It takes a community

The Camden Coalition in New Jersey and other health care systems are addressing the problem of hospital readmissions by bringing people together at the local level.

An elderly man with uncontrolled diabetes was returning regularly to a Camden, N.J. emergency department whenever his blood sugar reached dangerously low levels. Frustrated by the repeat visits, a case manager referred the patient to the Camden Coalition of Healthcare Providers, which sent in a team to follow the man after discharge and figure out what was driving the readmissions. Months later, the man has his diabetes under control, rarely visits the hospital and enjoys a better quality of life.

In the past, such patients probably would have continued to show up at the emergency department (ED) while their disease worsened and expenses piled up. But the nonprofit Camden Coalition is making inroads into reducing readmissions of frequent users of hospital resources by pooling the efforts of hospitalists, primary care physicians, nurse practitioners, social workers and other care providers so that patients are funneled back into primary care instead of falling through the cracks. The result has been fewer readmissions, less frustration among clinicians and better outcomes for patients.


“In most health care systems, people move from hospital to hospital, ED to ED, clinic to clinic, and there is really no level of thought about whether the system is working well for patients,” said Jeffrey Brenner, MD, a family physician at Camden's Cooper University Hospital who started the Coalition. “As a provider in a small office, I was realizing that I had absolutely no ability to impact their health because much bigger things were happening to them outside the office.”

Hospital readmissions are a major contributor to the high cost of health care in the U.S., and reducing such costs is a key goal of health care reform. According to a 2008 Medicare Payment Advisory Commission (MedPAC) report to Congress, almost 18% of Medicare hospital admissions result in readmissions within 30 days of discharge, resulting in $15 billion in annual expenditures. About $12 billion of that is spent on potentially preventable readmissions, the report found.

Research often cites poor communication and coordination at discharge as major contributors to readmissions. Patients, many of them older with multiple chronic conditions, are often discharged with little guidance or follow-up, MedPAC noted in the same report, and often do not understand what medications they need to take, what follow-up visits might be necessary or whom to call with questions.

Like the Camden Coalition, other health care systems and groups have set out to address systemic problems by bringing people together at the local level. Akron, Ohio-based Summa Health System seeks to improve care for seniors through collaborations between hospitals and nursing homes, while the Colorado Foundation for Medical Care uses transition coaches for hospitalized seniors in North Denver. By stepping up their communication and documentation, hospitalists play an integral role in these programs.

Camden Coalition takes to the streets

The Camden Coalition's Care Management Project takes a very personal approach to improving care, but its success is rooted in hard data. Led by Dr. Brenner, the group compiled a claims database based on annual visits to the hospital and EDs of three area hospitals—Cooper University Hospital, Virtua Health Camden and Our Lady of Lourdes Medical Center—for every Camden resident. The results showed that between 2002 and 2007, 20% of the patients admitted to the hospital and ED accounted for 90% of costs and that admissions were particularly high among a small number of patients—dubbed “super utilizers”—who were admitted between 24 to 324 times over a five-year period.

“It was eye-opening for all of us,” said Dr. Brenner. “We recognized at a patient-by-patient level that the system wasn't working but when you laid out the data, it was very striking. The system was expensive, wasteful and didn't benefit anyone.”

Initially funded by a Robert Wood Johnson Foundation grant (and now funded through the Merck Foundation), Dr. Brenner brought together hospitalists, primary care physicians, social workers, nurses and others to share information about patients considered high utilizers. Patient names were left out of the discussions but “pretty soon we recognized that we were dealing with the same folks and that we would have to work together to address the problem,” said Dr. Brenner. “This wasn't a hospital problem or a doctor problem but a citywide, system-level problem.”

Dr. Brenner put together a team consisting of a nurse practitioner, a community health worker and a social worker that reaches out to high users based on referrals from hospitals. The team shows up at the bedside and follows the patient home, which might turn out to be a homeless shelter or street corner. The goal is to transition the patient into primary care by offering assistance ranging from writing prescriptions or diagnosing conditions to helping patients find housing, open a bank account or apply for disability.

“Our mantra is ‘give us the worst of the worst, the people who are driving you crazy and let our team work with them,’” said Dr. Brenner.

So far, the plan appears to be working. According to the most recent data, hospital admissions of super utilizers dropped by about 40% since the utilizers enrolled in the program, lowering associated monthly hospital charges by more than $500,000.

The Coalition, which comprises eight employees including the three-member team, shares data about admissions of frequent ED users with the three hospitals. This gives hospitalists a better perspective on the full scope of a patient's problems, said Eric Kupersmith, ACP Member, head of the division of hospital medicine at Cooper University Hospital. “Rather than just discharge someone quickly and have them bounce back to Lourdes and back to us, we try to collaborate and pool our resources and deal with them in a comprehensive way,” he said.

That might involve referring patients to a nursing home or helping them get appropriate mental health care, said Dr. Kupersmith. Cooper coordinates with the Coalition at discharge to help eligible patients enroll with Medicaid or Medicare, which gives them access to the medications they need. Working with the Coalition has also made life a bit less chaotic for hospitalists, he added.

“For a handful of high utilizers that suck up a significant amount of your time as a hospitalist on a daily basis, it's very useful,” said Dr. Kupersmith. “Prior to working with the Camden Coalition, we might spend two hours a day on these patients trying to get them access to the things they need.”

The Coalition is in the midst of planning its next project, an electronic health information exchange that will allow physicians in the three hospitals to log into a Web-based system to access patients' lab results, radiology tests and discharge summaries—potentially avoiding repeat tests and longer hospital stays that can result when physicians don't know a patient's medical history. The system also will alert a Coalition staff member in real time when citywide care management patients are admitted to or discharged from the hospital and ED, said Dr. Brenner, putting hospitalists in a better position to help coordinate a patient's care.

“Hospitals are often overburdened but if you don't want to get overrun you have to think about these patients before they come and after they leave,” Dr. Brenner said. “It's not enough to deliver episodes of care—we need to figure out where patients are coming from, why they're coming and what we can do at a system level to have an organized response to them.”

Ohio project smooths transition for seniors

Summa Health System, which encompasses six not-for-profit community and teaching hospitals, four outpatient centers, a for-profit health plan and a physician-hospital organization, was struggling with prolonged stays, high readmission rates and spiraling costs when it began planning its Care Coordination Network (CCN) in 2002. Several years later, the system has reduced its 30-day readmission rate for patients discharged to skilled nursing facilities (SNFs) from 26% to 24%, reduced the average length of stay for those patients, and avoided surgery and test cancellations due to incomplete paperwork.

In the beginning, the biggest challenge was getting all 19 regional hospitals to agree to a standard discharge form used for patients transferred from the hospital to a nursing home, said Kyle R. Allen, DO, medical director of post-acute and senior services and chief of geriatric medicine for Summa. The universal transfer form, now used by the hospitals and SNFs including the 37 CCN facilities, includes basic patient information, special care orders and recent treatment history as well as a page for physician notes and a checklist of attached charts and tests.

The discharge form has improved communication during handoffs, which in turn has improved transitions to SNFs for patients, said Dr. Allen.

“When you get sick, you might have several sites of care, so transitions are very important and in order to do it right you need relationships with the next level of care,” he said. “You need a forum and structure to work on quality improvement. Otherwise you are just a hospital or a skilled nursing facility but the information is not connected.”

The health system also uses an electronic referral system, called the Extended Care Information Network, that allows hospitals to communicate with SNFs about patients' needs before they're discharged so that patients can discuss options with their physician before deciding where to go. The CCN and the Akron Regional Hospital Association also initiated communication with emergency medical services that transport patients between hospital and SNF. Based on EMS input, all patients now wear armbands with their names so medical personnel can identify those who are unable to communicate during transfer to the ED.

Inspired by the Care Coordination Network, hospitalists at Summa have followed Dr. Allen's lead on improving communication at discharge, said Robert Schaal, MD, senior partner of Inpatient Medical Services, a private hospitalist group that contracts with Summa and other area hospitals. For example, the group enters patients into a computerized communication system that immediately alerts the primary care physician by fax when their patient is admitted or discharged, along with providing information on disposition, medication lists, diagnoses and recommended follow-up, he said.

The computerized system is linked to billing so that physicians are required to enter information in order to complete the discharge, he added. The group has also started its own transcription service to ensure that discharge forms are completed with all necessary information and is planning to launch a call center to follow up with patients post-discharge.

The innovations are all aimed at improving the transition from hospital to primary care, where the group has seen its “biggest and most frequent failures,” he said. “It really requires that extra step—not only care when patients leave the hospital but a bridge to get them to the primary care physician so that the issues can be dealt with based on the facts rather than guesswork.”

Health coaches, better communication improve outcomes

To date, hospitals have had no financial incentive to reduce readmissions because the current payment system reimburses them based on admissions. So Jane Brock, MD, chief medical officer of the Colorado Foundation for Medical Care (CFMC), a Medicare Quality Improvement Organization (QIO), was pleasantly surprised when St. Anthony's Central Hospital in North Denver enthusiastically signed on to a pilot project aimed at reducing readmissions.

“We've heard a lot about the payment system being the problem but the level of frustration among direct care providers far outweighs whatever they think about the payment system,” said Dr. Brock. Also, getting better systems in place now makes sense for hospitals in light of Medicare's efforts to cut spending through pay-for-performance incentives. MedPAC has recommended reducing payments to hospitals with high readmission rates for certain conditions and rewarding hospitals that institute more efficient, money-saving processes.

CFMC's first Medicare-funded pilot project, which ended in December 2008, focused on improving the transition process for hospitalized seniors discharged to SNFs. CFMC partnered with St. Anthony's physicians at the hospital's Senior Clinic, Centura Health at Home Agency, and Physician Health Partners (a management services organization). The program, modeled on the Care Transitions Program developed by Eric Coleman, FACP, used health coaches to prepare patients for post-hospital appointments and improved communication between hospitalists and primary care physicians. At the end of the pilot, the hospital had reduced 30-day readmissions by 7% and cut 60-day readmissions by 50% compared with uncoached patients.

Improved communication at discharge between hospitalists and primary care physicians was critical to the pilot project's success, said Thomas Cain, ACP Member, a geriatrician at the Senior Clinic whose patients have an average age of 80. During the project, a hospitalist would contact Dr. Cain whenever one of his patients was admitted, discharged or experienced a significant change in condition during hospitalization. For example, Dr. Cain might get a call from the attending hospitalist that his patient was admitted with pneumonia and was ready for discharge, but wanted to go home instead of to the recommended nursing home. The hospitalist would express concern and recommend the patient see Dr. Cain the next day.

“We try to get our staff here to understand that the patient at home may require more attention,” said Dr. Cain. “And when the patient comes back [to my office], I've had that conversation about what happened in the hospital.”

The success of the pilot led to Medicare funding for an expanded program led by CFMC in Colorado and 13 other QIOs in communities nationwide. CFMC is now working on improving hospitalist-primary care physician communication by using text messaging and Web-based systems, said Dr. Brock. However, progress has met with some unexpected roadblocks, such as privacy regulations.

CFMC developed a Web-based system that would allow hospitalists and primary care physicians to access a password-protected patient database. However, the plan is on hold due to questions about compliance with HIPAA, said Dr. Brock. In the meantime, the hospital has purchased pagers for all of its hospitalists so they can send brief text messages when a patient is discharged.

“Text notification of discharge is still a good idea because it prompts the primary care physician that they have been given responsibility for a patient,” Dr. Brock said.

While the pilot project has ended, Dr. Cain is continuing to use health coaches or social workers in his practice to manage patient transitions after discharge. The coaches not only improve communication between patient and physician but also encourage the patient to take more responsibility for his or her own care, he said.

“A key piece is that the patient and family needs to take some responsibility about the medications being taken, recognizing red flags and how to contact the physician,” said Dr. Cain. “The real benefit is to those with chronic illnesses with complicated medication regimens who get overwhelmed by the disease and the system. We're guiding them to take some charge of how their disease is managed.”