Reducing Hospital Readmissions

By Beth Fitzgerald

Congestive heart failure landed Peter Parham in the hospital twice in one month this past fall, and the 77-year-old retiree would much rather have been home in Ewing -- taking his medicine, watching his diet and keeping the disease in check. To help patients like Parham avoid readmission to the hospital within one month of discharge, Robert Wood Johnson University Hospital Hamilton launched a new program in October that provides a "transition coach" who visits Parham at home to make sure he understands what he must do to stay out of the hospital.

"This is a good program that helps you take care of yourself," Parham said. His coach gave him a personal health record book to record his weight every day; excessive weight gain is a warning sign of heart failure complications. Parham also uses the book to keep track of his medications, write down questions to ask his doctors, and to express his personal goals: "to breathe better, and to be able to get up and around more—exertion was causing me a lot of breathing problems," he said.

The transition coach program at RWJ Hamilton, funded by a grant from the Robert Wood Johnson Foundation, is one of many efforts underway at hospitals throughout the state. There is a powerful motivation: Medicare has announced that in 2013 it will withhold 1 percent of a hospital's reimbursement if its 30-day readmission rate exceeds what the program deems reasonable for that hospital. That could cost some New Jersey hospitals millions of dollars, experts said; for many hospitals, Medicare accounts for as much as half the institution's revenue.

Hospitals are using a variety of approaches to stem readmissions: running hospital-based clinics to provide follow-up care to discharged patients, working with nursing homes to coordinate the care the patient gets when moving from hospital to nursing home, and providing telemonitors that transmit the patient's vital statistics to clinicians who can intervene if the patient's condition deteriorates.

RWJ Hamilton's program will focus on 350 patients over two years who are at least 60 years old and suffer from congestive heart failure or diabetes or both, and have at least one other chronic condition. It is a joint program with the Jewish Family and Children's Services of Greater Mercer County, which has extensive experience providing social services to the elderly in the community. Judy Millner of JFCS was trained as a transition coach, and she mentors the project's coach.

Joyce Schwarz, vice president of quality at RWJ Hamilton and project director, said in order to reduce readmission, it's critical that patients see their primary care physician within a week of discharge from the hospital. But physicians tend to be booked up; "so they get an appointment in three weeks, and before the three weeks are up they run into trouble and wind up back in the hospital before they even see their doctor." Millner said the patient is coached "to be engaged and empowered" as a patient: "We do role playing to ensure that the appointment is made and that it's not three weeks before they see the doctor."

Schwarz said that traditionally, "We have put the responsibility on the [healthcare] professionals to manage your healthcare. 'See me in six months. Take this medication.' But where is the patients' responsibility, what if they don't take their medication?" She said the goal of the coach is to get patient actively involved in their health.

Continue reading this story in NJ Spotlight.

NJ Spotlight is an online news service providing insight and information on issues critical to New Jersey.