Lee Health, a four-hospital health system in southwest Florida, takes a multipronged approach to reducing readmission for patients with chronic conditions.

  • Patients with chronic obstructive pulmonary disease receive three visits from home health nurses the first week after discharge, and follow-up calls for 90 days.
  • A heart failure coordinator at each of the system’s four hospitals facilitates bedside rounds and makes sure the entire team is providing consistent education.
  • The case management staff teaches the staff at skilled nursing facilities how to recognize signs that indicate a patient’s condition is getting worse and what to do about it.

A comprehensive, multipronged approach to reducing readmissions has paid off for Lee Health, a healthcare system with four acute care hospitals serving a five-county area in southwest Florida.

The all-cause readmission rate at Lee Memorial Hospital, the healthcare system’s flagship hospital located in Fort Myers, is 15.9%, compared with 18.9% for the state of Florida and the 18.2% national rate.

Initiatives enacted by the health system include a follow-up program for patients discharged with chronic obstructive pulmonary disease (COPD), aligning with post-acute providers in the area to prevent unnecessary readmissions, standardizing heart failure treatment across the health system, and working with other providers to standardize educational materials.

Since more than 50% of patients are discharged to home, Lee Health created a program to smooth the transition and determine ways to keep patients from coming back to the hospital, says Thomas J. Pennsy, RRT, MBA, executive director of home health for Lee Health.

“We analyzed our chronic disease patients who were being readmitted within 30 days and determined that a large number are heart failure patients, and that the readmission rate for patients with COPD was climbing about the same time the Centers for Medicare & Medicaid Services [CMS] added COPD to its readmission reduction program,” Pennsy says.

The hospital team modeled its initiatives after The Care Transitions Program and sent several staff members for training on the model at the Division of Health Care Policy and Research at the University of Colorado’s School of Medicine, where the program was developed.

Lee Health initiated a readmission reduction program for its home health patients being discharged to home with a primary diagnosis of COPD. Patients who participate in the program currently have a 17.2% readmission rate, compared with 22.5% of patients who do not participate.

A registered nurse leads the program and is the central contact point for the clinicians caring for the patients, Pennsy says.

Here’s how the program works: When a patient meets criteria for the program, the hospital case manager notifies the program nurse, who communicates patient information to the home health staff. “They determine the patients’ understanding of their disease, what services they need, and collaborate on an individual plan,” says Cathy L. Brady, RN, director of clinical operations for home health at Lee Health.

Home health nurses visit patients in the program three times the first week after discharge, and follow up depending on the patient’s needs. They check vital signs, assess the patient’s condition, and continue the patient education. A respiratory therapist also visits the home to evaluate the patients and determine if they are having problems using their equipment or understanding their medication regimen.

“If we find any glitches right after discharge, we can get a head start on fixing them rather than finding out there were problems when the patient comes back to the hospital and needs to be readmitted,” Brady says.

A lay assistant calls patients for 90 days after discharge at intervals that are based on the patient’s condition and educational needs. The assistant reinforces the patient’s treatment plan and education, and alerts the home health team if the patient is experiencing problems or has questions.

All four hospitals in the Lee Health system have received heart failure accreditation from the Society of Cardiovascular Patient Care for standardizing heart failure care across all facilities.

The hospitals all have a heart failure coordinator who facilitates bedside rounds by a multidisciplinary team. Members of the team educate heart failure patients on their disease and collaborate on a discharge plan. The patients also receive a toll-free number they can call after discharge with nonemergent questions and concerns.

Instead of being hospitalized, patients with abnormal fluid retention can visit the rapid diuresis clinic established by each hospital, where they receive the treatment they need in just a few hours.

Lee Health Home Health provides telehealth monitoring to patients who might benefit, Brady says. The telehealth program provides a scale, a blood pressure monitor, and/or a pulse oximeter, depending on the patient’s diagnosis. Patients read their vital signs every day and transmit them to the telehealth nurse.

If the results look out of range, the nurse calls the patient, conducts an assessment, and determines the course of action. “Our goal is to intervene quickly if patients have abnormal vital signs,” she says.

The health system is piloting a telemedicine care transition program with a group of physicians, Brady adds.

Lee Health’s case management department formed an alliance with skilled nursing facilities, home health agencies, and assisted living facilities in the area to collaborate on creating smooth transitions and avoiding unnecessary readmissions, says Barbara L. Kenney, RN, system director of case management for Lee Health.

For instance, the hospital staff and post-acute providers have initiated a nurse-to-nurse handoff when patients move from one level of care to another. The group developed a project with primary care physicians to have advance directives in place and in all patient charts.

Another project is to provide consistent education for heart failure and COPD patients at all levels of care, Brady says.

“We found that, unfortunately, we were working in silos and every provider was using different teaching methods, which was extremely confusing for the patients,” she says. “We’re working together as a team from acute to post-acute to find the best teaching tools and teaching methods and standardize them across the continuum.”

The Lee Health case management team completed training on the Interventions to Reduce Acute Care Transfers (INTERACT) tool and trained all the employees at post-acute providers to use the tool. The INTERACT training teaches participants how to recognize changes in patient behavior that could indicate problems, such as shortness of breath, and to report them, Kenney says.