Dorothy is a 94-year old woman with well-managed congestive heart failure. She enjoys water aerobics and travel. Her condition recently required her to undergo a successful microvalve surgery. Despite being discharged to a skilled nursing facility, Dorothy was readmitted 3 days later because she was not given the correct medications.
Upon her second discharge from the hospital, Dorothy’s adult children took charge of her care. Confused by handwritten discharge instructions and the fact that the hospital pharmacy sent Dorothy home with new meds but not those she was taking prior to admission, her children sought the advice of clinicians. A home health nurse helped them prevent a second error, and another hospitalization, by clarifying that Dorothy should continue taking her old meds while also taking the new ones.
Such simple errors can bear heavy consequences for health delivery systems. The moral of this story: even great surgical outcomes can be undone by poor discharge procedures. In Dorothy’s case, having proactive caregivers and appropriately communicating with a home health nurse prevented a second readmission.
And even when discharge is perfect, patients and their caregivers may still need more handholding, especially when their care needs are complex.
The case for supporting a seamless journey along the care continuum is building as payment models penalize readmissions and reward quality and experience. More delivery systems are recognizing that patient care begins before an in-person visit and continues through multiple care settings – with growing emphasis on the home as a critical center of care.
For example, St. Vincent Health is a hospital system with 20 health ministries serving 47 counties in central and southern Indiana. St. Vincent remotely monitored chronic disease patients using a multi-part telehealth system that included biometric monitoring, video visits, and daily health questionnaires. In less than 2 years, heart failure readmissions were reduced to 3% (well below the national average of 21%). St. Vincent Health estimates that expansion of the program to 40,000 patients will bring per-patient costs to a level that makes this level of home support even easier to justify across a broader system.
As my colleague Liz Boehm pointed out last week in Transitions to Primary Care: Navigation is Key!, Bon Secours Health System took a different approach, hiring clinical navigators (both inpatient and outpatient) to help manage high-risk patients in-person and by phone. Appropriate patients were identified using registries and care management software, and the support brought all-cause readmissions down below 2%. Of note: Bon Secours implemented its navigation program prior to securing reimbursement. Based on the success of the program, the system has secured 3 accountable care contracts and is in negotiations for 2 more.
There are many lessons we can glean from these examples, but one stands out to me: Bridging to home needs more than just phenomenal discharge planning but a constant connection, perhaps by phone or remote monitoring, to the patient. It needs recognition of the idea that the exam room of the future is where the patient is, and that “discharge” is soon to be an expression of the past.
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