EXCESSIVE HOSPITAL READMISSION rates contribute to the problem of high costs and fragmented quality in the US health care system. Hospital readmissions are often associated with health service shortcomings such as incomplete discharge orders, inadequate verbal and written continuity of patient care needs, and preventable adverse events such as medication maladministration or omission. The high cost of caring for patients with congestive heart failure (CHF) exceeds $12 billion per year and is primarily due to frequent hospital admissions and readmissions for decompensation.1 Patients with CHF have a higher readmission rate (20%-25%) within the first month of discharge than any other common medical condition.2 Readmission rates for patients with CHF at the James A. Haley Veterans Administration (VA) Medical Centers were 22% to 25% in 2010-2012.3
Congestive heart failure is recognized as the leading cause of hospitalization in the elderly.4 The Agency for Healthcare Research and Quality has acknowledged that readmission rates are often attributed to poor coordination and continuity among treatment providers. Nearly 20% of Medicare discharges are followed by an adverse event within 30 days (usually related to medication mismanagement), leading to readmission.5 Readmission may also be due to poor transitions from hospital to home. For example, the patient and his or her significant others may not have the basic knowledge, skills, or ability to provide necessary follow-up care. This results in a deterioration in patient health well before the post-hospital discharge follow-up appointment.6
An innovative approach to post-hospital care that controls costs while reducing admissions is clearly needed. Home telehealth (HT) monitoring is a capable technology that can be implemented to enhance quality and improve access. This article describes an HT intervention designed to reduce readmissions at a VA hospital located in Central Florida. The quality study focuses on 3 questions when comparing 3 outcomes from a 4-month period with HT to the same 4-month period before HT. The questions are (1) Do veterans have fewer hospitalizations with HT? (2) Does the HT have lower costs? (3) Do veterans report greater satisfaction with HT?
MATERIALS AND METHODS
Home telehealth
Technology
Home telehealth is defined as a 2-way interactive audio/visual communication between a health care provider and a patient posthospitalization.7 An important and easily used component of the HT intervention includes phone care, which is the clinical initiation of phone calls by a registered nurse (RN) using evidence-based disease management protocols (DMPs) to assess patient well-being in a standardized manner. The RN uses a scripted DMP based on the CHF disease process to assist the patient and/or his or her family in reinforcing the post-hospital treatment plan.8 Utilizing HT monitoring, complemented with phone care, is believed to allow a veteran to actively participate in his or her post-hospital treatment plan, thereby resulting in a positive and cost-effective outcome. Home telehealth interventions can be implemented on the same day or shortly after a patient returns home postdischarge.9
Supporting evidence
Several studies demonstrate that HT technology, along with RN case-managed phone care interventions, is associated with preventing or delaying hospital readmissions by limiting hospital utilization to those who need it.1,9,10 Home telehealth interventions simultaneously helped patients recover at home in the immediate posthospitalization time period. Home monitoring via telehealth technology has been shown to reduce health care delivery costs and increase patient and family involvement in skill transfer, confidence, and overall satisfaction.11
Staff roles
The Patient Aligned Care Team (PACT) practice model consists of the primary care provider (MD, DO, advanced registered nurse practitioner, or physician assistant), RN care coordinator, licensed practical nurse, and administrative clerk. The PACT and mental health practitioners approve enrollment into HT for the patient and provide the reason for enrollment, the individualized goals, and targets for the patient to be included in the HT plan of care. It is important for the provider to have a good understanding of the benefits HT can provide to the patient's mental and physical well-being. The PACT manages the patient's overall health care, provides or approves consult for HT, and works in collaboration with the HT team (RNs and tele/video technicians). Specialists, hospitalists, and other care providers also play key roles in enhancing the patient's overall HT experience. Although all enrolled HT veterans must have a primary care or mental health provider, HT staff collaborate as part of the overall coordination of care with all providers involved in the veteran's care. This collaboration ensures the best possible outcome for the veteran patient.
Veterans are often admitted to private sector facilities and are comanaged for discharge purposes. Developing relationships with all members of the veteran's health care team is fundamental to improving outcomes. HT care coordinators work with the on-call hospitalists (MDs) who evaluate the patient when he or she arrives at the hospital. When the veteran is admitted, the HT RN care coordinator begins planning for transition of the veteran from the institution to the home setting.
Patient sample and data extraction
As mentioned earlier, the goal of utilizing HT for discharged patients was decreased cost combined with increased efficiency. The metrics used to measure goal attainment were readmission rates, cost, and veteran satisfaction.
Readmission
One hundred percent medical record review of CHF admissions in the computerized patient record system was performed, using the date range of June-September 2012 compared with the same period of time in 2013 (June-September 2013). The prior admission discharge summary was assessed to ensure a precise review of the patient's hospital course prior to readmission within a 30-day period.
Cost
Individual costs were measured for every veteran. These vary on the basis of clinical presentation/comorbidities. Costs are reported cumulatively, based on the average cost per day, average length of stay, number of 30-day readmissions, and total cost. These metrics were used to determine return on investment for the HT program and to compare metrics with best practice hospitals of similar acuity and size.
Veteran satisfaction
This was monitored and conveyed on a monthly basis via VA standardized customer service tools and reports. Opportunities related to satisfaction with patient care, continuity, and care coordination were identified in the "Voice of the Veteran" surveys, as well as additional communication tools such as patient letters and comment cards. The patients' verbatim comments were acknowledged by the facilities' patient advocate staff and noted in the summary report.
Statistics
This project compared the outcome measures obtained from patients who used telehealth technology and phone care with those who did not elect to use this technology, to determine the effectiveness of these interventions on the readmission rate. Specifically, the author compared the outcome measures of HT versus standard treatment over a 4-month period (June-September) in 2013 to assess the difference in the readmission rate between those patients who used HT with those patients who did not. Since the variables were dichotomous in nature, the [chi]2 and odds ratio tests of significance were used.
RESULTS
On the basis of the data displayed in Table 1, the obtained [chi]2 value of 4.14 (df = 1, P = .042) indicates a significant difference between the outcomes of patients exposed to HT versus those who elected to use standard treatment (no HT). Odds ratio of 1.95 indicates that the use of HT is twice as likely to be successful versus standard treatment.
Patient population
Over the 4-month project period in 2013, a total of 218 male veterans aged 65 to 86 years were admitted with the primary diagnosis of CHF. Of these, 119 (55%) were voluntarily enrolled in HT and 99 (45%) made an informed decision not to enroll in HT. The expressed central theme of those who chose not to use HT was that the use of HT was viewed as a "leash" or intrusion on his or her private life. Those patients who used HT were twice as likely to avoid a hospital readmission for CHF.
Health status
Of those readmitted in 2013, 52% had medication-related issues. These included medications not optimized, incorrect medication reconciliation, and medication nonadherence due to lack of patient motivation. Twenty-three percent were readmitted because of "other causes" such as an infected wound, dementia, gastritis, alcohol intoxication, dehydration, pneumonia, and bronchitis. Veterans in 2012 had similar results, with 53% having medication-related issues and 25% readmitted because of other causes. The veterans in both years had comparable health status, indicating that HT made a difference in readmission rates.
Readmission
In HT, 20 (17%) were readmitted within 30 days. Of those who refused HT, 28 (23%) were readmitted. In the 2012 comparison period, 56 (25%) were readmitted. Sixty percent of these readmissions were due to medication noncompliance. None of these veterans received HT.
Cost
Payment-related policies and the methodology to calculate the hospital readmission payment are based on a myriad of adjustment factors. This is a complex system, given the fact that there is no set cost for an admission due to the primary diagnosis (CHF), which is frequently accompanied by several comorbidities.
Based on the 2013 Veterans Equitable Resource Allocation (VERA) Cost Report (VA Cost Report FYTD 2013, 2013),12 the average cost per day to treat a patient with CHF at the Tampa VA hospital between October 2012 and June 2013 was $3328 (Table 2), with an annual reimbursement of $12 146. The patient with CHF experienced an average length of stay of 3.8 days, which equates to a cost of $12 647 per admission, representing a loss of $501 per episode of care ($12 647 cost, less $12 146 VERA annual payment). It is estimated that the use of HT and phone care interventions can reduce length of stay by 1/2 day per admission (from 3.8 to 3.3 days), resulting in a net positive cash flow of $1164 ($12 146 VERA annual payment, less $10 982 expense).
Satisfaction
Overall satisfaction results for patients with CHF indicate a 25% increase in "outstanding" scores, from an aggregate of 12% June-September 2012 to 15% June-September 2013. Patient comments indicate a central theme of increased autonomy and control in their care as well as a general sense of increased well-being.
DISCUSSION
The evidence-based nursing interventions of HT and phone care considerably reduced the readmission rate by more than 5% over the 4-month period when compared with standard treatment. While this reduction demonstrates a substantial improvement in outcomes, we cannot discount the need for a greater level of pharmacist intervention in discharge teaching, to include strategies and actions that address medication review, reconciliation, and compliance. Addressing these medication management opportunities has the potential to further decrease the readmission rate, overall costs, and increase patient welfare.
Limitations
No random assignment was performed, so the sample interpretation is not generalizable to the overall population. All of the patients were educated and advised of their option to either enroll in the HT program or receive standard care. However, the technical expertise (variability) of the clinician was not assessed as part of the enrollment process. Home telehealth interventions impact on the patient-clinician relationship, and how the dynamics of changing technology effect the patient's participation in care delivery merit further exploration.
Study and interventions
On the basis of a review of 2012-2013 clinical data,3 inefficiencies in patient handoff resulted in fragmented postdischarge management, to include inadequate pharmacy medication reconciliation, patient education, and scheduling coordination for timely follow-up care. Patients may be discharged too early in response to administrative pressures to treat more patients, with the overarching goal of reducing patient backlog and wait times.
Standardizing staff education and communication tools that are used to discuss the benefits of HT compared with standard treatment may provide a more consistent patient experience and increase patient engagement with technology. Approximately 63% of clinical staff members did not meet the continuum of care principles for sustaining quality-based outcomes until management implemented evidence-based CHF DMPs and clinical practice guidelines that complemented medical staff-approved standard operating procedures.
Prestandardization, RNs did not consistently discuss/review the signs/symptoms of CHF to report to the MD, as there was no tool available. Medical record reviews revealed sporadic documentation relative to weight at discharge and gain compared with baseline, shortness of breath/respiratory status, swelling of abdomen and/or lower extremities, energy/performance status, review of follow-up appointments, and symptoms to look for that merit clinician contact/intervention.
RNs in the pilot study currently utilize the DMPs and clinical practice guidelines in a standardized question-based format when contacting the patient to discuss and address symptom management. There is a significant amount of literature that demonstrates that the prescription of self-managed care over the phone is value-added and serves to decrease the need for inpatient care.13-16 Competent adult patients have a right to refuse utilizing HT, especially given other evidence-based options. However, they may be less inclined to do so once they understand the personal benefits of HT related to decreased out-of-pocket costs, travel, and time away from home. The 99 veterans who refused the use of HT either did not have Internet connectivity or did not want to have the HT equipment in their home. Clinicians need to appreciate and validate the patient/family's concerns by addressing them in a manner that enhances their sense of control. Increasingly, new telehealth delivery models are emerging (2-way interaction via smartphones and webcams), and some of these involve dramatic changes in current and future health care transformation brought about by the emerging developments in technology from both the clinical and patient advocacy perspectives.
CONCLUSION
The use of RN-managed HT and phone care technologies prevents or reduces rehospitalizations due to worsening of heart failure. This is due to professional ability to recognize early changes in physiologic and clinical status. Both HT and phone care interventions demonstrate financial savings due to prevention of admissions and associated readmissions to the hospital. The use of HT monitoring initiatives that include follow-up phone care, telephone case management, and patient-focused self-care initiatives improves quality and increases access to care by decreasing the readmission rate. These activities encourage patient autonomy and involvement in their care. In addition, the literature reports that treating patients in their home environments promotes family socialization and community engagement at a lower overall cost and is a central theme in the synthesis of research.
Next steps
While the 218 reviewed electronic medical records represented 100% of the CHF veteran cohort treated in the hospital during the 4-month period, none of the patients were female. This was because only males met the age criteria (>=65 years). Female veterans could be evaluated separately as a group, with interventions tailored to meet gender needs. No change to the DMPs is required since CHF symptoms are not gender specific but may vary/worsen with age.
Group medical appointments will be established through collaboration between pharmacy, nursing, nutrition, and primary care clinicians who utilize a shared medical appointment clinic format. Referral from Primary Care and Cardiology will be initiated by a group clinic consult. The group heart failure clinic (GHFC) will involve the patient attending 4 sessions (1 per month) addressing heart failure overview, medications, lifestyle modifications, diet, and nutrition. The GHFC can address 5 to 8 patients per session along with family members over the 1.5-hour session, with the primary objective of evaluating the impact of a multidisciplinary GHFC on quality of life via use of a cardiomyopathy questionnaire. Secondary objectives will address medication optimization and heart failure-related utilization of hospital resources to include emergency department and primary care visits.
The author recommends that this study on the use of HT to reduce the readmission rate of patients with CHF be replicated in other hospitals in the public and private sectors for a period of at least 1 year to include an analysis of hospital occupancy rate.
REFERENCES