Congestive heart failure landed Peter Parham in the hospital twice in one month this past fall, and the 77-year-old retiree would much rather have been home in Ewing -- taking his medicine, watching his diet and keeping the disease in check. To help patients like Parham avoid readmission to the hospital within one month of discharge, Robert Wood Johnson Unversity Hospital Hamilton launched a new program in October that provides a "transition coach" who visits Parham at home to make sure he understands what he must do to stay out of the hospital.
"This is a good program that helps you take care of yourself," Parham said. His coach gave him a personal health record book to record his weight every day; excessive weight gain is a warning sign of heart failure complications. Parham also uses the book to keep track of his medications, write down questions to ask his doctors, and to express his personal goals: "to breathe better, and to be able to get up and around more—exertion was causing me a lot of breathing problems," he said.
The transition coach program at RWJ Hamilton, funded by a grant from the Robert Wood Johnson Foundation, is one of many efforts underway at hospitals throughout the state. There is a powerful motivation: Medicare has announced that in 2013 it will withhold 1 percent of a hospital's reimbursement if its 30-day readmission rate exceeds what the program deems reasonable for that hospital. That could cost some New Jersey hospitals millions of dollars, experts said; for many hospitals, Medicare accounts for as much as half the institution's revenue.
Hospitals are using a variety of approaches to stem readmissions: running hospital-based clinics to provide follow-up care to discharged patients, working with nursing homes to coordinate the care the patient gets when moving from hospital to nursing home, and providing telemonitors that transmit the patient's vital statistics to clinicians who can intervene if the patient's condition deteriorates.
RWJ Hamilton's program will focus on 350 patients over two years who are at least 60 years old and suffer from congestive heart failure or diabetes or both, and have at least one other chronic condition. It is a joint program with the Jewish Family and Children's Services of Greater Mercer County, which has extensive experience providing social services to the elderly in the community. Judy Millner of JFCS was trained as a transition coach, and she mentors the project's coach.
Joyce Schwarz, vice president of quality at RWJ Hamilton and project director, said in order to reduce readmission, it's critical that patients see their primary care physician within a week of discharge from the hospital. But physicians tend to be booked up; "so they get an appointment in three weeks, and before the three weeks are up they run into trouble and wind up back in the hospital before they even see their doctor." Millner said the patient is coached "to be engaged and empowered" as a patient: "We do role playing to ensure that the appointment is made and that it's not three weeks before they see the doctor."
Schwarz said that traditionally, "We have put the responsibility on the [healthcare] professionals to manage your healthcare. 'See me in six months. Take this medication.' But where is the patients' responsibility, what if they don't take their medication?" She said the goal of the coach is to get patient actively involved in their health.
Dr. Charles Riccobono, chairman of the Performance Improvement Department at Hackensack University Medical Center, said "Medicare views readmission to be a major problem that is costing the country a lot of money." He said the cost of avoidable readmissions have been estimated to be as high as $40 billion a year.
At HUMC, a team of executives from throughout the medical center are working together to find ways to reduce readmissions, Riccobono said. One initiative is targeting nursing home residents who are often readmitted to the hospital, to determine if changing the care delivered at the nursing home would reduce readmissions. He said nurses at HUMC are following up with patients at nursing homes and making discharge phone calls to patients to make sure they understand their instructions.
One strategy to reduce readmissions is telemonitoring of patient vital signs, to quickly identify changes that require a phone call or a visit to the healthcare team. In 2009, Monmouth Medical Center launched an "outpatient heart failure management program" that includes telemonitoring. A scale with a wireless connection goes home with the patient, who each day steps on the scale, and the weight is transmitted to the hospital; diabetic patients take their glucose readings and plug the information into the telemonitor.
Sharon Holden, assistant vice president, cardiopulmonary, critical care and emergency services at Monmouth Medical Center, said the hospital "will intervene immediately," if the clinical parameters raise red flags; for example a weight gain of more than two pounds might result in an immediate increase in the dosage of the patient's diuretic. "Many, many times this avoids an unnecessary visit back to our emergency department," she said.
And the impact on readmission is truly striking, Holden said: of the heart failure patients who go home with a telemonitoring system, only 9 percent are readmitted in 30 days; for those who chose not to use telemonitoring, 28 percent are readmitted.
Holden said it's not just the data that's received via telemonitoring, but the interventions that occur that make the difference. "You can't just have someone feeding data—based on specific information, the patient will be spoken to or seen. You have to have clinical intervention."
After heart failure patients are discharged from the hospital, they return within seven days to Monmouth Medical's outpatient program, where an advanced practice nurse, "sees them for an hour and a half to do a full evaluation; and then they spend a half hour with a dietician," Holden said. The patients will come back for follow up visits, depending on what they need; the visits may be twice a week, once a week, or once a month. "They are also given the nurse practitioner's phone number."
An advanced practice nurse provides a clinic for heart failure patients at St. Joseph's Regional Medical Center in Paterson, which next year plans to add a similar clinic for stroke patients.
Maria Brennan, chief nursing officer at St. Joseph's, said the program is aimed at patients "who come into the hospital time and time again with the same diagnosis. Our goal is to try to manage the patients at home."
The problem: after heart failure patients were discharged from the hospital it was taking a month for them to get an appointment at clinics that treat a general range of ailments. "They can't wait a month. They need to be seen a week after discharge to make sure they are on the right medication, that they are following the right diet, and that if they have questions they have a person they can ask," Brennan said.
Ilene Matza, the advance practice nurse of cardiology, said there are some patients she has been seeing since the clinic began two years ago. "I see improvements in their lives," she said. "I see them feeling better; I see them not getting short of breath, and being able to tolerate physical activity. We talk a lot about exercise. Many people don't think they can do any exercise if they have heart failure, and actually they can."