Disease management program lowers hospital readmission days

Study followed chronically, critically ill patients after discharge

A post-hospital disease management program for patients who have lengthy stays in the intensive care unit can reduce readmission lengths of stay and pay for itself, a study by researchers at Case Western Reserve University has shown.

The program did not make a significant difference in reducing the actual number of readmissions, but it did dramatically reduce the number of readmission days.

Among the 180 patients who survived the study period and were readmitted to the hospital, those who were assigned to the disease management program had an average of 5.77 fewer hospital days than patients who were in the control group.

The researchers multiplied the average savings of $19,000 per patient (based on the mean hospital charge of $3,415 per day) by the 93 patients in the study group who were readmitted to the hospital, which resulted in a total $1.8 million potential reduction in hospital charges associated with readmission.

"We came up with a reduction to the health care system of $1.8 million vs. the cost of two advance practice nurses and administrative costs. The cost of delivering the services was much less than the savings," says Sara L. Douglas, RN, PhD, associate professor, school of nursing at Case Western Reserve University in Cleveland and a primary investigator in the study. The study was funded by the National Institute of Nursing Research and results were published in the Journal of Critical Care, a publication of the American Association of Critical-Care Nurses.1

Critical post-discharge period

During the study, advanced practice nurses followed the patients for eight weeks after they were discharged from the acute care hospital. That time period was chosen because chronically, critically ill patients are at highest risk for readmission during the first two months after discharge, Douglas says.

"The interventions began after discharge. We were not interested in changing what happened with the hospital discharge," Douglas adds. The nurses followed the patients closely for two months, through every transition. When a patient transferred from one level of care to another level, or to home, the nurses visited within 48 hours.

"This is something that currently doesn't happen in our health care system. The nurses saw the patients in the hospital, then followed them through their stays in the long-term acute care facilities, rehabilitation facilities, through their discharge to home," Douglas says.

Douglas attributes the lower length of stay for patients in the study to the comprehensive information that the nurses who had been following the patients were able to provide to the hospital when the patients were readmitted.

"The communication and coordination role of the nurses was instrumental in reducing the length of stay when patients were readmitted. When the patient was readmitted, the hospital staff were able to spend less time putting together a history of what had gone on with the patient and were better able to treat the immediate problem," Douglas says.

Patients who qualified for the study had complex conditions and had been on a ventilator for at least 72 hours at University Hospital, a 900-bed pediatric and adult tertiary care medical center in Cleveland.

The majority of patients in the study were middle-aged or elderly with chronic health conditions or chronic critical illness. Neurological disorders or events such as Parkinson's disease, brain tumors, and major strokes were the No. 1 cause of admission, followed by cardiac events and respiratory conditions, says Clareen Wiencek, CNP, one of the nurses who helped coordinate care for patients after discharge.

Other patients who met the criteria included middle-aged people who were in automobile accidents or who had systemic infections following surgery.

Bridge between acute and post-acute stays

"These were not your typical patients who spend a few days in rehabilitation after discharge. It was a varied patient population and each one needed an individual plan of care. They were very complex patients who had complicated stays in the acute care hospital. We were the bridge between the acute care stay and the post-acute stay," says Helen Foley, MSN, RN, the other advanced practice nurse who worked with patients during the study.

Only about 20% of the patients in the study were discharged to home. The remainder were discharged to at least one post-acute facility such as a long-term acute care facility, a rehabilitation facility, or both.

Patients were identified while they were in the intensive care unit and approached about participating as they approached discharge. When patients consented to participate in the study, Wiencek and Foley reviewed the chart, then met with the patient and family members and collaborated on a discharge plan with the hospital's discharge planners, social workers, nurses, and physicians.

Because the nurses spent time with the patients and family members during the hospitalization, they were familiar with the patient's family situation and other factors that could affect the discharge destination. This enabled them to help the hospital discharge planners create a plan and get the patient discharged in a timely manner.

The nurses gathered information from the chart by talking to the hospital multidisciplinary team and family members. They provided the information, along with the comprehensive discharge document, to the physicians and nursing staff at the post-acute facilities that received the patients and to the patient's primary care physician.

"We wanted the primary care physician to know what happened in the hospital and the goals of care whenever the patient goes home and is cared for by the primary care physician," Douglas says.

The nurses were able to write a detailed patient care summary of the hospital stay and set goals for the rehabilitation period, Wiencek says. They faxed the patient care summary to the receiving facility and visited the facility within 48 hours of the patient's admission.

Targeting transitions of care

"A lot of things fall through the cracks when patients are transferred from one facility to another. We identified early on that when a patient moves from one facility to another or is discharged to home, the situation is ripe for problems caused by miscommunication," Wiencek says.

The nurses kept their pagers on 24 hours a day, seven days a week during the entire study so if they couldn't be there in person, the hospital, nursing home, rehabilitation facility, or home care agency could contact them by telephone to ask questions about what had been going on with the patient.

"By streamlining communication and coordination of care, the nurses were able to facilitate the patients getting the care they needed at the receiving facility in a timely manner," Douglas says.

"When patients were transferred to other facilities, the onsite visits by the nurses were helpful in providing timely information to the treatment team at the receiving facility and enable them to take care of the patients' needs more quickly and to serve the patients better," Wiencek says.

The nurses participated in the patient care conferences at the receiving institutes and were welcomed because they could fill in the gaps and help staff understand what had happened during the patient's hospital stay, Foley says. For instance, at one conference, the physician at the receiving facility expressed a desire to see the echocardiogram. Foley went out to her car, called the laboratory, and by the time she was back in the conference, the report had been faxed to the physician.

"The people at the receiving facilities appreciated the comprehensive information they received. These patients have had a complicated hospital stay and they found it helpful to get details about what happened," she says.

About a third of the patients in the study had cognitive issues at discharge and were not able to engage in lengthy conversations, which made the personal visits by the nurses an important component of the program because it would have been difficult to manage these patients over the telephone, Douglas says. During the personal visits with the patients, the nurses picked up on problems that the patient or caregiver had not thought of mentioning to the treatment team at the new facility.

For instance, they noticed that the patient was confusing his medications or that the family didn't have enough supplies for dressing changes to get them through the weekend.

Almost every patient discharged to home had home health care. The case management nurses completed a physical assessment in the home, helped with medication instructions, and met with the home care nurses, providing detailed typewritten patient care summaries with information about the patient's medical condition, medical history, hospital stay, and discharge needs.

During the home visits, the nurses often picked up changes in the patient's condition or noticed that family members were having problems coping. "We intervened numerous times by calling the physician or sending the patient to the emergency room when a patient's health status required it," Foley says. In one case, a patient's blood pressure was so elevated that the nurses put him in the car and took him directly to the emergency room.

"As case managers, we worked closely with the home health agencies and the primary care physicians to support the patients in the community," Wiencek says. The nurses frequently accompanied patients on their physician visits, filling the doctor in about what had happened during the hospital stay.

"When the patients were readmitted to the hospital, we tried to be there, especially if they came back to our hospital. If we couldn't be there, we'd make telephone contact and fax the patient care summary as quickly as possible. We cut out the time that it took for the hospital treatment team to learn what was going on with the patient," she adds.

An additional benefit of the study was the help and support the nurses provided to the family members. "The transition between facilities is a scary time for families and they were happy to have someone to support them and guide them through the health care system, to oversee the transition of care, and help them advocate for themselves as necessary," Foley says.

Families of patients with complex needs must make a lot of decisions about the next level of care and how the patient's care could best be managed, she adds. The nurses helped them understand their choices and, in some cases, helped with end-of-life decisions.


1. Chronically Critically Ill Patients: Health-Related Quality of Life and Resource Use After a Disease Management Intervention. Am J Crit Care 2007 16:447-457. (Available on-line at www.ajcconline.org.)