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Care Coordination Yields Lower Readmission Rates

 Metropolitan Hospital, HHC Health and Home Care

A special collaboration among staff at Metropolitan Hospital, HHC Health and Home Care and the MetroPlus Health Plan has helped lower the readmission rate among congestive heart failure patients by a third by providing coordinated care from the emergency room visit and hospital admission to discharge and follow-up outpatient care.

Richard Siegel, Senior Associate Director of Social Work at Metropolitan Hospital, said staff took on the project in July 2011 because their 30-day readmission rate for heart failure patients had consistently remained at 30 percent compared to the national average of 24.7 percent.

The integrated team put together a plan that starts with educating patients at the bedside to help them better understand this chronic illness and how to manage it. They then connect patients to Health and Home Care for follow-up at home, and make an appointment for the patient to return to the cardiac clinic, ideally within seven days, for follow-up outpatient care. Nine months after the program was put in place, readmission rates for heart failure patients had fallen below the national average and been reduced to 20 percent.

“Because of HHC’s integrated healthcare delivery system design, these three distinct groups of caretakers were able to come together as one and design a seamless plan to coordinate care across the multiple levels of services these patients need to help them manage their condition and stay out of the hospital,” said Siegel.

Many hospitals across the country, and the 11 acute care facilities at HHC, have made a renewed effort to reduce preventable readmissions as they will soon face financial implications for high hospital readmission rates. Beginning in October, the Centers for Medicare and Medicaid Services (CMS) will decrease hospital payments by up to 1 percent of their base Medicare reimbursement for patients who are readmitted to the hospital within 30 days of their last admission.

Dr. Ferdinand Visco, Chief of Cardiology and leader of the project, said patients are readmitted to the hospital for reasons including a lack of information about their chronic disease and how to manage it, lack of prompt access to a doctor when their condition starts to worsen, and lack of support to help them pursue follow-up care. Most heart failure patients at Metropolitan are under age 65, but the ages range from 24 to 99, Dr. Visco said.

The team used Breakthrough, HHC’s process improvement methodology, to identify the causes of the 30 percent readmission rate for heart failure patients and create a plan for change that could be quickly implemented and sustained.

Key components of the care coordination strategy include:

  • An education program, including a workbook for the patient, in which nurses, dieticians and physicians work with patients and families to improve their understanding of the medical condition, triggers that set it off and how to manage it once they are discharged.
  • Securing a home health nurse from HHC’s Health and Home Care to provide care for patients once they are discharged and giving the RNs access to the patient’s electronic medical record so they too can review important information and track the patient’s progress.
  • Using a Telehealth nurse to monitor patients by phone and electronically using a scale and blood pressure monitor, both linked to a modem that transmits the member’s readings.  The nurse assesses patients for symptoms that could indicate worsening heart failure and coordinates care.
  • Priority access to cardiology clinic appointments when a patient’s condition worsens.
  • A scale, courtesy of MetroPlus, that patients can take home to regularly weigh themselves as part of self-managing the illness.
  • A follow-up call after discharge from a MetroPlus representative to ensure a smooth transition to home and make sure patients were able to secure all medications and know the date and time of their next appointment.
  • Weekly meetings of the medical team, the home care agency and the health plan to discuss cases and coordinate care.

The team saw a higher rate of success among patients who enrolled in the heart failure clinic and visited the clinic within seven days of being discharged. Of 153 congestive heart failure patients in the database, the team was able to enroll 91 in the heart failure clinic. Of those, 24 visited the heart failure clinic within seven days of discharge and of those only two were readmitted within 30 days.

There were 174 admissions, since some patients were admitted more than once, with 34 of those readmissions occurring within 30 days. That’s a 20 percent readmission rate, compared to 30 percent readmission rate nine months earlier.

“We improved outcomes for patients and improved the level of care provided by the hospital,” Dr. Visco said.

“The program was a huge success not only for patients but for staff who began to see the results of their hard work,” said Susan Lehrer, Associate Executive Director of Care Management/ Telehealth for HHC Health and Home Care. “And thanks to the Breakthrough process, the staff from Metropolitan Hospital, Health and Home Care and MetroPlus were empowered to work together across the health care continuum and create a true model of accountable patient-centered care.”


September 2012

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