Each dot on the map represents the home address of clients who received transitional home care from CCNC during their study.
Each dot on the map represents the home address of clients who received transitional home care from CCNC during their study. Illustration courtesy CCNC.

Payment regimens in the health care system are changing and, increasingly, hospitals will be penalized when patients are readmitted frequently. But a focus on patients transitioning from hospital to home is paying off.

By Rose Hoban

Jenny Arledge has been telling this story a lot lately, about the respiratory patient who kept coming back to the emergency department at Mission Hospital in Asheville, where Arledge works.

“She was in her early 50s and really engaging and bright, but she kept coming back to the hospital, and we couldn’t figure out why she kept coming back,” said Arledge, the head of the transitional case management program at Mission. “She came in about four times in a year, and was sicker with every admission, and not doing well at home.”

The patient had been taught how to use her inhalers and other medications and was given detailed written instructions that described her disease and how to troubleshoot problems.

One way nurses at Mission work with patients is by writing information and goals on a whiteboard in each room. Jenny Arledge said the simple technique is a powerful teaching tool. Photo courtesy Mission Health System

But at some point, it would fall apart and the woman would end up back at Mission.

Then one day, during an admission, the woman was assigned a nurse who would help her with her transition back to the community after her hospitalization. This “transitional care manager” was getting to know the woman when she revealed something she usually kept secret: She couldn’t read.

“This was a patient who had gotten through her adult life without revealing this to anyone,” Arledge said. “She could sign her name, could do basic essential math, could pay bills, but could not read the instructions on her medication bottles, couldn’t read printed instructions we were giving her.

“She was a highly functional illiterate,” she said.

Her care manager color-coded the patient’s medications, redeveloped her handouts and did some more-intensive teaching. Most important was the nurse who followed her home and provided follow-up and assistance on the phone when she needed it.

The patient hasn’t been readmitted to the hospital since.

Arledge uses this story as an illustration of the power of forging relationships with patients who are about to embark on one of the most perilous journeys in the health care system – the trip back home from the hospital.

Identifying the problem

For years, hospital staff around the country talked about how “discharge planning needs to start at admission,” but the reality is that, for many patients, once the hospital door closes behind them, plans fall apart easily.

As a result, many patients get caught in a revolving door of becoming sick, going to the hospital, getting better and then being discharged to their homes, where they deteriorate and end up back in the emergency department.

“There’s been a huge disconnect,” said Brian Bixby, a nurse practitioner at the University of Pennsylvania School of Nursing who works with the care transitions program there.

University of Pennsylvania nursing professor Mary Naylor created the first transitional nursing project and has been studying the model of care for a decade. Image courtesy UPenn

“Even with a person who gets discharged with home-care nursing, there’s no connection between the parts of the health system,” he said.

Bixby explained that a hospital discharges a patient and tells them to call their primary care provider to get new prescriptions. But what if the primary care doctor has no appointment slots for several weeks? Or the new prescriptions are not the same as the old medications? Often no one coordinates how it all fits together for the patient.

It’s a recipe for confusion.

“I had a patient once, he needed a medication, but the folks in the hospital called it into the wrong drugstore,” Bixby said. “So he went to the drugstore and the medication was something that wasn’t available in every pharmacy. So he figured out where the medication was and took the extra three-hour bus trip to get the medication.

“This gentleman followed through, but some other person would say, ‘I’ll just go back to the hospital,’” Bixby said.

It was these kinds of mix-ups that caught the notice of Bixby’s co-worker Mary Naylor. About a decade ago, Naylor realized patients were getting lost in the transition and devised a model of nursing care that follows patients from hospitalization to home, checking on the patient and helping them get their needs met in the critical first few weeks after returning home.

And it worked. Naylor found that patients who received this kind of attention did not end up cycling back to the emergency room. And in multiple studies of the practice, Naylor found the savings to hospitals and the health care system as a whole far outstripped the cost of the nursing care.

“The biggest headline is the cost savings,” said Bixby, who has worked on research studies with Naylor. He said the savings are $2,000 to 2,700 per patient. “But there’s other outcomes too, like increased time to readmission, increased time to death, improved quality of life. Patient satisfaction is also really high, and provider satisfaction is high also.”

He said that in the group of frail, sick people he and Naylor have studied, the interventions have decreased the cost of hospital admissions overall and avoided re-hospitalizations.

Managing the transition

Similar results were found in a large statewide study done by Community Care of North Carolina (CCNC), the organization that manages about 1.3 million of the state’s Medicaid patients. The study was published earlier this month in the journal Health Affairs.

A million of those Medicaid patients are low-income children and their parents, but another 300,000 people come from the so-called aged, blind and disabled population, patients who often have multiple health care and social problems.

Each dot on the map represents the home address of clients who received transitional home care from CCNC during its study. Illustration courtesy CCNC

CCNC started performing the same kind of service, managing transitions back into the community after hospitalization, in 2008, slowly scaling the service up statewide.

Between July 2010 and July 2011, CCNC care managers from around the state were working with about a thousand Medicaid patients each month to help them manage their transition from hospital to home, and tracking their results. They also kept data on people who were not yet in the program.

“These were patients with multiple chronic conditions,” said Annette DuBard, a doctor who works at CCNC and was one of the study authors. “For example, they have [emphysema and chronic bronchitis] and heart failure and diabetes and schizophrenia or depression. That would be a typical patient in this study.

“And we followed people to every corner of the state,” she said. “I can tell you stories about patients in trailers an hour down backroads that care managers made their way to.

“So I don’t want to underestimate what it means to be deploying this program to every nook and cranny of the state. This was not just in an urban hospital; this was in every part of North Carolina.”

CCNC researchers found that even for the most medically fragile patients, they were able to prevent about one in every six hospital readmissions.

When asked how much money that saved the Medicaid program, DuBard said she couldn’t be sure, as most of CCNC’s 800 care managers handled other patients as well as the people in the study.

“We’re confident that this is a positive return on investment because of the size of the effect,” she said. “Inpatient therapy is far more expensive than the salaries of the social workers and nurses who act as care managers.”

And DuBard also found that the sickest, most complicated patients did best using this model of care.

“For patients in the highest risk subgroup, one readmission was averted for every three patients who received an intervention,” she said. “That means the return on investment is dependent on targeting patients smartly.”

According to DuBard, CCNC’s program now tracks more than 4,500 patients monthly as they’re discharged from the hospital.

Finally, a carrot

It’s those kinds of outcomes that have executives at hospitals like Mission, and now most of the state’s other large hospital systems, taking notice. While hospital leaders will argue that initiating a transitional care management program is all for the patients, the reality is that there are financial incentives for providing the service.

At the beginning of August, the federal Centers for Medicare and Medicaid Services announced financial penalties for hospitals with high readmission rates for Medicare patients. Dozens of North Carolina hospitals ended up losing Medicare dollars because too many of their Medicare patients were returning to the hospital within a month of discharge. Mission was not penalized.

Also; provisions of the Affordable Care Act that are going into effect will incentivize coordination of care to prevent problems for patients both in and out of the hospital.

Not only governmental payers but payers such as insurance companies could soon follow suit in imposing penalties on hospitals with high readmission rates. As insurers move to paying for an “episode” of care, rather than on a fee-for-service basis, hospitals could end up losing money if patients are being readmitted quickly.

So hospital planners look at the CCNC results, Naylor’s research and the positive stories out of places like Mission and make moves to initiate similar transitional care programs.

“It seems like a no-brainer that if you have people at a heightened risk and you help shepherd them through the vulnerable period, they’ll do better,” said Bixby. “It only sounds expensive. But even with the cost of extra services of the nurse, we still save a significant amount of money and, most importantly, people do better.”

“If this kind of care were a pill, it would have been on the market 10 years ago, and no one would have questioned it,” he said.

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