St. Luke’s program aims to keep patients out of the hospital
November 2, 2009
One issue highlighted during debates over healthcare reform is hospital readmissions. An article in “New England Journal of Medicine” examines this issue ("Rehospitalizations Among Patients in the Medicare Fee-for Service Program," published April 2, 2009). The study finds nearly 20 percent of Medicare beneficiaries discharged from a hospital were readmitted to the hospital within 30 days of discharge. The study estimates rehospitalizations accounted for about $17.4 billion in hospital payments from Medicare in 2004.
According to the “MedPac 2007 Report to Congress: Promoting Greater Efficiency in Medicare,” research indicates many hospital-based initiatives that improve communication with patients and other caregivers and coordinate care after discharge may prevent some hospital readmissions.
In 2006, St. Luke’s Hospital in Cedar Rapids, Iowa launched one such program called Transitions Home. St. Luke’s Heart Care Services team made the move after learning more about the Institute for Healthcare Improvement’s (IHI) Transforming Care at the Bedside program. IHI’s national program aims to create an ideal transition home for patients who were being discharged from medical and surgical units.
“St. Luke’s focused on heart failure because of the high readmission rate,” said Peg Bradke, RN, MA, St. Luke’s Heart Care Services director. “We looked at how we could make the patient’s transition home more family friendly. And in particular we identified specific ways where there was a breakdown in communication, which in many cases led to a patient being readmitted to the hospital.”
St. Luke’s team set a goal of reducing unplanned heart failure (HF) readmissions by 50 percent. The team used a methodology, which included the patient and caregiver – ensuring that they fully understand their diagnosis, plan of care and follow-up care with their doctor.
St. Luke’s identified four key changes to achieve the ideal care transition from hospital to home:
Enhanced assessment of patients
Enhanced teaching and learning
Patient-centered communication hand-offs
Post hospital follow up
To make these changes St. Luke’s identified interventions to provide HF patients with the best transition either to home or to a long-term care facility. Each discharged HF patient receives patient-friendly written information, a home visit from a nurse within 48 hours; a follow-up appointment with their doctor within three-to-five days and seven days after discharge the patient receives a follow-up telephone call from an advanced practice nurse. In addition, St. Luke’s provides a calendar of useful patient information, a class on heart failure management and a refrigerator magnet listing the signs of heart failure.
“We really worked on staff education,” said Bradke. “Our staff wanted to empower the patient and their loved ones to recognize the signs of heart failure, know what medications they are taking, review what kinds of foods they can eat, how much weight gain is acceptable and how they can monitor vital signs. The same educational offerings were given to the nursing home staff and home health care.”
Another item included in the patient education materials was a color-coded chart, which showed patients how to interpret their symptoms and what action they need to take. All of these educational materials assist patients in taking a more pro-active approach in their care.
“The whole idea behind the Transitions Home program is to get the patient engaged and involved in their healthcare,” said Todd Noreuil, MD, Cardiologists, P.C., and St. Luke’s Chronic Heart Failure Program medical director. “We do this by supporting them, learning about their condition and teaching them what they need to keep an eye on. All of the follow-up phone calls and visits are meant to reinforce the key points they learned during their hospital stay. These would be taking their medications, the importance of salt restriction, checking weight gain and reporting any of these symptoms. Patients seem to really like it.”
St. Luke’s far exceeded its original goal of reducing heart failure readmission rates and looks to continue this trend.
“St. Luke’s is having success with this program,” said Dr. Noreuil. “The readmission rate for the last 2 ½ years is at six percent. The St. Luke’s Transitions Home program has been recognized as an example for the rest of the nation in articles published in the “Wall Street Journal” and “Washington Post.”
