Strategies shared to reduce hospital readmissions

Patients who return to the hospital within a month of being discharged represent one of the most persistent and costly, yet preventable, problems in American heath care.

But few solutions have been implemented on a widespread scale. Until now.

On Wednesday, more than 200 area hospital administrators, doctors, nurses, and others met with national experts at the Union League in Center City to learn about strategies to reduce hospital readmissions in the five-county Philadelphia area.

One approach is to use nurses to proactively treat the highest-risk patients - older people with multiple chronic illnesses - who cost the most money.

Another idea was to use a computer-animation program nicknamed "Louise" to prepare patients and their families for the return home. And yet a third was to use "transition coaches" to help patients better manage their own care after a hospitalization.

"We have a lot of interesting innovative practices to share . . . and hopefully that can really accelerate the pace of change in addressing this problem," said Kate Flynn, president of the regional Health Care Improvement Foundation, which is leading the local effort in partnership with Independence Blue Cross.

The initiative is part of a third group: the Partnership for Patient Care, a joint project of Independence, the improvement foundation, and the hospitals.

The effort - dubbed Preventing Avoidable Episodes or PAVE - has a goal to eliminate 10 percent of hospital readmissions in Southeastern Pennsylvania over 18 months.

That could result in substantial savings for the broader health system. In 2008, the Pennsylvania Health Care Cost Containment Council reported, there were 57,852 readmissions within 30 days of initial discharge, leading to $2.5 billion in hospital charges.

Of those, more than 22,000 were related to complications of care and infections. Those second hospitalizations led to bills totaling more than $1 billion.

Moreover, the cost containment council found that readmissions in Pennsylvania have held steady at about 19 percent for the most recent five-year period examined.

National studies have made similar findings, concluding that one in five hospitalized patients are readmitted within a month of discharge.

At Boston University Medical School, physician Brian Jack has helped pioneer a redesign of the hospital discharge process to better educate patients and their family members.

Jack's Project RED - reengineered discharge - uses a 10-point checklist that includes teaching patients about their illness throughout their stay; organizing post-discharge services such as follow-up appointments and prescriptions; ensuring that the discharge plan adheres to recognized guidelines shown to work; reviewing with patients what to do if they have a problem; and giving the patients a written discharge plan that is easily understood.

As a result, Jack told those gathered at the Union League, emergency room visits and readmission were reduced 30 percent.

Building on that work, Jack has worked with computer scientists at the Massachusetts Institute of Technology to develop a virtual discharge adviser for patients and their families. Named "Louise" - a second version is called "Elizabeth" - the computer animation is in computer jargon an "Embodied Conversational Agent."

Using the patients' discharge plans and medical records, Louise enabled patients to take their time to truly understand their medications, appointment schedules, and other instructions for when they got home.

The program has been a hit with patients who rated it near perfect in follow-up surveys, Jack said.

For example, one patient said: "I prefer Louise, she's better than a doctor, she explains more, and doctors are always in a hurry."

Mary Naylor, a professor at the Penn School of Nursing, described another effort that uses advance practice nurses - with master's degrees or higher - to target the highest risk patients - the chronically ill elderly who account for 75 percent of Medicare costs. She said the program reduced rehospitalizations through three months and saved more than $2,000 a month for each participant.

"The root cause of the problem is that people haven't been adequately prepared to recognize early on that they are running into trouble," Naylor said.

The intense intervention using nurses is geared to "interrupt the chronic ill trajectory that many of these patients are on," Naylor said. "It is really about investing in the patients and their family caregivers in ways that the current system hasn't."