July 5, 2013 – The old telephone company slogan “Reach out and touch someone” wasn’t just a catchy phrase. The personal touch can make a big difference.
In fact, a new study has found that nurses’ personal contact with patients recently discharged from the hospital can also reduce the chances that they’ll need to be readmitted. The study, which was conducted by the Bronx Collaborative, examined the effectiveness of enhanced personal contact with patients before and after discharge. Their findings: patients who received at least two extra “personal contacts” during the transition process were much less likely to require rehospitalization within 60 days of discharge.
The Bronx Collaborative is a partnership between three nonprofit hospitals in the Bronx, N.Y., and two health insurers. The hospitals are Montefiore Medical Center, Bronx Lebanon Hospital Center and St. Barnabas Hospital, and the two insurers are Healthfirst and EmblemHealth. The five collaborated to develop an initiative called the Care Transitions Program, or CTP, that would reach out to patients who were determined to be most at risk for readmission.
The design team for this study was interested in earlier research on methods to improve care transitions.
“But they were done in populations that were not completely like our population that we serve here in the Bronx,” said Anne Meara, RN, MBA, associate vice president, Network Care Management, CMO, Montefiore Care Management.
The goal of the collaborative became to find ways to reduce readmissions in the population that they serve–a very diverse population, many with multiple diseases or conditions. And they wanted to put evidence-based practices from models such as the Coleman Care Transitions Initiative and Project RED to work in serving their population.
“We really had a significant impact,” said Meara. “I think that that’s got really broad ramifications in other communities like ours.”
Nurse care transition managers had four possible interventions to use with patients: (1) a pre-discharge educational session with the patient; (2) a post-discharge call within 48-72 hours of discharge to make sure that a follow-up visit with the patient’s physician was scheduled; (3) a phone call between 7-14 days to make sure the patient had actually gone to the appointment; and (4) calls between 15-60 days post-discharge just to check on the patient.
The goal was to employ at least two of those interventions with patients. The results: of 500 patients who received at least two interventions, 17.6 percent were readmitted within 60 days, compared with 26.3 percent who didn’t get enhanced interventions.
“We were very successful in proving that it does work,” said Janet Kasoff, EdD, MA, BSN, director, CMO, Montefiore Care Management Center for Learning and Innovation and the manager of the Care Transitions program. “The ability to replicate it [in other facilities] is very possible because our protocol is very prescriptive.”
For this particular study, the collaborative received a $574,000 grant from the New York State Health Foundation (NYSHF) to pay for the care transition managers, care transitions assistants and a pharmacist.
Amy Shefrin, program officer for the NYSHF, praised the collaborative members’ willingness to come together and work on new ways to make a difference.
“We think the Bronx Collaborative really provided that leadership and vision” that’s needed to make a difference in readmission rates, she said.
It’s particularly unusual for payers to be involved in this type of initiative, said Shefrin. In this case, the health plans both paid a fee for participating patients who received at least two interventions and participated in the design team. “That doesn’t happen enough,” she said.
It just made sense for EmblemHealth to sign on, said vice president Joseph Zeitlin, MD.
“Working with hospitals to get them to really reinvest in the discharge process can only be helpful,” he said.
The health insurance company already had experience in this arena that it could share. EmblemHealth launched its own program in 2010 to examine the effectiveness of integrating a dedicated team into a large practice to work with patients who needed transitional care and services. The results, which were published in the American Journal of Managed Care, found that additional interventions did reduce those patients’ readmission rates.
Meara noted that current readmission predictive tools don’t include data on factors like psychosocial factors. Yet, that information can be very useful when it comes to determining who may be likely to be readmitted–and why. It’s useful to know, for example, that a patient doesn’t have access to reliable transportation to get back and forth to those follow-up doctor’s appointments.
“We need to get better at collecting that information in a way that’s consistent and able to be mined to use in predicting who’s going to be readmitted,” she said, adding that it’s important for organizations to know what resources they bring to the table to address those factors.
All the efforts that are going into studies like this are worth it, Zeitlin said, and not just because readmissions are costly for hospitals and health insurers.
“Readmissions are just a devastating event for patients and their families,” he said. “And we want to be able to be part of the process that affords to them the safe transition back to the communities and their providers and to be able to get back to their lives as soon as possible.”
Social Workers Can also Lower Readmissions Rates
In a related study, researchers from Binghamton University’s College of Community and Public Affairs and SUNY Upstate Medical University recently discovered that their program using social workers to establish new community-based alternatives to reduce readmissions among high risk patients is proving to be successful. The study is examining two years’ worth of data from 100 patients who live independently but are at high risk for readmission to the hospital. According to the researchers, preliminary analysis shows that social worker intervention reduces the chances of those patients returning back to the hospital shortly after discharge.
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