it much easier for her to take her six prescription medications. "I really like that I don't have to fuss around with a lot of different bottles and it's all color-coded by the time and pill," she says. Her hospital experience was a good one, she adds, "but I certainly don't want to go back in."
The first cuts to reimbursement from Medicare will focus on congestive heart failure, heart attack and pneumonia, which account for the majority of re-admissions due to recurrence, complications and poor adherence to medications and post-hospital regimens. Consumers can check their local hospital's readmission rates for these three conditions at hospitalcompare.hhs.gov.
e announced it will provide $500 million in grants for organizations that work with hospitals on programs to reduce re-admissions. The government is funding an effort to help hospitals adopt Project RED, a discharge-planning program developed by Boston University that helped cut re-admissions at Boston University Medical Center by 30% in a 2008 study. Researchers there have developed the "virtual discharge advocate," Louise, to help explain home care to patients.
Re-admissions often occur because of poorly communicated instructions, such as when a rushed staff member hands a pamphlet or a printout with scant information to a patient or relative. "I got more instructions on how to take care of a goldfish I took home from the pet store as a kid than we give some people we send home from the hospital," says Victor Caraballo, senior medical director of Independence Blue Cross in Philadelphia. It is providing $5 million to a patient-safety initiative involving more than 70 hospitals and aiming to reduce re-admissions by 10% by next spring.
Hospitals using a program called Project RED (it stands for "Re-Engineered Discharge") start to prepare for discharge when the patient is admitted. They assign a nurse "discharge advocate" who will educate the patient about the diagnosis, arrange follow-up appointments and confirm medication plans. At discharge, the nurse provides an individualized instruction booklet that is also sent to the patient's regular doctor. The nurse reviews the instructions and asks patients to explain them in their own words. Two days later, the nurse calls to identify and resolve problems.
Lynn Leighton, vice president of health services for the Hospital and Healthsystems Association of Pennsylvania, says hospitals often combine Project RED's discharge planning with after-care programs such as the Transitional Care Model, designed at the University of Pennsylvania. It requires nurses to visit chronically ill high-risk patients at home and coordinate care with doctors and pharmacists.
Health First, of Rockledge, Fla., uses Project RED in three of its four Florida hospitals. In a pilot from September 2010 to March 2011, readmissions of congestive heart-failure patients in one unit was reduced by 29% compared with such patients in units where the program wasn't used. Health First hired discharge advocates to help patients with home care and ensure they see a doctor within seven days. James Palermo, chief medical officer, says for hospitals, one of the barriers to wider use of these programs is spending "a significant amount of money that isn't reimbursable."
A study at Boston University Medical Center has shown use of the virtual discharge advocate helps cut costs. Appearing on a computer screen wheeled up to the patient's bedside, Louise reviews the discharge packet while the patient holds a paper copy. Patients react to her questions, including whether they understand an instruction, using a touch screen. Louise—whose name was chosen by focus groups—was designed based on how real nurses interact with patients. But unlike real nurses, Louise always has time to repeat something a patient doesn't understand.
Brian Jack, an associate professor at Boston University who developed Project RED, says in a recent study the use of the discharge plan with human nurses cut costs by about $123 per patient and took about 81 minutes of a nurse's time; the virtual discharge system automates 30 minutes of that time, for a total savings of $145 per patient. "It can be so complicated if you are sick and sleep-deprived in a noisy hospital, and you've been taking pain medications or have a fever," says Dr. Jack. "The last thing you are able to do sometimes is concentrate on these relatively complex things."
Hospitals can download the tools for Project RED from the program's website. The nonprofit Joint Commission Resources has also received funding from the Agency for Healthcare Research and Quality to help about 250 hospitals adopt Project RED tools, and Boston University has licensed the program to San Francisco-based Engineered Care, which sells a software program with a soups-to-nuts discharge-planning program to hospitals, including the Louise virtual-discharge feature.
Correction & Amplification
The portion of Medicare patients who are readmitted within a month after a hospitalization is 20%, or one in five. An earlier version of this article incorrectly said that one in 20 end up back in the hospital.
Additionally, Medicare's Hospital Compare website is found at the address of hospitalcompare.hhs.gov. An earlier version of this article gave an incomplete URL for the site, incorrectly calling it hospitalcompare.gov.
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