Facing costly penalties, hospitals find ways to improve care

They followed John Dunning out the hospital doors last February, but they still won’t let go.

They call. They leave messages. They offer to come to his Ladera Heights home.

“They’ve been there constantly,” Dunning, 63, a plumber for Los Angeles Unified School District, said of the nurses, dieticians and others who track him. “It makes you feel good that they’re concerned.”

Concern is part of it. But officials at Providence Little Company of Mary Medical Center in Torrance, where Dunning was treated for heart failure in February, say all the extra vigilance comes down to something else: They want to keep patients such as Dunning out of the hospital for 30 days after discharge.

A provision under the Affordable Care Act allows Medicare to penalize hospitals for high readmission rates within 30 days of discharge, particularly among patients with heart attacks, heart failure or pneumonia. At least eight hospitals statewide already have faced stiff penalties, including San Gabriel Valley Medical Center and Glendale Memorial Hospital, according to Kaiser Health News.

So hospitals near and far have begun various initiatives, such as forming teams with nurse navigators, pharmacists and dieticians to educate patients before and after they are discharged from hospitals; collaborating with the local YMCA for low-cost exercise programs; and even implementing a Big Brother-like approach of having colleagues spy on one another to ensure adequate handwashing.

“At the end of 2009 and beginning of 2010, we recognized the problem of readmissions,” said Muriel Schonbachler, a nurse navigator at Providence Little Company in Torrance who specializes in cardiac patients.

“I put together a support group for those with heart failure, because it’s such a growing population and one of the largest groups readmitted to the hospital.”

Schonbachler said the heart patient is taught the early signs and symptoms of failure, such as swelling of the legs, ankles and feet, shortness of breath, and fatigue. A pharmacist shows them how to take medication and a dietitian goes over food choices. After the patient leaves, Schonbachler calls them for follow-ups and makes sure they know when their next appointment occurs. Some patients receive home visits and go to support groups.

By the end of last year, the hospital saw a 16 percent decrease among congestive heart failure patients, she said.

But challenges remain for some hospitals that have yet to develop programs or form relationships with other medical facilities, nursing homes, and community services, said Julia Slininger, vice president of quality and patient safety for the Hospital Association of Southern California.

She said hospitals are working on communicating better, not only internally, but with other medical centers.

“Electronic health records are somewhat helpful, but all systems do not yet ‘talk’ to each other, and concerns with maintaining compliance with healthcare information privacy is still a challenge as well,” she said.

Slininger said another challenge is what the patient does after leaving the hospital.

“Patient compliance is always and has always been a challenge, but it is our job to maximize their participation in their care plan by helping them understand the importance of their role in staying well, to make sure their families or caregivers understand, and put them in touch with added resources they may need,” she said.

All the initiatives won’t stop readmission, she and others say, but hospitals now have to work harder to try.

“Sometimes everything is done optimally and patients are still readmitted, oftentimes with a different condition than the index condition (heart failure, pneumonia, or heart attack) that brought them into the hospital in the first place — the conditions that CMS tracks for readmissions,” she said. “But we do need to be challenged — all providers across the continuum — to do a better job of coordinating care and helping patients stay well, creating more of a health-care system than a “sick care” system in our communities, our state, and our nation.”

A report released by the Center for Medicare & Medicaid Services in March found that from 2007 through 2011, the hospital readmission rate averaged 19 percent nationally, but fell slightly to 18.4 percent in 2012. Authors of the report said it was unclear why the slight decrease occurred.

Meanwhile, thousands of hospitals have joined the federal Medicare program Partnership for Patients, which has two goals by the end of 2013: to decrease preventable hospital-acquired conditions by 40 percent and decrease hospital readmissions by 20 percent, compared to 2010.

Long Beach Memorial Hospital joined the effort as well and opened a special heart clinic to follow up with patients, said Donna Hartman, vice president of clinical quality & patient safety.

“We’re actually making the visit to their home, post-discharge, which is a new program for us, and we plan to grow that and continue that,” Hartman said.

The goal is to increase family participation in helping the patient become healthy, she said.

“When you’re in the business of providing health care, a huge part of the role is educating our patients,” Hartman added. “In the past, we did not explain things as well as we should have. Sometimes the medications alone are daunting.”

At Desert Valley Hospital in Victorville, which recently ranked highly on a Consumer Reports study of surgical safety, the hospital has emphasized educating the staff on the importance of the initiatives themselves, said CEO Margaret Peterson.

“Everybody’s measuring hand washing, but one of the things we’ve done is rather than measuring the amount of soap used, we’re actually doing a lot of observing,” Peterson said. “We have people who are like secret shoppers. People don’t realize they’re being watched. They are also corrected.”

All of these initiatives can only be good for the patients, but there will be bumps along the way, added Bruce Nelson, director for community services at Glendale Adventist Medical Center. The hospital has teamed up with other medical facilities in Glendale to design a system that allows a patient’s test results, for example, to be viewed by doctors at all facilities, without compromising privacy. The hospitals also are reaching out to the YMCA and YWCA to help patients find healthy solutions within the community.

“All three hospitals (in Glendale) have collaborated together,” he said. “It’s important to cooperate where it makes sense.”