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Fixing the ‘revolving door’

By David Gulliver
6/23/2009 © Health News Florida

A decade ago, Sarasota Memorial Hospital found that almost one-third of its congestive heart-failure patients ended up back in the hospital in the year following discharge. Most were coming through the emergency room, running up big bills.

Hospital officials decided to see whether the "revolving-door syndrome" could be fixed by setting up a special Heart Failure Clinic with staff that would glom onto the patients while they were still in the hospital and stick to them like glue after they left.

It worked: After a year, when the data were assembled on 107 heart-failure patients, the hospital found the readmission rate in the group dropped from 31 percent in the year before the project to 3 percent in the year after.

The program won one of two clinical innovation awards from VHA, the national community hospital network, in 2001. “This award is a tribute to everyone in the hospital,” said Bob Smith, then the director of the Heart Failure Clinic. 

It's still working: State data for last year at www.FloridaHealthFinder.gov show the hospital’s overall 10.7 percent rate of readmission within two weeks was better than expected for its population, and among patients going through the special clinic, the rate was less than 4 percent. 

But Smith's wish, "that other hospitals and health care systems can emulate our program to achieve the same success,” hasn't been met. As Health News Florida reported June 16, Florida hospitals' average readmission rate for congestive heart failure patients actually went up in 2008, according to state data.

That one-year jump translated into extra admissions for 500 patients and an estimated $12 million in extra charges – about $4 million in payments. 

While some health economists point out that readmissions are a potential source of revenue for hospitals -- which may discourage them from trying to curtail them -- Sarasota Memorial found it actually saved money by preventing recurrent episodes.

The clinic kept patients out of the emergency room, where care is more expensive. Officials say that in its first year, it saved the hospital $250,000 in unpaid bills or insurer payments that didn’t cover costs. A patient seen in the clinic 15 to 20 times cost about $1,200 for the year, compared to $4,280 for one inpatient heart failure admission, the study found.

Readmission rates are a measure of hospital quality, healthcare experts say, since a quick return indicates a patient either left too soon, acquired an infection, or failed to get (or maybe understand) instructions for follow-up at discharge. 

Florida Hospital Association tackled the readmission problem a year ago, forming a voluntary collaborative that includes about 100 hospitals. "We've brought in examples from across the country," said FHA's Kim Streit, who's leading the initiative. "We're revising discharge instructions, making sure patients understand them and get follow-up visits."

Heart failure is one of the most common conditions leading to hospital stays -- in Florida, it trails only childbirth and psychoses – and is more likely to result in readmission than any other ailment, according to an April study in the New England Journal of Medicine.

Sarasota Memorial had a road map on how to proceed, drawn up by the Institute for Healthcare Improvement, American College of Cardiologists and accrediting group the Joint Commission. It includes seven components of care, including ACE inhibitors, beta blockers and anticoagulants when indicated, immunizations and detailed discharge instructions.

Prevention of readmission begins before a heart-failure patient leaves. At Sarasota Memorial, Susan Gaillard, a cardiac-certified nurse, meets with each one and then calls after discharge.

She counsels them on nutrition and exercise, offers them referrals to clinics for sleep apnea (which stresses the heart) and physical therapy, and even a service that delivers low-sodium meals, because sodium causes fluid buildup. She also stresses the importance of taking their medications as prescribed.

“I find a lot of patients who can’t afford their meds and aren’t taking their ACE inhibitor or beta blocker and they’re back in the hospital. That happens a lot in this economy,” she said.

After discharge, Michael Blanchette, an advanced registered nurse practitioner (ARNP), takes over. He's that rare health-care provider who actually wants patients to call him over the weekend. 

In checking patient Billie Peters, 90, one recent Tuesday, Blanchette found her weight was up two pounds, indicating a possible fluid build-up. Peters had noticed the gain over the weekend, but she said she didn’t want to "bother" him when she already had this Tuesday morning appointment.

When you’re a heart- failure patient, a wait of two or three days isn’t trivial. Blanchette chides her gently: “You should have called me.” 

Peters admits she feels full even though she's eating less. “You may still have a little extra fluid on board,” he tells her. He adjusts her dosage of torsemide,a diuretic, and instructs her to call him the next day.

A major part of his job is working patients up to the maximum tolerated dosages under guidelines. For example, carvedilol, the beta blocker sold as Coreg, often has a starting dose of two 3-mg pills daily. Cardiologists normally want to build that to two 25-mg doses, but patients sometimes feel dizzy or faint. Blanchette helps people get to the stronger dose by teaching them how to avoid the side effects.

Sometimes, the most effective way to prevent readmission is the simplest: taking a good history. In one case, a patient who frequently had an upset stomach admitted that she treated it with baking soda in water. That added up to 14,000 mg of sodium a day -- some seven times the recommended daily maximum level.

The cure was simple: an over-the-counter antacid.