Making sure patients connect with a doctor within a week of leaving the hospital to discuss any concerns, manage medications and address potentially dangerous complications — it’s a simple concept that has shown promising results.
And patients who follow up with a physician inside that seven-day window are less likely to be readmitted to hospital, according to a two-year study by the Camden Coalition of Healthcare Providers. The findings were published in late January by the JAMA Network, the American Medical Association’s online journal.
Using a three-pronged outreach strategy that involved financial incentives for providers, personal assistance for patients in securing and scheduling appointments, plus help with transportation to the doctor and out-of-pocket expenses, the coalition’s 7-Day Pledge program was able to reduce hospital readmissions in the following months by as much as ten percentage points.
“It’s statistically significant. And there are dollars attached to that and there are real patients attached to that,” said Dawn Wiest, the coalition’s director of research and evaluation.
While the study was not designed to maximize or measure savings, rough calculations suggest there could be more than $10,000 savings in healthcare costs on average, in each hospitalization that is avoided; in Camden’s case, these costs are often covered by Medicaid. The work is not easy, coalition members said, and it depends on data-sharing and other collaboration among healthcare providers that have traditionally been competitive, and other groups, but it has potential.
Improving outcomes, reducing costs
For the patient, a prompt post-hospital check-up can — in addition to flagging possible dangers — bring peace of mind, noted Rev. Yvonne Lawrence Sims, a member of the coalition’s Community Advisory Committee, whose husband was recently hospitalized.
“It takes the anxiety off your mind” to not have to wait weeks for a follow-up appointment, Sims said, “and it can keep you from going back to the hospital for the same thing that was just supposed to be rectified.”
Hospital readmission is considered a key indicator of care. Reducing these repeat visits was one of the goals outlined in the federal Affordable Care Act, as part of the law’s push to improve patient experiences and address rising costs.
According to the JAMA article, data from 2012 showed that one in 12 patients admitted to an acute-care facility nationwide returned within 30 days, adding $16 billion to the country’s annual tab for medical care. In addition, one in four of these readmissions are preventable, in large part through better post-discharge care.
Getting in to see a doctor can be hard, however, given the shortage — nationwide and in New Jersey — of primary-care providers. Many are also reluctant to take on new Medicaid patients, since they usually receive less for treating these individuals than they do for those with private insurance. That problem is particularly acute in Camden, where more than half the residents are covered by Medicaid, versus one in five statewide.
Looking for a quicker follow-up
But the Camden coalition, launched in 2002 in an effort to improve care for vulnerable patients, particularly those with complex medical needs, found it was in a position to help address this gap. Leaders at the nonprofit coalition — which connects healthcare providers, social service agencies and community organizations — decided to use its data-sharing network and the relationships they had built to help more Camden residents get access to quicker follow-up care after a hospitalization and, in January 2014, they launched the 7-Day Pledge.
The coalition first recruited a dozen primary-care practices and worked with schedulers and office staff to help streamline the appointments process in an effort to make room for more patients. The group also offered incentives of up to $150, on top of the usual Medicaid reimbursement, for providers who treated an individual within a week of being discharged.
“We talked to them about what it would take to create space in your schedule,” said Natasha Dravid, the coalition’s director of clinical redesign initiatives. “Bringing the additional payment to the table made that conversation easier, but everyone basically agreed on the value of the program.”
When the program started, community health workers from the coalition sought to recruit patients through bedside visits to hospitals throughout the city; occasionally they followed up with folks by phone after discharge. The group focused on individuals with a certain level of clinical complexity, as well as mental-health needs.
Through this process, they engaged more than 1,500 patients to be part of the 7-Day Pledge program. (Individuals in the community could also sign on to the program, promising to seek out care within seven days and follow other discharge instructions, as part of the effort to spread the word about the importance of these post-hospital checkups.)
Cash incentives for doctors
The health workers then used their connections, and the cash incentives, to secure a follow-up visit for these participants with an appropriate, accessible primary-care provider. (For some, this meant finding space in the schedule of their usual doctor; for others, it involved connecting them with a primary-care practice.) But with deep experience in the Camden community — among the poorest nationwide — coalition staff knew this help alone would not be enough, so they made sure transportation and pocket money for each patient were incorporated in the program.
The coalition contracted with a local cab company known for its quality service to ensure these patients could get to the doctor’s office for the post-discharge appointment. “Many people don’t have transportation,” noted Rev. Sims, adding, “Jack or Jane may have taken you to the hospital, but Jack or Jane isn’t (necessarily) available to take you to the follow-up.”
The program also gave each patient a $20 gift card to help offset expenses associated with the office visit, like unexpected child-care costs, or lunch on the road. “We use the word ‘incentive,’ but the gift card is not necessarily an incentive,” Dravid explained. “It’s really a recognition of all those barriers that our patients face in their daily lives.”
Overall, results from the 7-Day Pledge program — which ran through April 2016 — showed that less than 13 percent of those who saw a doctor within the seven-day window were readmitted to the hospital within 30 days, versus close to 18 percent of those who did not get that follow-up care.
The impact over 90 days was even greater: 28 percent of those with quick after-care were readmitted during that three-month period, versus 39 percent who did not get the same post-discharge attention after their first hospitalization.
Camden coalition members said it takes a certain volume to make the program worthwhile economically, but the model shows promise. The organization hopes insurance companies will consider implementing similar models, using physician incentives to ensure patients get prompt follow-up care in order to reduce readmissions. Coalition leaders also aim to work with other groups in New Jersey and nationwide to help them establish similar initiatives.
“There are a lot of different ways to think about what’s next,” Dravid said. “It’s hard work…to build systems (like this) across competing health networks. But we really do believe the program is scalable.”