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Family Matters: How to Divvy Up Your Stuff
Myths
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Ken's Corner: ‘It
Was a Dark and Stormy Night’ ... and Then What?
Leaving Hospital? Heed Care Tips or You May Return
By Lauran Neergaard
WASHINGTON
(AP) — Michael Lee knew he was still in bad shape when he left
the hospital five days after emergency heart surgery. But he was
so eager to escape the constant prodding and the roommate’s
loud TV that he tuned out the nurses’ care instructions.
“I was really tired of Jerry Springer,” the New York man says ruefully. “I
was so anxious to get out that it sort of overrode everything else that was going
on around me.”
He’s far from alone: Missing out on critical information about what to
do at home to get better is one of the main risks for preventable rehospitalizations.
“There couldn’t be a worse time, a less receptive time, to offer
people information than the 11 minutes before they leave the building,” said
readmissions expert Dr. Eric Coleman of the University of Colorado in Denver.
Hospital readmissions are miserable for patients, and a huge cost — more
than $17 billion a year in avoidable Medicare bills alone — for a nation
struggling with the price of health care.
Now, with Medicare fining facilities that don’t reduce readmissions enough,
the nation is at a crossroads as hospitals begin to take action.
“Patients leave the hospital not necessarily when they’re well but
when they’re on the road to recovery,” said Dr. David Goodman, who
led a new study from the Dartmouth Atlas of Health Care that shows different
parts of the country do a better job at keeping those people at home.
The Dartmouth study was commissioned by the Robert Woods Johnson Foundation,
which then invited the AP as a partner to explore through focus groups it organized
what happens at the hospital level that makes readmissions so difficult to solve.
In Portland, Ore., nurses at Oregon Health & Science University start teaching
heart failure patients what they’ll need to do at home on their first day
in the hospital, instead of just on their last day.
In Salt Lake City, a nurse acts as a navigator, connecting high-risk University
of Utah patients with community doctors for follow-up treatment and ensuring
both sides know exactly what’s supposed to happen when they leave the hospital.
Some techniques are emerging as key, Coleman said: Having patients prove they
understand by teaching back to the nurse. Role-playing how they’d handle
problems. Finding a patient goal to target, like the grandmother who wants her
heart failure controlled enough that her feet don’t swell out of her Sunday
shoes.
_____
You’d
be mad at having to return your car to the mechanic within a month,
yet rehospitalization after people get their hearts repaired too often is treated
as business as usual, laments Dr. Ricardo Bello, a cardiac surgeon at New York’s
Montefiore Medical Center.
Heart surgeons try to prevent that by re-examining patients two to three weeks
after they go home. But Montefiore patients tend to be readmitted sooner than
that.
So last fall, Bello’s team began a special clinic where nurses check heart
surgery patients about a week after they go home, at no extra charge — and
have a chance to re-teach those discharge instructions when people are more
ready to listen.
Plus, for that first month at home, patients are supposed to wear a bracelet
with a phone number to reach Montefiore’s cardiac unit 24 hours a day
with any worries.
“It changed my conception of dealing with a doctor,” said Michael
Lee, 60.
Montefiore surgeons repaired a life-threatening crack in Lee’s aorta, the
body’s main blood vessel, but his recovery derailed days after getting
home. He quit some medications. He was scared to wash the wound that ran from
chest to navel, an infection risk. He developed a scary cough and called that
special clinic in a panic.
It turned out the cough was a temporary nuisance — but nurses discovered
a real threat: Lee’s blood pressure was creeping up, a risk to his healing
aorta. Those pills Lee quit were supposed to keep it extra low, a message he’d
missed. And some hands-on instruction reassured Lee that he could handle his
wound without tearing it.
Without the clinic, “he’s definitely somebody we would have been
called to see in the emergency room,” said physician assistant Jason
Lightbody.
_____
In
heart failure, a weakly pumping heart allows fluid to build up until patients
gasp for breath. Spotting subtle early signs like swelling ankles or creeping
weight gain is crucial. But at the Oregon Health & Science University,
nurse practitioner Jayne Mitchell spied as patients were told what to watch
for as
they were discharged — and they barely paid attention.
The new plan: Learn by doing.
Every morning, hospitalized patients weigh themselves in front of a nurse,
record the result and get quizzed on what they’d do at home. Gained
2 pounds or more? Call the doctor for fast help. Lots of day-to-day fluctuation?
A weekly
log can help a doctor tell if a patient is getting worse or skipping medication
or having trouble avoiding water-retaining salty food.
Step 2: These patients need a check-up a week after they go home. The hospital
makes the appointment with a primary care doctor before they’re discharged,
to ensure they can get one.
And for some high-risk patients who live too far away to easily track, Mitchell
is pilot-testing whether a high-tech option helps them stick with care instructions.
During that first vulnerable month at home, those patients record their morning
weight, blood pressure and heart rate on a monitor called the Health Buddy.
It automatically sends the information back to Mitchell’s team at OHSU
and also will flash instructions to the patient if it detects certain risks.
_____
The
customized programs reflect the Dartmouth study’s findings
that there’s
great geographic variability in hospital readmissions.
In Miami, for example, more than a quarter of Medicare patients with heart
failure returned to the hospital within a month in 2010, the latest data
available. That’s
double the readmission rate for those patients in Provo, Utah.
In Dearborn, Mich., the readmission rate for pneumonia was 20 percent, twice
that of hospitals in Salt Lake City.
“Every place is different and faces different challenges in terms of improving
care after patients are discharged from the hospital,” Goodman said.
This page and its contents ©2013
Metropolitan News Company, Inc.
