Can virtual nurses reduce hospital re-admission rates?

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Posted Dec. 15, 2011, at 5:37 p.m.

What patients can do

Hospitals cannot reduce re-admission rates on their own. Success will depend on a coordinated approach involving primary-care doctors, pharmacists, an improved system of electronic health records and, perhaps most important, patients themselves. There are several simple but vital steps that patients should follow before and after leaving the hospital:

  • Make sure you understand your diagnosis and what was done to you.
  • Know whom to follow up with (physical therapist, your regular doctor, a nurse, etc.).
  • Schedule a follow-up appointment with your regular doctor before leaving the hospital; make sure to see him or her soon after discharge.
  • Ask your hospital doctor to communicate with your regular doctor.
  • Go over every medication on your discharge list with your doctor or nurse. Compare those drugs with medications you were taking before you entered the hospital to ensure there are no duplications or dangerous interactions.
  • Get contact information for any questions or problems you might have after discharge.
  • Ask about what to expect during your recovery and what symptoms to look for should something go wrong.
  • If some test results are pending, make sure you know how to obtain the results.
  • Before you sign your discharge summary, make sure you understand everything. Ask someone — a nurse, a doctor, a social worker — to explain it to you.
  • Bring a copy of your discharge summary to your follow-up appointment.

All of this increases the odds that, when you leave the hospital after surgery or illness, you won’t be coming back again soon. The health care system will save money, and you’ll be able to undertake your recovery, in your own bed, at home. And who wouldn’t prefer that?

It’s a return trip nobody wants to take: You are discharged from the hospital only to find yourself re-admitted a few days later.

More and more people are finding themselves in this revolving door — at a cost to both hospitals and patients. A 2009 study in the New England Journal of Medicine showed that one in five Medicare patients discharged from the hospital had to be re-admitted within 30 days; 34 percent were back within 90 days. Those return trips cost the health care system more than $17 billion a year.

Re-admission rates have increasingly become a measure of a hospital’s quality of care. As part of the Affordable Care Act, Medicare is planning to tie payment to re-admission statistics, even penalizing hospitals for re-admissions deemed avoidable.

With that punishment looming, hospitals and health policy experts are trying to figure out why so many patients are making round trips.

Are patients simply being let go too soon? While some patients may be let go before they are “completely and totally recovered,” said Carolyn Clancy, director of the Agency for Healthcare Research and Quality, the issue is far more complex than that. Sometimes, infections develop. In other cases, there is unexplained bleeding. Medication errors are a big factor, too. Often a patient isn’t able to get an appointment with a primary-care doctor or the patient simply feels that something isn’t right and doesn’t know where else to turn.

Researchers looking at this trend are discovering that breakdowns occur on multiple levels. The most critical failure seems to be in the discharge process, when the hospital should be preparing a patient for release. Instead, said Brian Jack, a family physician at Boston University Medical Center, the process is often a “perfect storm” of errors that begin even before a departing patient has reached the parking lot.

Many patients leave the hospital without understanding much about their diagnosis or how to handle their condition at home, including what medications to take, Clancy said.

Poor coordination of care and poor transitions in a fragmented system is how Jesse Pines, director of the Center for Health Care Quality at the George Washington University School of Public Health and Health Services, described it.

Proper post-hospital care involves many complicated steps. There are medication routines, follow-up sessions with doctors or physical therapists, adjustments to diet and lifestyle, even knowing what number to call if there’s a problem or a question. It can be very difficult to manage all this, especially if a patient has no caregiver at home or is in a weakened state upon release.

Many hospitals put instructions in writing, handing departing patients a “discharge summary” of steps they need to follow at home. But that summary can be difficult to read or understand; often it is handwritten and filled with jargon. And putting a discharge summary together is not always a doctor’s highest priority. The task often falls to others — nurses or medical residents — who rarely have the time to make sure the patients understand the plan for follow-up care.

Jack and his colleagues designed an approach that aims to streamline the process. It relies on checklists for the staff to make sure that nothing is missed and it assigns a staff person called a discharge advocate to coordinate post-hospital care and follow up with patients after discharge.

Of course, this process can be quite time-consuming. This is why Jack and his colleague Timothy Bickmore of Northeastern University have enlisted “Louise,” an avatar, or virtual discharge advocate. She appears on a computer-like screen that is rolled up to patients’ hospital beds to walk them through the discharge process.

Louise can spend 40 minutes or more with every departing patient. She is never distracted and can create well-targeted discharge summaries using information about each patient. Louise can communicate using synthetic speech and through a touch-screen display. And patients actually like her, Clancy said, “some … better than real, live nurses.”

Louise is part of a program called Project RED, for “Re-Engineered Discharge,” which has shown a 30 percent reduction in re-admission rates in clinical trials, according to Jack. Similar initiatives are being tested in hospitals around the country.

There is some urgency for hospitals to start to take matters into their hands, Pines said, because Medicare penalties are set to kick in soon and avoiding re-admissions “will become a real economic incentive.” Initially, performance evaluation will be focused on re-admissions related to three major conditions: heart failure, heart attack and pneumonia.

Ranit Mishori is a family physician and faculty member in the Department of Family Medicine at Georgetown University School of Medicine.

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