Patients discharged from an inpatient facility to home following treatment for an acute or chronic illness are at risk for complications. Patients are in a weakened state and in need of support. An older adult or chronically ill patient may be reliant on family members, who have other commitments, to obtain medications and groceries, or for transportation to primary care provider (PCP) appointments. To be effective, services provided to patients must span across settings, reduce preventable hospitalizations, and actively involve patients in the self-management of their care (Home Health Quality Improvement, 2010).
Approximately one in four to five patients discharged from the hospital is rehospitalized within 30 days (Hospital Compare, 2015). Patients transition across healthcare settings with little communication between providers (Home Health Quality Improvement, 2010). Often patients are not adequately educated on the behaviors and tools they need to self-manage their care while living in the community setting. Additionally, patients receive education on managing their acute or chronic conditions while in a weakened or fragile state.
As the number of patients with chronic diseases continues to grow, so do the number of preventable hospitalizations. Excessive hospital readmissions within 30 days of discharge is an issue currently being addressed by the Centers for Medicare and Medicaid Services (CMS) (Readmissions reduction program, 2014). The number of potentially avoidable hospitalizations is thought to be 382,846 annually, with a potential cost savings of $3,126,998,895 (Walsh et al., 2010). Studies have shown implementing interventions targeting the transitional period between healthcare settings reduces rehospitalizations (Home Health Quality Improvement, 2010).
CMS has implemented monetary penalties for hospitals exceeding the 30-day rehospitalization benchmark for the diagnoses of heart failure (HF), acute myocardial infarction, pneumonia, chronic obstructive pulmonary disease (COPD), and total knee/hip arthroplasty (Readmissions reduction program, 2014). The visiting nurse association (VNA) implementing this project receives patient referrals from hospitals and subacute rehabilitation centers that are working toward reducing the number of 30-day readmissions. The purpose of this article is to describe a project to identify high-risk patients and implement transitional care interventions to reduce the number of readmissions. Through funding from the Grotta Fund for Senior Care, the VNA implemented a transition program to address hospitalizations among patients with HF, COPD, and diabetes mellitus (DM). These diagnoses were agreed upon by the upper management at participating inpatient facilities and the VNA, based on the diagnoses CMS identified as targets of monetary penalties and data from the Centers for Disease Control and Prevention (CDC) stating that, “chronic diseases and conditions - such as heart disease, stroke, cancer, DM, obesity, and arthritis - are among the most common, costly, and preventable of all health problems” (CDC, 2015).
Once the program intervention was agreed upon by the management at the inpatient facilities and the VNA, a registered nurse (RN) employed by the VNA was chosen for training and implementation of the program. The RN held a Bachelor of Science degree in nursing and was the VNAs' telehealth nurse. The telehealth nurse previously monitored patient data and communicated with the patient's PCP and nurse. Care Transition Coach duties were added to the telehealth nurse's responsibilities. The RN was also previously certified in Integrated Care Management and received an additional certification, prior to the start of this project, in the Coleman Model (The Care Transitions Intervention, n.d.). The Integrated Care Management certification was obtained through the Sutter Center for Integrated Care. Integrated Care Management (ICM) has a Triple Aim in tune with healthcare reform, to achieve better health and better care at lower costs. ICM is a person-centered, evidence-based practice model that aims to improve coordination of care across healthcare settings and provide health literate care. ICM addresses caring for the patient with dignity and respect, guiding the patient in setting up personal goals, and treating the patient as a partner in his/her care (Sutter Health, Sutter Center for Integrated Care, n.d.).
The RN also received additional training in the Coleman Model. The Coleman Model, also known as The Care Transitions Program, consists of a transitions coach visiting the patient in the hospital, when possible, and then following up with the patient at home. The visits are designed to assist patients to develop self-management skills, become more involved in their care, and reach their goals while transitioning across healthcare settings. The follow up at home consists of an in-home visit and phone calls utilizing tools such as a personal health record (The Care Transitions Intervention, n.d.).
After selecting and training the RN in the Coleman Model as the Care Transitions Coach (CTC), the VNA's Director of Quality and Director of Marketing trained hospital and subacute rehabilitation staff (i.e., discharge planners, unit supervisors, staff nurses) on the program criteria: patients with greater than one hospitalization in the past 12 months; one or more of the following chronic diseases (HF, COPD/pneumonia, DM); polypharmacy of greater than or equal to five medications and psychosocial issues (i.e., lives alone/ineffective caregiver, nonadherent to plan of care). The inpatient staff was also trained on the self-management tools, and the telehealth equipment the patient would utilize while in the facility and then at home.
The training of the inpatient facility staff occurred over several weeks through multiple group meetings prearranged by the Director of Quality and the Director of Marketing with management at the inpatient facilities. The CTC also conducted training as needed, on a one-on-one basis with inpatient staff, after the initial group training, during patient visits. Once all inpatient staff were trained on the elements of the program, it was implemented, and the first patient was referred to the program in February 2014. Patients were admitted to the program for a full year with the last patient being admitted in February 2015.
Patients meeting the criteria were identified by the hospital's discharge planners while the patient was still in the hospital, and referred to the VNA's CTC, who then visited the patient for the first time while he/she was still in the inpatient setting. Once the patient was admitted to the program, the CTC followed them for 90 days after the hospital discharge date.
On the first visit with the patient, the CTC reviewed the program, obtained consent, asked the patient about his/her goals, set up the telehealth equipment, and reviewed self-management tools (i.e., paper copies of patient-specific zone tools, vital sign/symptom logs, and personal health records). The CTC also demonstrated the use of the telehealth equipment and utilized the teach-back method to ensure the patient knew how to use the equipment prior to the conclusion of the first visit. After the demonstration, the CTC observed the patient: pushing the button to turn on the telehealth equipment; placing the blood pressure cuff on his/her own arm; placing the pulse oximeter on his/her own finger; standing on the scale; and answering the questions on the telehealth monitor. The patient then began monitoring his/her vital signs, and signs and symptoms of disease exacerbation while still in the inpatient setting, with the support of the inpatient staff as needed. The data collected on the telehealth equipment were automatically transmitted to the VNA at the conclusion of each telehealth session, and were reviewed by the CTC on a daily basis.
Upon discharge from the hospital, the inpatient discharge planner ensured the telehealth equipment was sent home with the patient and the CTC scheduled a second visit to the patient's home within 48 hours. This second visit allowed the CTC to see the patient/caregiver in his/her home environment. During the second visit, the CTC assessed the need for additional interventions, completed a medication reconciliation, reviewed the self-management tools (including motivational interviewing to work with the patient on his/her goals), assessed the patient's ability to self-manage medication, follow-up with doctors, plan meals, and obtain food. The CTC also set up the telehealth equipment in the home. The patient continued to monitor vital signs, and signs and symptoms of disease exacerbation via the telehealth equipment daily, with the results automatically transmitted to the VNA's CTC. The third visit by the CTC occurred during the patient's follow-up visit with their PCP. The purpose of the joint visit by the CTC with the patient to their first PCP appointment was to coach the patient during the visit. The coaching consisted of guiding the patient on questions to ask and information to convey to the MD. If the patient declined a visit with the CTC to accompany him/her to the appointment, a third visit was made at the patient's home following the PCP visit. Additionally, the patient received coaching from the CTC on questions to ask and information to convey to the PCP about vital signs and control of his/her chronic disease. This coaching was provided by phone, prior to the PCP visit, to assist the patient in effectively navigating the visit.
The patients remained on the program for 90 days, starting from the date of hospital discharge. During the 90 days on the program, the patients continued to utilize telehealth with the data being automatically transmitted to the CTC at the VNA. The telehealth equipment, utilized for the first 30 days the patient was on the program, was a monitor with a wireless connection that automatically sent data to the VNA.
After the patient utilized the monitor for 30 days, the monitor was removed, and the patient was transitioned to another form of telehealth known as interactive voice response. When patients were transitioned to the interactive voice response, they were given their own blood pressure machine, pulse oximeter and scale, provided through the grant, to check their vital signs daily. While on the interactive voice response version of telehealth, the patients received an automated computerized call asking for input on their vital signs and symptoms of disease exacerbation. The computerized calls are a form of telehealth that asks specific disease-related questions and prompts patients to enter their vital signs and symptoms of disease exacerbation. An example of a question is: Are you experiencing more shortness of breath today? The telehealth system uses branch logic based on the answer the patient provides. If the patient answered “yes” to that question, the telehealth system asked additional questions related to shortness of breath. This information was then electronically transmitted to the CTC. From days 31 to 60 patients received daily computerized telehealth calls, and for days 61 to 90 patients received weekly computerized telehealth calls. Weekly calls during days 61 to 90 assisted in weaning the patients from the program and transitioning them to independence. Following 90 days on the program, patients were discharged.
In addition to the CTC reviewing the patients' data each morning and contacting the patient if an issue was identified, the CTC provided patient education/coaching spaced out over the 90 days the patient was on the program. The education was on a different topic (living with their specific chronic disease, exercise, nutrition, or medications) every other week for 8 weeks, provided over the phone during weekly calls. After educating the patient on a topic, the CTC would follow up the next week to see what the patient remembered from the education and reeducate as needed.
During the weekly calls, the CTC also coached patients on ways to control their chronic disease, utilizing role playing, teach back, and motivational interviewing to identify patient-centered goals. Motivational interviewing (MI) asks the patient questions about their goals related to health. MI assists the patient in determining his/her own goals, identifying support that will help them obtain the goal, and identifying obstacles to obtaining the goal (i.e., a patient wants to control her HF, but her daughter is only able to shop for her once a month, buying canned and prepackaged foods so they will last the month). MI is an evidence-based, patient-centered approach that assists the clinician in engaging patients in their own care. The practice of MI involves utilizing open-ended questions and techniques for guiding patients in making plans for change (Home Health Quality Improvement, 2010). Examples of open-ended questions utilized in MI are “has anything been getting in the way of you taking your medications? Or, you sure have lots of pills to take, how do you manage?” (Home Health Quality Improvement, p. 26).
In addition, patients were educated by the CTC on the utilization of personal health records and vital sign/symptom logs. The personal health record for each patient included all the medications the patient was taking and the reason; signs and symptoms of acute exacerbation of the disease (red flags) and what to do in the event of an exacerbation; and the patient's goals and contact information for the patient's providers (i.e., pharmacy, PCP). The vital sign/symptom log was a tool the patients used to track their vital signs and symptoms on a daily basis. The purpose of the log is for patients to have a clear picture of what the vital signs and symptoms were, so they could share them with the PCP and also track if they had gained weight, and so on. The patients were educated by the CTC on these tools throughout the program in an attempt to develop the habit of recognizing trends and calling for help before requiring hospitalization.
Patients and caregivers were also educated by the CTC on disease-specific zone tools for HF, COPD, and DM. Zone tools help the patients self-manage their care. The zone tools have clear guidelines that are color coded like a traffic light. If the patient is in the green zone (i.e., no weight gain, no shortness of breath), then they should continue taking their medication, diet, and so on, as ordered. If the patient is entering into the yellow zone (i.e., 2-lb weight gain in a 24-hour period, sleeping sitting up), they may be in need of treatment changes and should contact the nurse or PCP for intervention. If the patient is in the red zone (i.e., chest pain, severe shortness of breath), they are instructed to call 911 or the PCP emergency service immediately. The congestive heart failure zone tool was obtained from the Agency for Healthcare Research and Quality website (U.S. Department of Health & Human Services, n.d.). The COPD zone tool was obtained from the American Lung Association website (American Lung Association, n.d.) and the diabetes zone tool was obtained from the Institute for Healthcare Improvement website (Institute for Healthcare Improvement, n.d.).
As part of the program intervention, each patient was offered two grocery-shopping trips with a registered dietitian who was employed by the VNA. The dietitian would meet the patient or caregiver at a supermarket of the patient's choice and spend approximately an hour and a half teaching the patient/caregiver how to read labels and select appropriate foods. The dietitian would shop the outer aisles of the store where fresh produce, meats/poultry/fish, and frozen foods are stocked. While shopping the outer aisles, the dietitian would educate the patients/caregiver on healthier food choices and consuming less processed, high-sodium, high-sugar, and high-fat foods, which are located in the inner aisles of the store. The dietitian called the patient/caregiver to set up the grocery-shopping trips approximately a week after the patient returned home. The shopping trips were scheduled at the patient/caregiver's convenience any time during the 90 days on the program.
To measure success or failure of the program, the number of hospitalizations in the 90 days prior to the current hospitalization was compared with the hospitalizations in the 90 days immediately following discharge from the hospital. Another measurement of hospitalizations was the 30-day rehospitalization rate. This measurement was chosen as it is the period in which hospitals are penalized if the patients are readmitted. The goal was to achieve an average 30-day rehospitalization rate of less than or equal to 10% for program participants, demonstrating that the VNA could assist the hospital in preventing patients' rehospitalization.
The analysis of the data consisted of comparing the number of hospitalizations in the 90 days preceding the current hospital admission, to the number of hospitalizations in the 90 days following discharge from the hospital, for each individual patient. For example, the number of hospitalizations for patient A in the 90 days preceding the current hospital admission was compared with the number of hospitalizations for patient A in the 90 days following discharge from the hospital. This analysis was done for each individual patient in the program. The Wilcoxon T+ test in vassarstats.net was utilized to determine if a statistically significant difference existed between the numbers of hospitalizations.
The program coordinator (Director of Quality at the VNA) also compared the number of rehospitalizations within 30 days of hospital discharge (n = 8) with the number of patients on the program (n = 102) to determine a 30-day rehospitalization rate.
A total of 102 patients were admitted to the program over a 1-year period, with an average age of 71.85 years (range 22-95 years). Sixty-one females and 41 males were admitted to the program. Forty-seven patients had a primary diagnosis of HF, 28 patients had a primary diagnosis of COPD, 24 patients had a primary diagnosis of DM, and three patients had a primary diagnosis of pneumonia. Another six patients were admitted to the program but stopped using the telehealth equipment after a couple of days and were discharged from the program. Additionally, over the year, 117 patients were referred to the program but not admitted. The reasons for nonadmission were: refusing service, permanent placement in a long-term-care facility, admitted to hospice service, or expired prior to admission to the program.
The number of hospitalizations in the 90 days prior to the current hospitalization was 126. In comparison, the number of hospitalizations in the 90 days following the hospital discharge was 36. Utilizing the Wilcoxon T+ test, there is a statistically significant difference in the number of patients admitted to the hospital (p < .0001). Twenty-two patients accounted for the 36 hospitalizations. Nine of the patients with hospitalizations had a primary diagnosis of HF, seven patients had a primary diagnosis of COPD, and six patients had a primary diagnosis of DM. Eighty patients did not have any hospitalizations in the 90 days following discharge from the hospital.
In the 30 days following discharge from the hospital, eight of the 102 participants were rehospitalized. The calculation for the rehospitalization rate was 7.8%. This surpassed the goal of achieving an average 30-day rehospitalization rate for program participants of ≤10%. Four of the patients with a 30-day rehospitalization had a primary diagnosis of HF, three patients had a primary diagnosis of COPD (two of these patients had a secondary diagnosis of HF), and one patient had a primary diagnosis of DM.
Transitioning patients across healthcare settings is a vulnerable time for patients and also an opportunity to improve communication and actively involve patients in their care. Patients enrolled in the Transitioning Patients to Independence program experienced improvement in both hospitalization and rehospitalization outcomes. Giving patients the tools, support, and coaching they need to identify trends occurring with their health, as well as educating patients on signs/symptoms of exacerbation of their disease, living with their disease, exercise, and nutrition, significantly decreased the number of hospitalizations and rehospitalizations.
Patients with cognitive issues or difficulty with the technology, or who were without a family member to support them, were not included in the project, limiting generalization to these populations. Patients were not followed up after discharged from the program. Continued follow-up after the 90 days would be helpful to see if the patients continued to manage their care and remain out of the hospital.
The cost for the program was $100,170 over a 1-year period, which included salary and benefits; project-related equipment (telehealth equipment); supplies (scales, BP machines, pulse oximeters, pillboxes); travel; care transition intervention training; and printing (publicity, educational material). This project was added to the responsibilities of a nurse who was already performing telehealth duties, so the salary and benefits were calculated as a portion of that nurse's annual salary. As this was a position that was already budgeted (the telehealth nurse was already in place prior to this project), it was a sustainable project.
A reduction of 90 hospitalizations produced a potential savings of $735,120 to the healthcare system. This calculation is based on the cost of potentially avoidable hospitalization as reported by Walsh et al. (2010). In reality, the cost of the hospitalizations could amount to much more. The intangible benefits of the program include improvement in the patients' quality of life, and an improved hospitalization rate, which may make the VNA a more appealing referral source for inpatient facilities and increase referrals to the agency.
The implementation of the Transitioning Patients to Independence program resulted in a statistically significant decrease in the number of hospitalizations and 30-day rehospitalization rates. The education of staff in transitional care and giving chronically ill patients the tools and support to become independent in their care was shown to decrease hospitalizations. Additional programs are recommended to identify if transitional care programs are effective long term and are effective for other diseases and in different geographical areas.