The New Health Dialogue

Several weeks ago I heard two medical teams, one from New York and one from Minnesota, speak about their ongoing efforts to improve outpatient care of patients with congestive heart failure -- more specifically, about how to improve the transition between hospitalization and community-based care, so that the patient doesn’t boomerang right back into the hospital. Avoidable hospitalizations are common. They cost Medicare billions of dollars a year. I once interviewed a patient who literally could not remember how often he had been hospitalized within just a few months.

The new health reform law takes some steps to address the readmission challenge. Starting in 2012, hospitals with particularly high rates of avoidable readmissions will have Medicare payments reduced. That's the stick. On the carrot end, new models of care and payment systems (bundling, medical homes, accountable care) will create new pathways to improve care coordination and disease management. That would make it easier, for instance, to pay for a nurse practitioner to check up on a newly-released heart failure patient.

The Journal of the American Medical Association (USA Today’s Steve Sternberg wrote about it) published a study that provides more evidence that we do, in fact, know how to reduce high readmission rates among the million or so Medicare patients with heart failure who are hospitalized each year. Drawing on data from more than 30,000 Medicare patients, the study found that hospitals that follow up for a week after discharge bring down the hospitalization rates significantly. The study drew on quality-improvement data that 225 hospitals provide to the American Heart Association.

Unfortunately, good follow up care was not the rule. More than half the hospitals did not follow up with these frail, elderly and sick patients during that first critical week after discharge. Medication reconciliation is one danger area. Most of the patients are taking multiple medications that they may or may not understand, that they may or may not actually have at home, that may or may not be a good mix with the medicines they were taking before they went into the hospital. Diet is also important. I’ve spoken to heart failure patients who had been told to follow a low-salt diet but had no idea that meant they had to avoid high sodium processed foods. They thought it was just about the salt shaker on the table.

As the JAMA article said:

For patients with heart failure, the transition from inpatient to outpatient care can be an especially vulnerable period because of the age of the patients, complex medical regimens, the large number of comorbid conditions, and the multiple clinicians who may be involved.

We did find that patients discharged from hospitals with the highest rates of early follow-up by a cardiologist had lower risk of 30-day mortality, consistent with other studies of cardiology care for heart failure.

As USA Today noted, “Key questions remain unanswered, including who is responsible for these patients' care." The hospital? The doctors? Medicare? The current health care delivery system doesn’t do a good job of paying for care coordination and follow up, and not all very sick patients meet the strict Medicare criteria for home nursing visits. Health reform will encourage more team based care, more integration between inpatient and outpatient, and more payment based on quality, not quantity.

Some health care systems and providers are already taking the necessary steps. At the IHI conference I attended, Minnesota's Allina Hospital and Medical Clinics described how they are trying to create much smoother transitions, much better planning, and much better tools, including a symple red-yellow-green traffic light kind of chart, for patient self-management. They identify the most fragile patients while they are still in the hospital and line up supportive services. They make outpatient appointments before the patient leaves the hospital. They have difficult but necessary conversations about advanced care planning with patients with severe illnesses. The doctors who gave the presentation did not claim to have solved the readmission problem, but they are making progress.

The other team was from the Mount Sinai Medical Center in New York, and they spoke of collaborations between the hospitalists, the outpatient docs, and a nurse practitioner who met the patient in the hospital and then focused on the first few critical days after the patient left the hospital. The nurse doesn't follow the patient indefinitely, but creates a "critical bridge" between inpatient and outpatient care.

Expect to see more creative approaches in the coming years. Because as the JAMA research shows, they can work.