THE BRONX — A group of Bronx hospitals and insurance companies have found that a nurse's phone call can help treat one of modern medicine's greatest ailments: patients who must return to the hospital soon after they leave.
Hospital readmissions are a chronic, costly epidemic in the United States — Medicare patient readmissions alone cost $26 billion each year.
In The Bronx, the problem is especially acute — the county’s 30-day readmission rate in 2010 of 18.1 percent, or nearly one in five patients, was the highest of 306 hospital regions examined in the 2013 Dartmouth Atlas Report.
But now, three Bronx nonprofit hospitals and two payer companies have released a study showing that an innovative program they designed, which keeps nurses in contact with patients after they leave the hospital, reduces the number of patients who are readmitted.
The findings are particularly relevant today with the Affordable Care Act’s focus on driving down health care costs and Medicare’s new policy of penalizing hospitals with overly high readmission rates, the study's sponsors said.
“There’s a whole constellation of things that factor into [readmissions]," said Anne Meara, who led the study and is associate vice president of network management at Montefiore Care Management. “We really believe it is our mission to figure out how we can do a better job of dealing with those issues.”
There are many reasons why recently released patients end up back in the hospital.
Many struggle to recall discharge instructions they were told at the hospital while still stressed and medicated.
Some return to isolated home lives where there is no one to monitor the food they eat or pills they take.
Others are bombarded with housing woes, job worries, family dilemmas, transportation challenges and other obstacles that thwart their recoveries.
The study followed 775 patients over 10 months. The patients were all Bronx residents ages 50 or older who had a telephone where they lived and were expected to be discharged from one of the three hospitals.
The 500 patients who received at least two interventions through a special “care transitions” program had a 17.6 percent 60-day hospital readmission rate.
Meanwhile, the 190 patients who received standard care had a 26.3 percent readmission rate.
The interventions, performed by special “care transitions” nurses, included an educational session before the patients left the hospital, then periodic phone calls once they returned home.
The nurses used the calls to discuss medications, check for symptoms and make sure the patients visited a doctor within two weeks of leaving the hospital. If the patients couldn’t fill a prescription or find a ride to the doctor, the nurses were ready to offer help.
The care transition program helped keep more patients than normal from returning to the hospital for several reasons, according to Meara and others involved.
First, it created uniform procedures for following up with patients, training staff and entering data that — crucially — makes it clear who should interact with discharged patients and how.
Second, it enabled the designated nurses to strike up a rapport with patients, which helped them stay in touch after the patients returned home.
And third, it involved the payers, who agreed to pay a fee for these transition services, which demand an up-front investment but can lead to big savings.
Bronx Collaborative, the group that designed the program and the study, was founded in 2009 and has focused on reducing preventable hospital readmissions.
It includes Bronx Lebanon Hospital Center, St. Barnabas Hospital and Montefiore Medical Center, as well as the payer organizations EmblemHealth and Healthfirst.
