When a patient is discharged from St. Joseph Regional Medical Center in Bryan, Texas, a disease management team swings into action. Within 24 hours, a transfer-of-care note is faxed to the primary care physician and a hospital nurse coordinator contacts the primary care nurse to discuss follow-up and medication reconciliation. Within 48 hours, the patient receives a “homecoming call” to ensure he or she is following discharge instructions, is taking medications appropriately and is not having a problem.
Since the hospital implemented these procedures in 2007, readmissions for congestive heart failure (CHF), acute myocardial infarction, pneumonia and stroke have dropped by about 20%.
St. Joseph is among a group of hospitals that have initiated disease management programs to improve patient care and lower the high cost of readmissions. Integral to these programs are computerized protocols, clinical pathways and evidence-based order sets that guide physicians and nurses in the care of patients, both in the hospital and at discharge. In the past, a patient's hospital experience often ended at discharge. Now, a promptly delivered expanded discharge summary—detailing procedures carried out during hospitalization, consultations, discharge medications and recommendations for follow-up care—often bridges the transition from the hospital to the outpatient setting.
Hospitalists are important to the success of disease management programs because they are positioned to guide the patient through the system and act as a liaison with primary care, said Joseph Li, ACP Member, director of the hospital medicine program at Beth Israel Deaconess Medical Center (BIDMC) in Boston.
When a patient is admitted to BIDMC with acute decompensated heart failure, for example, he or she is seen by a hospitalist, who provides acute care in accordance with the heart failure pathway, ensures the patient and family members receive necessary condition-related education and arranges for follow-up care at the heart failure clinic after discharge. The hospitalist enters a comprehensive discharge note in the electronic health record, which is then available to clinic physicians when the patient comes in.
“One of the most important things we do as hospitalists is ensure that patients get follow-up care, to minimize rehospitalization,” said Dr. Li. “This includes referring patients to the clinics, communicating with primary care physicians and giving patients a copy of their discharge note so everyone is working off the same document.”
An added value of such coordination is that the patient likely will return to the same hospital rather than going elsewhere if readmission is required, which means more consistent care, Dr. Li said.
Pathways and protocols
The four hospitals in Georgia's Piedmont Healthcare System apply disease management strategies to its stroke, chronic obstructive pulmonary disease, orthopedic joint replacement and CHF programs. For patients admitted to a Piedmont hospital with CHF, the pathway automatically prompts for diuretics, an angiotensin-converting enzyme (ACE) inhibitor, and an echocardiogram.
“Previously, I probably thought of these things at 3 a.m., but it was by the seat of my pants,” said Frederick Willms, FACP, a hospitalist who is chair of the department of medicine at Piedmont Fayette Hospital. “Now if a CHF patient has renal failure and I don't give an ACE inhibitor, I have to check a box to explain why, and choose a different treatment.” Similarly, because venous thrombosis prophylaxis is built into all order sets, if it's not needed, the physician must unclick it.
At discharge, the pathway prompts such simple but important orders as ensuring the patient has had pneumonia and flu vaccines, and gives instructions for daily weighing and reporting a significant increase. All CHF patients are automatically referred to the CHF clinic at discharge, an order that must be unclicked if not deemed appropriate.
“With this pathway, we're seeing a tremendous decrease in mortality, and greater satisfaction in taking care of people,” said Dr. Willms. “For heart failure, we used to see readmission figures as high as 20%. Using disease management protocols, rates at Piedmont Fayette are down to about 7%.”
Having computerized protocols and order sets also means that hospitalists don't have to trust everything to their memories, even when they're being pulled in five different directions in the wee hours of the morning, Dr. Willms said.
“For example, when an elderly patient with diabetes who has recently had MRSA comes in from a nursing home, I just click on an order set and the protocol lists the appropriate antibiotic and dosage. I don't have to look it up or think about it; all the science and literature is in the order set.”
Getting with the program
Piedmont Healthcare System has also begun to apply disease management principles to acute as well as chronic conditions. This past year, the focus has been the national Surviving Sepsis campaign.
“Prior to the campaign, our system-wide mortality rate for patients with severe sepsis on the hospitalist service was 29%—now it's 19%,” said Matthew Schreiber, ACP Member, medical director for hospitalist services. Because of the better outcomes in sepsis, the hospital has seen a large cost savings from decreased use of ICU beds and continuous venovenous hemodialysis, he added.
Early detection and aggressive, consistent treatment are the keys to saving the lives of patients with sepsis. Previously, a patient seen in the emergency department with signs of infection would have to wait to see a physician, who would then order the appropriate laboratory tests, said Dr. Willms. “By the time all the labs are back, many hours may have passed, and the patient could be in shock,” he said.
Under the sepsis protocol, within one hour, a patient presenting with signs of infection and at least two signs of systemic inflammatory response syndrome (SIRS)—elevated heart rate, leukocyte count, temperature and respiratory rate—is treated with an intravenous bolus of fluid and antibiotics, and blood samples are taken for serum lactic acid and a culture.
The hospitalist can then take a close look at the patient's risk factors and decide on a course of treatment. A 25-year-old patient with community-acquired pneumonia is likely to have different organisms and require different treatment than an elderly patient with diabetes who comes from a nursing home and is taking steroids, Dr. Willms said.
“This protocol has lowered our hospital mortality from about 3.0% to 1.4%,” said Dr. Willms. He estimated that it has saved more than 60 lives in the Piedmont system in the past year. “This kind of medicine really makes a big difference,” he said. “I've been in practice 32 years, and for the first time in years, I'm excited about medicine again.”
The hospitalist experience
“Disease management programming is at its best in our hospital for pre-liver transplant patients,” said Guy Lubliner, MD, medical director of the subspecialty hospitalist service at Physicians Foundation at California Pacific Medical Center. “Where I see hospitalists playing a key role is bringing it all together for the patients and their families before discharge, and ensuring they have needed medications and information on managing symptoms at home. We're in the process of trying to mirror the model for other chronic diseases.”
Mack Blanton, FACP, a hospitalist and program medical director for St. Joseph, said he uses evidence-based medicine order sets every day. “By doing this, core measures become essentially default orders, making it less likely that the physician will fail to accomplish a core measure. And I believe that the homecoming call and medication reconciliation have helped to decrease readmission rates,” he said.
“There are absolutely no downsides to these programs,” said Dr. Willms. “We see more patient and payer satisfaction, as problems are addressed quickly and aggressively, resulting in shorter hospital stays. And, although we don't have any greater contact with primary care physicians, I believe they're getting more useful data. Disease management protocols allow us to expeditiously deliver evidence-based, excellent patient care in a consistent manner.”