Valley Hospital brings back house calls in an effort to reduce readmission of heart patients

The Valley Hospital in Ridgewood has started making house calls to patients who have been discharged from the hospital — to make sure they’re having a smooth transition to their home environment, and don’t suffer a relapse that lands them back in a hospital bed.

Valley’s Mobile Integrated Health Program uses a team approach. The pilot program that began in August has hospital paramedics, accompanied by a critical care nurse and an EMT, making home visits to recently discharged patients with cardiopulmonary disease. The paramedics assess the patients’ home environment, making sure there are no hazards that could lead to a fall. And if the patients are in distress, the nurse can provide IV medication or a breathing treatment. Finally, the team makes sure the patients have the right medications, as well as the proper food in their kitchen if they’re on a restricted diet.

Like hospitals nationwide, Valley is striving to reduce patient readmissions. Medicare now imposes financial penalties on hospitals if their 30-day readmission rate is excessive, and making sure patients thrive at home after they leave the hospital is an important benchmark of health care quality.

Lafe Bush, Valley's director of emergency services, oversees the paramedics making the home visits. He said sending paramedics to help stabilize patients after discharge from the hospital is common in the Midwest. He said Valley may be the first New Jersey hospital to pilot this approach.

Robin Giordano, supervisor of Valley's heart failure program, said, “This population of chronically ill patients, who are generally elderly, have frequent bounce-backs to the hospital —which we know is not good for them.”

Bush said the home visit occurs within 24 hours of the patient’s discharge from Valley: “We evaluate them at home, and check to see if they are in any distress.”

If they are, the critical care nurse on the team can contact the doctor and start treating the patient. If necessary, the paramedics will transport the patient back to the Valley ER.

But if the patient is doing fine, the visit will focus more on education: surveying the home environment for safety hazards, installing grab bars in the shower, reviewing medication instructions, reminding the patient to make a doctor’s appointment. The team also will evaluate whether the patient is a candidate for visiting nurse care, which is provided by Valley Home Care, or might need a home health aide for bathing and meal preparation.

“This is a one-time home visit to make sure you’re on the right path and guide you to the next step,” Bush said. “It is part of the continuum of care.”

Giordano said the program addresses the major issues that send patients back to the hospital:
“Generally, patents don’t come back because of some illness; it is because some basic needs are not being met.”
Medication issues, for example: The patient may not understand the meds, or hasn’t gotten a new prescription filled and is still taking the meds from before they went into the hospital.

“Another thing that brings people back is their home environment not being safe; patients will come back within days of going home because they’ve fallen,” Giordano said.

Or the patients may be readmitted because their condition has taken a turn for the worse.
Giordano said the team will ask, “Who is the care person at home: is it your son or your daughter or your neighbor?” For those who have no support system, the team may get a social worker on the case.

Bush said the program is starting with heart failure and pulmonary disease patients and, eventually, “We want to expand this to everybody, regardless of their diagnosis.”

Right now, Valley is covering the entire cost of the home visits, but Giordano predicted that eventually this will be covered by Medicare and commercial insurance

This is the latest in a number of programs by Valley to reduce readmissions. And Giordano said they are having an impact: Valley now has a 30-day readmission rate of 22.3 percent, down from 26.4 percent 18 months ago.

Peter Southway, 80, of Wyckoff, got one of the first Valley home visits in August.

“It was excellent — they took my blood pressure and did an EKG and said my heart was fine,” Southway said. “They made me feel very comfortable. After you get home, they check to make sure you’re OK. I think it’s a good idea.”

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More U.S. hospitals to receive 30-day readmission penalties

A total of 2,610 hospitals in the U.S. will see their Medicare payments docked in fiscal 2015 for having excessive numbers of patients return to the hospital within 30 days of discharge.

The CMS posted its third round of readmission penalties, which will affect Medicare reimbursements from Oct. 1, 2014, through Sept. 30, 2015.

The tally of hospitals subject to fines next year is about 400 more than in the first two years of the program (2,225 in fiscal 2014 and 2,217 in fiscal 2013), according to data obtained from Kaiser Health News.

Of the ones facing the newest round of penalties, 39 received the maximum fine of 3%. Twelve of them had zero penalties in the first two years of the program, and nine of them (about 23%) are in Kentucky.

Because the maximum penalty is higher in 2015, comparing changes from 2014 to 2015 requires measuring the penalty as a percentage of the largest possible reduction. By this measure, 13 hospitals improved their standing by more than 50%, but 75 hospitals did at least 50% worse.

Only 769 hospitals will not see a Medicare pay cut because of readmissions. Among those for which data is available from all three years, 571 have never been penalized.

The Hospital Readmissions Reduction Program is a quality-improvement effort created as part of the Patient Protection and Affordable Care Act. Hospitals with excess numbers of patients returning within 30-days of discharge following treatment for heart attack, heart failure and pneumonia began having Medicare payments docked up to 1% in fiscal 2013. That number increased to 2% in fiscal 2014.

In fiscal 2015, the fine increased to 3%, and two additional measures were added for readmissions rates following treatment for chronic obstructive pulmonary disease (COPD) and total hip and total knee replacements, which may account for the increased number of fines.

Policy experts are increasingly raising concerns that hospitals in poor communities are unfairly punished by the program after observing that safety net providers were more likely to receive penalties in the first two years of the program.

“We expect this trend will continue,” Akin Demehin, senior associate director of policy for the American Hospital Association, said in a statement. The CMS, he said, has “raised the financial stakes” but continues to resist requests to adjust for socioeconomic factors.

source (list of hospitals and penalties at website)

Readmission rate continues to drop for Medicare beneficiaries

HHS has a long way to go toward meeting its end-of-2014 patient-safety goals, but newly released data appear to show encouraging progress on preventing repeat trips to the hospital and curbing adverse events, such as falls and infections.

The all-cause 30-day readmission rate for Medicare beneficiaries continued its downward trend, dropping to 17.5% through the end of 2013, according to an HHS report released Wednesday. That's down from the most recent numbers, published in December on the CMS' blog, showing a readmission rate hovering just under 18% during the first eight months of 2013. The Medicare all-cause readmission rates had held stubbornly around the 19% mark from 2007 to 2011, before dipping to 18.5% in 2012.

In a news release, HHS said the two-year drop amounted to 150,000 fewer preventable readmissions.

HHS also touted a 9% decrease in preventable harms since 2010—from 145 hospital-acquired conditions per 1,000 discharges to 132 HACs per 1,000 discharges—a reduction it said accounts for 15,000 fewer deaths and $4.1 billion in savings.

Federal officials credited the gains in part to its Partnership for Patients initiative, a $1 billion safety initiative launched in 2011 with funds from the health reform law that aims to reduce readmissions by 20% and hospital-acquired conditions by 40%, both by the end of this year.

The six-page report drew data from a number of sources, including the Agency for Healthcare Research and Quality, the Center for Disease Control and Prevention's National Healthcare Safety Network, and the Partnership for Patients' hospital engagement networks.

The Partnership for Patients has drawn sharp criticism from some leaders in the patient-safety field, who argue the lack of standardized measures make HEN data unreliable. 

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Readmissions Penalties By State: Year Two

Armed With Bigger Fines, Medicare To Punish 2,225 Hospitals For Excess Readmissions - (August 2013) - Medicare will levy $227 million in fines against hospitals in every state but one for the second round of the government’s campaign to reduce the number of patients readmitted within a month, according to federal records released Friday.

Medicare evaluated the readmission rates of 3,379 hospitals in determining the second year of penalties in the Hospital Readmissions Reduction Program. Medicare will apply the penalties to all its payments for patient stays between Oct. 1, 2013, and Sept. 30, 2014. 

click for access to information by state and by hospital