“She’s a tough case,” said her son, Bobby , who has a big hand in her care. “One thing affects the other thing affects the other thing affects the other thing.”
But, he said, the family’s relationship with the nurse has been essential at heading off some problems before they require an inpatient stay.
The goal is to be proactive, said Julius Yang, medical director of inpatient quality. “Patients don’t call us when they are starting to experience problems,” he said.
The hospital plans to expand the program, with help from a $5 million federal grant, to serve 250 patients per month by December, adding seven transition counselors and four pharmacists to work in a large physicians’ group affiliated with the hospital and in several other practices and community health centers.
Helping people to understand their medications is key, Moravick said. The typical Medicare patient might be on 13 or more medications. Adding another during a hospitalization can mean a big change in routine or side effects, she said.
In the hospital’s cardiology department, nurse practitioners are taking on the role of talking with families and with primary care doctors about a patient’s post-discharge plan. And, starting about a year and a half ago, cardiologists began working night shifts in the emergency department, where up to about 7 percent of patient visits are heart-related.
Patients who were recently treated for a heart attack and show up at 10 p.m. in the emergency department with a twinge in their chest often are not comfortable going home without being assessed by a cardiologist, said Dr. Peter Zimetbaum, director of clinical cardiology. Having a specialist working alongside emergency staff can help to get those patients appropriate care without hospitalizing them.
The problem of avoidable readmissions is “a new phenomenon,” Zimetbaum said. It used to be that primary care providers kept in close contact with their patients, visiting in the hospital, treating them when they were discharged, and sometimes paying house calls.
But health care changed. Frontline physicians don’t have the same time for each patient they once did. Specialists filled their roles in the hospital.
“We haven’t figured out yet how to deal with the pieces that I think we’ve lost,” Zimetbaum said.
The Institute for Healthcare Improvement is in the fourth year of a program funded by the Commonwealth Fund, a private foundation focused on health care quality, to work on the issue in several states, including Massachusetts. Dr. Saranya Loehrer, who is a director with the program, said she is hoping this year brings some clarity on what it takes for hospitals to lower their readmission rates.
One challenge, she said, is that the problem — and the solution — is not fully within hospital control. It requires “a community approach,” with other providers, services, and family involvement.
Patients at UMass Memorial Medical Center and its affiliates will begin to see stoplight signals — a red, yellow, or green marker on their chart and in their hospital rooms — to indicate how close they are to being discharged, a reminder for families and physicians to plan for what comes next.
The hospital also has added an automated system to contact every patient within 24 hours after they go home to see if they need a follow-up call from a nurse. And it plans to install software to identify patients who are at highest risk for frequent hospitalization.
The hospital system is set to lose about $1.5 million in Medicare revenue this year because of its elevated readmission rate, said Dr. Robert Klugman, chief quality officer. Regardless of penalties, he said, investing in better care is essential to working within the newer models of paying for health care.
“We’re building the infrastructure, and it’s the right thing to do,” Klugman said.