Extending hospital to the primary care office
Nurses follow patients for 30 days post-discharge
A program in which care transition specialist nurses follow patients for 30 days after discharge and support them in adhering to their treatment plan is reducing readmissions at Beth Israel Deaconess Medical Center in Boston.
"We’re seeing encouraging signs from this program. We have tried a lot of different ways to reduce readmissions, from revising our discharge paperwork to setting up follow-up appointments. The whole process showed us how complex a problem readmissions are," says Laura Doctoroff, MD, FHM program director.
The program started with a small pilot project in which two nurses followed about 250 patients who were treated at the hospital-based primary care practice. Patients in the pilot were hospitalized with heart failure, pneumonia, or acute myocardial infarction.
Following the success of that program, Beth Israel Deaconess applied for and received a $5 million Center for Medicare & Medicaid Innovation grant to launch a Post-Acute Care Transitions (PACT) program. The hospital expanded the program to target patients treated at six practices and who were hospitalized for all diagnoses.
All Medicare patients who are treated by the six primary care practices and admitted to the hospital as inpatients are enrolled in the program, with the exception of oncology, psychiatric, and obstetrical patients. Patients receiving observation services are not included in the program. "We know that it’s sometimes hard to determine which patients are at risk for readmission, and that’s why we enroll almost all patients," she says.
"We chose very different practice sites, including an academic practice that employs residents, a community health center, and private practices. Everybody in the hospital has medical needs. We wanted to find out how the model works for patients with readmission risks based on psychiatric or social issues as well as medical conditions," Doctoroff says.
The hospital tied its readmission reduction program to primary care practices because that’s where patients are being seen during the critical weeks after discharge, Doctoroff says. "Physician practices are in the best position to prevent readmissions. In the hospital, we touch patients for only a short period of time. Even if we develop a great discharge plan, it can fall apart unless somebody is there to support the plan after discharge," she says.
The program has eight full-time nurses and four pharmacists. They are supported by a social worker whose position is funded by a private foundation. The nurses are assigned to primary care practices and collaborate with primary care providers on helping the patients manage their conditions and adhere to their treatment plans after discharge. "When they work with one primary care practice, the nurses develop a relationship with the physicians and office staff, they learn how the practice works, and become an extension of the primary care office into the hospital," Doctoroff says.
The nurses visit the patients in the hospital and conduct an assessment that includes how well patients understand their condition, what kind of support they have in the home, how compliant they have been with their treatment plan in the past, how many times they have been hospitalized for the same condition, and other factors that may contribute to their risk for readmission. If patients have complicated social situations or need community resources, the nurses can call on the social worker for assistance.
After patients are discharged, the care transition specialist nurses follow them, mostly by telephone, for four weeks. They make sure the patients have gotten their prescriptions filled, understand how to take their medicine, and that they are taking it. They make sure the patients have a follow-up appointment and have transportation. The frequency of the interventions is based on patient need, Doctoroff says. For instance, a patient who had a total knee replacement may need only a phone call once a week to check on pain control and how physical therapy is going. On the other hand, if a heart failure patient is struggling to understand the treatment plan and diet, the nurse may call several times a week.
The pharmacists conduct medication reconciliation on admission and ask questions to determine patient adherence. When patients are about to be discharged, they conduct medication reconciliation again and educate patients on their medication regimen. After discharge, the nurses get the pharmacists involved if patients are having medication problems.
When patients are discharged to a skilled nursing facility for rehabilitation, the pharmacists follow up when patients are being discharged from that facility. "They conduct medication reconciliation with the medication list from the skilled nursing facility and obtain a complete list for the primary care physician. This is invaluable for the physicians because medications are changed so frequently as patients go through the continuum," Doctoroff says.
The nurses typically are following up with 40 to 45 patients at a time. Whenever possible, the nurses see the patients in person when they come back to their primary care physician or when they see a specialist. "The nurses who work with the primary care providers based in our hospital clinic have an easier time seeing patients in person. For the case managers who work with other practices, it’s more practical to follow the patients by telephone," she says.