Program to lower readmissions improves patient care, saves money

When the Pittsburgh Regional Health Initiative wanted to find ways to help community hospitals reinvent themselves, it started by asking physicians: What do you need?

The organization, part of the Jewish Healthcare Foundation, got some expected responses, such as access to specialty care, nutrition programs for patients.

But one intrigued the organization’s officials: We don’t have time to spend with patients after they leave the hospital or a way to track them so they don’t get sick again and have to be readmitted.

“The problem is, if you’re a small practice, you don’t have the staff to build a patient-centered medical home operation,” which many larger hospitals and practices do, said Keith Kanel, the Health Initiative’s chief medical officer.

When his organization looked at the numbers for some of the diseases with the highest 30-day readmission rates – chronic obstructive pulmonary disease, acute myocardial infarction (heart attack), and heart failure – the results were “ridiculous,” Dr. Kanel said.

About one in five patients at local community hospitals were being readmitted to the hospital within 30 days after discharge. That not only is not good for the patient, it is costly to the insurers, whether government or private, which have to pay for those readmission visits, and a burden on the hospitals if the patient is poor and does not have insurance.

Exactly why so many people were being readmitted was as varied as each individual’s medical history. But Dr. Kanel and his staff had an idea to try to change the result.

“We thought, let’s work with physicians’ practices and build Primary Care Resource Centers in the hospitals,” he said. “Let’s hire nurses and pharmacists in these centers, and make them people from the community hospitals, so they’re familiar faces.”

The idea was to introduce hospitalized patients to a nurse and a pharmacist who would follow up with them after they left the hospital – not just by phone, but in person in the home if needed. The contact would continue for at least 30 days.

The project began two years ago with a pilot grant from Highmark to Monongahela Valley Hospital that paid for a dedicated pharmacist to work with three nurses in the first Primary Care Resource Center.

Louis J. Panza, Monongahela Valley’s president, said he jumped at the chance to participate in the program, which he saw as fulfilling his goal for his hospital: “Take care of every patient as if they’re your mother.”

“Do they understand their medication? Do they understand their instructions from the doctor?” he said. “These are important questions and we know they weren’t being answered right because we knew there were numerous readmissions that were preventable.”

The program selected three experienced nurses who already worked at Mon Valley, in addition to a pharmacist. It began by targeting patients at the hospital with COPD and eventually added cases of heart failure and acute myocardial infarction.

The team began by meeting patients in the hospital before discharge to talk about their follow-up care, made calls after they left the hospital within two days, and made visits with them within five days if they found they did not have help at home or questions that only a home visit could help solve.

But from there, the program quickly evolved to include responses to the myriad social and health issues that play a role in patients’ being readmitted to the hospital.

It created education sessions for patients who were going to be on oxygen because of their COPD, or patients who needed to use inhalers for medication.

Officials found an organization – Breathe PA – that could provide air conditioners to patients who did not have one, after staffers found during in-home visits that some patients were living in hot conditions that would worsen their health. They coordinated with transportation agencies to help patients without their own cars make their appointments in the hospital.

“It has gone way beyond what we thought it would be,” said Susan Campus, a Mon Valley nurse with more than 20 years’ experience who is the head case manager for the Primary Care Resource Center there. “It’s about building bridges to resources for our patients.”

Clifford Schmidt was one of Mon Valley’s first patients.

Stricken with COPD and diabetes, he uses a wheelchair much of the time to get around; he was not crazy about getting in-home visits.

“I don’t usually like to ask for anything from anybody,” said Mr. Schmidt, 71, a burly, 6-foot-6-inch, retired heavy-equipment operator in Monongahela whose work on diesel-fueled equipment for decades took a toll on his lungs.

But Resource Center nurses like Deborah Holman, who visited him recently in his home after he put in a call complaining of shortness of breath and nausea, have made him feel less reluctant to ask.

“We need more people who care in the world like her,” he said of Ms. Holman as she took his vitals and recommended he take a dose of prednisone from his puffer to help with his breathing -- all the while kibitzing with him about his family, friends and food.

His medical condition and social situation are more dire than most, so the program has continued to visit with him regularly, well beyond the normal 30 to 60 days most patients need. But it seems to have helped. He has been readmitted in the last two years, but fewer times than he probably would have been otherwise.

“Sometimes I think, ‘What good do these visiting nurses do?’” Mr. Schmidt said. “Then I look at my [health] records and I can see what they do.”

Mon Valley’s experience in the first year proved the value of the program.

“We easily reduced the readmission rates from 20 percent to 18 percent and then to 14 percent,” Dr. Kanel said.

The initial data from that was strong enough to persuade the Centers for Medicaid and Medicare Services Innovation Center to award the Pittsburgh Regional Health Initiative $10.4 million to expand the concept to six other community hospitals in the region for two years: Butler Memorial Hospital, Conemaugh Memorial Medical Center in Johnstown, Indiana Regional Medical Center, Sharon Regional Medical Center, Wheeling Hospital and Uniontown Hospital.

At each location, the hospital has tweaked the format to address its patients’ needs – creating ideas for the other hospitals to add.

For example, in Butler, the staff noticed that patients not only had problems understanding medication, but in understanding the impact of what they were eating.

“We knew our patients needed more education on it,” said Erin Stewart, a nurse and director of Butler’s Primary Care Resource Center project.

In a former patient room retrofitted with carpeting, a table and chairs for patients and their families to sit, the Butler center built a mini food pantry on shelves, stocking it with boxes of cereal, soda, cottage cheese and other foodstuffs, to teach patients how to read a food label.

“One of the things we show them is that there is a lot of salt in their diet,” Ms. Stewart said. “And if your maximum intake is 2,000 milligrams and you eat a half-cup of cottage cheese with 481 milligrams, you’re already a quarter of the way there.”

Now, the other hospitals have created food pantries, too, to educate patients. It’s proof, Dr. Kanel said, “that the best ideas are from the front lines.”

Through the first year for the six hospitals enrolled in the project, and first two years for Mon Valley, the programs helped about 3,650 patients, and saved about $41 million for Medicare alone by reducing readmission rates.

That’s real savings, and Butler and all the other hospitals hope the insurers see the program’s value and they’ll not only be able to continue its operation, but to expand it to more patients with additional diagnosis.

“We’re hoping some of the payers [insurers] will step in and help pay for our staff” in the PCRC program, said John Reefer, a Butler physician and vice president of professional affiliations.

This fall, Dr. Kanel and his staff are going to hold a summit with insurers to present their findings from the first full year of results, in the hope that they will agree to share in the savings and pay to continue the program beyond the federal grant.

“We think this would benefit everyone, and we hope they agree,” he said.

This story was originally published by the Pittsburgh Post-Gazette.