Here’s the case scenario: An 84-year-old New Jersey woman with congestive heart failure and other ailments is discharged from the hospital.
The woman is soon visited at home by a Mercer Care Transitions team member who discovers she is missing several medications. The team member calls the pharmacist and arranges for new medications to be delivered to her home. A follow-up visit reveals the patient has had a sudden weight gain; the team member promptly confers with the physician and the prescription is adjusted.
On both occasions the woman could have ended up back in the hospital. But New Jersey is moving forward — as a key element of the Patient Protection and Affordable Care Act — with innovative programs like Mercer Care Transitions, supported by Robert Wood Johnson University Hospital Hamilton, to keep recently discharged patients out of the hospital.
Much of the focus of the Affordable Care Act has been to provide health coverage for more Americans, and that’s extremely important. Yet this new law is about so much more. The aim also is to improve health quality and reduce costs by keeping people well. As the Medicare Quality Improvement Organization of New Jersey, that’s our goal as well.
One way to improve care is to end revolving door hospital admissions and readmissions. The effort is needed in New Jersey, where we have above-average hospital readmission rates and where 58 out of 63 hospitals have been penalized by Medicare for excessive 30-day hospital readmissions.
The New Jersey hospital readmission rate has been dropping in the past two years — from nearly 21.55 percent in mid-2011 to just above 20 percent, as of the end of March of this year. But New Jersey still remains well above the national average of 18.44 percent.
The good news is that our rates are dropping faster than the rates in other states. This is due in large part to the ongoing efforts of our Care Integration Community Coalitions. At Healthcare Quality Strategies Inc. (HQSI), we are working with more than 125 providers around the state to create these coalitions. The result is innovative work to reduce costs and, more important, to keep patients at home.
No one should be in a hospital if they do not absolutely need to be there, and no one wants to have to
go back to the hospital ER because they have nowhere else to turn.
Hospitals, other healthcare providers, and community groups throughout New Jersey are working together as teams focused on the wellbeing of community residents. These coalitions include physicians, visiting nurses, health coaches, health care coordinators, pharmacists, and other professionals who closely follow discharged patients at high risk for readmission, such as elderly patients with multiple medical conditions.
Without a doubt the penalties being levied on hospitals for excessive readmissions are driving some of this cooperation. Hospitals now have an obligation, and a financial incentive, to follow patients in the community and work with other healthcare providers, physicians and families, and community organizations to make sure patients have what they need to recuperate at home. But more than that, it’s the recognition that a person’s health and wellbeing does not start and end in a hospital.
Home visits are key. A patient may have stomach pains and end up in the hospital and prescribed a battery of expensive tests. But perhaps the patient lives alone and is losing his taste and smell and, as a result, is eating spoiled food.
A home visit is much less expensive than a lower GI series and often far more effective. We talk about noncompliant patients. But perhaps the patient cannot afford the medications, doesn’t understand the directions, or simply can’t get a ride to the drug store.
A home visit can provide solutions, or lead to small changes that prevent further illness or damage. Maybe it’s as simple as moving a rug before an elderly person trips and breaks a hip.
Other innovations include hospital-based pharmacies that provide patients with all their medications before they even leave the hospital, and the creation of “discharge coaches” who help families and patients understand what they need to know before they go home.
At HQSI, we help communities — and even competing hospitals — work together to keep discharged patients safe and at home. We look at the data but know that behind the statistics are real people whose lives can be improved through higher quality health care.
Healthcare is not just an abstraction or a headline — it’s doctors, nurses, pharmacists, infection preventionists, administrators, community organizers, and many others working together to keep every individual as healthy as possible and enjoying life on his or her own terms.