When you’re old and frail, just taking care of yourself can be a challenge. You may take quite a few pills every day, need to monitor your blood pressure, watch your weight and diet. A young, sharp mind might be overwhelmed, and in old age, minds can also get a little fuzzy.
Now throw in a hospitalization: a heart attack, pneumonia, a scary experience that leaves you shaken and weaker, maybe in need of rehabilitation or home care for awhile. And as you’re being discharged, you get new prescriptions and all sorts of complex instructions.
Quite often, experts say, patients just can’t grasp it all, and they get confused at home. They may not notice they’re gaining water weight, a red flag after congestive heart failure. They may not see they’re taking a double dose of the same drug, or two drugs that interact badly.
Within a month, Medicare statistics show, about one in five patients is re-hospitalized. And it’s not just the ones who go home: About half of Medicare hospital discharges go into another type of professional care, and among them, a third are re-hospitalized within 30 days.
Now, as part of a nationwide effort to change this, Quality Partners of Rhode Island is working with local hospitals to connect with patients at key transition points and, through education, support and communication with their caregivers, help them avoid another hospitalization.
The three-year project, dubbed “Safe Transitions,” is one of 14 across the country sponsored by the Centers for Medicare & Medicaid Services as part of a larger patient safety initiative.
Quality Partners, which has a major contract with CMS for quality-improvement work, launched the pilot phase Jan. 27 at Newport Hospital. Over time, the work will expand to six more facilities: Our Lady of Fatima Hospital, Kent Hospital, The Miriam Hospital, Rhode Island Hospital, Roger Williams Medical Center and Women & Infants Hospital.
Quality Partners hired four “coaches” to work with patients, caregivers and clinicians, but the goal, said project head Dr. Stefan Gravenstein, clinical director of Quality Partners, is to develop systems that can then be “handed off” to hospitals and providers.
The “Safe Transitions” team is not working with a blank slate. Hospitals have admission and discharge systems to address these issues, but leaders admit they don’t quite meet patients’ needs, especially in an era when patients are rushed out of the hospital as fast as they can be.
“The health care environment and expectations for hospitalization have changed dramatically in the last several years,” said Cathy Duquette, vice president of nursing and patient-care services at Newport Hospital. “Hospitals are under incredible pressure to really limit the hospitalization to the acutest, the most sick phase that the patient has.”
As soon as a patient can be managed at home or in another facility, she said, “we’re under a lot of pressure … to get them out.” And in the rush to move the patient along, nurses don’t have time for in-depth conversations.
“We give them printed information, we go over all their medications, and we go over all their instructions,” Duquette said. “But we’re lucky if we get to do it once and then go over it quickly as they’re walking out the door with their family.”
This is where Safe Transitions comes in. The project is focusing on Medicare beneficiaries who are hospitalized with congestive heart failure, heart attacks, chronic obstructive pulmonary disease and pneumonia – all very common and often requiring re-hospitalization, Gravenstein said. In the first week, seven patients were recruited, Duquette said.
Patients who wish to participate will get one or two interventions:
The first, which already started at Newport Hospital, is based on a model created by Dr. Eric Coleman at the University of Colorado that involves coaches talking with the patient before discharge for about 45 minutes, then following up with a home visit in a day or two.
The second is based on Project RED, developed by Dr. Brian Jack, now at Boston University, and involves rolling in a computer on a cart with a touch screen and an interactive, animated program that allows the patient to ask questions and follow up as much as needed, then prints a report for the discharge planner.
The Coleman model has been shown to cut re-hospitalizations by 30 to 50 percent, Gravenstein said, and Jack’s model has reduced re-hospitalizations by about 30 percent. Both will be tried extensively to ensure hospitals get the systems that work best for them.
“We want to touch as many people as we can with the interventions, and part of our goal is that aside from being effective [clinically], it’s also cost-effective,” Gravenstein said. The Safe Transitions team will work with the hospital staff to change “the culture of care” and maximize efficiency, he said, and if the effort succeeds, “we think we can demonstrate that we can save money at all levels” – even to the hospitals themselves.
Vincent Mor, chair of the department of community health at Brown University and a nationally recognized expert in health care systems and long-term care, said the work that Gravenstein – who is also a Brown geriatrics professor – and his team are doing is very important, because there’s plenty of evidence that many re-hospitalizations could be avoided.
Mor himself is doing research in this area, using nationwide Medicare data, and while his focus is on how state policy and other factors affect transitions, this project is directly addressing the problem, which is critical, Mor said.
“It’s a really big issue clinically, and it’s a big issue fiscally,” he said. “Any mechanism that can be used to reduce the rate of those problematic transitions, to smooth them so the bounce-back rate is reduced, is extremely important.” •
To learn more about Quality Partners’ care transitions work, go to www.riqualitypartners.org; for more about Dr. Eric Coleman’s Care Transitions Program, go to www.caretransitions.org. The Web site for Dr. Brian Jack’s Project RED is www.bu.edu/fammed/projectred/.
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