Hospital, nurses team up to prevent readmissions

Initiative targets at-risk patients

In an effort to reduce readmissions, University Hospital in Newark, NJ, partnered with the Visiting Nurses Association Health Group and developed a program that uses intensive case management to reduce readmissions for patients with multiple chronic conditions.

University Hospital is the only public hospital in New Jersey. Many patients are Medicaid recipients or are self-pay and/or need charity care. "We have a large population without insurance or who have pending Medicaid applications. Many of these patients have psycho-social needs, have problems obtaining the supplies or medication they need, and/or have problems navigating the healthcare system," says Edwin Fernandez, RN, BSN, care coordination manager at University Hospital.

The I-Care-4-Health Transitions in Care program provides assistance for at-risk patients who have no insurance, as well as those covered by Medicaid and Medicare, says Melissa Scollan-Koliopoulos, EdD, APRN-BC, CDE, BC-ADM, assistant professor of medicine, division of endocrinology, diabetes, and metabolism, UMDNJ New Jersey Medical School in Newark. "Most facilities have focused on readmission for Medicare patients, but Medicaid may launch its own penalties for 30-day readmission and we want to prepare for that. It's good for the patients as well as being good for the hospital for us to make sure that patients can be safely discharged and follow their treatment plan at home," she says.

The I-Care-4-Health team includes two navigators who are certified home health aides from the Visiting Nurses Association Health Group that the hospital funds with grants from the Robert Wood Johnson Foundation and the Healthcare Foundation of New Jersey; an RN who is a certified diabetes educator, an advanced practice nurse who is an expert in healthcare behavior, and a physician with expertise in internal medicine and diabetes.

The unit-based case managers conduct daily rounds with the multidisciplinary treatment team and identify patients appropriate for the program, Fernandez says. They assess patients for discharge needs within 24 hours of admission and work with the I-Care team to arrange whatever resources the patients will need when they leave the hospital.

The 130 patients currently in the program have one or more chronic diseases including diabetes, heart failure, hypertension, atrial fibrillation, chronic obstructive pulmonary disease, asthma, HIV, or sickle cell disease, Scollan-Koliopoulos says. Patients referred to the program have no primary care physician, which puts them at high risk for readmission because there is nobody to pick up care after discharge, she adds.

When patients are referred to the program, the patient navigators visit them in the hospital to explain the program and enroll patients who agree to participate. The patient navigators visit the patients every day in the hospital and focus on linking them with a primary care provider, either at a federally qualified healthcare center, or the hospital's clinics.

They help the patients identify resources that can pay for their healthcare and help eligible patients fill out the paperwork for Medicaid or charity care. They help patients sign up for medication assistance or other community resources that can help with their post-discharge needs. The team works with hospital physicians to make sure patients have prescriptions that qualify for the $4 prescription program at local pharmacies when appropriate. In some cases, the program provides patients with a supply of medication until the medication assistance program comes through, Fernandez says. "It's really helpful to have I-Care-4-Health on the front line to help with resources such as cab fare for office visits and equipment like crutches and walkers," Fernandez says.

The I-Care-4-Health team conducts medication reconciliation to make sure nothing falls through the cracks. For instance, patients with diabetes may have a prescription for insulin but not for syringes, according to Scollan-Koliopoulos or they can't afford to have their prescription filled.

"Some of these patients are working but may be getting paid under the table so there's no verifiable income source. Others may make a little too much for charity care and may need to find alternative care. We try to help them as much as we can to determine their barriers to receiving care and overcome them so they can develop a relationship with a primary care provider," Scollan-Koliopoulos says.

A key to the program is providing follow up with patients within 72 hours of discharge, she says. "They need help in learning which symptoms indicate they should come back to the emergency department and which can be managed at home. If nobody helps them understand, they'll come right back to the emergency department," she says.

The patient navigators reinforce the education that patients receive from the treatment team and follow up at home to make sure they understand.

"We want them to come back to the emergency department when it's appropriate and before they get so sick they need to be admitted, but we want the timing to be right," she says.

The patients have the cell phone numbers of the entire team and can call anyone any time of the day or night. "If they can't get in to see a primary care physician, we try to help them manage over the telephone or meet with them," Scollan-Koliopoulos says.