Rush, though, began its own program two years ago because its staff had long suspected that the detailed discharge plans they sent home with patients—covering follow-up doctors’ appointments, prescriptions and health services offered in their communities—were often ignored. The hospital’s rates of readmission for heart attack and pneumonia patients, at about 20 percent, are in line with the national average, according to CMS data. Its readmission rate for heart patients, at 27.8 percent, is slightly higher than the national average of 24.5 percent.
“The frustration was knowing how broken the system was once they went home,” says Madeleine Rooney, a social worker with Rush. “They got home, and they were on their own. That can be scary and overwhelming for people.”
A few calls, a big difference
Under Rush’s Enhanced Discharge Planning Program, hospital social workers begin to make follow-up calls to patients—their average age is 74—within a few days of their discharge. Patients over the age of 65 are referred to the new program if they live alone and take a number of medicines, or have a history of hospitalizations.
Of the 1,248 patients called between March 2007 and April 2009, about 60 percent needed help, according to the program’s records. The cost to Rush? About $60,000 a year, most of which went to pay the salary of one additional social worker. The program calls for social workers to coordinate services available in the community. Often just small pieces of information about services, or help pursuing them, are all that is needed.
Meals and wheels
When the program began, Rush found that many patients had trouble scheduling their follow-up doctors’ appointments or getting transportation to the doctor’s office. Some couldn’t afford to fill all their prescriptions. Others reported delays in visits by a home health care agency or delivery delays of equipment such as wheelchairs or oxygen. One man with special dietary needs was signed up to get home-delivered meals but never got his food. The meals were being delivered to the wrong address.
What the new Rush program does, says Anthony Perry, a geriatrician at Rush, is look beyond medical treatments to see what the patients will need once they have left the hospital’s care. “We only see a piece of that patient, and we sometimes don’t know what all the issues are” when the patient returns home, he says.
Perry says social workers are best equipped to make the follow-up calls, especially to older patients, because they are familiar with the community services and can cut through bureaucratic thickets.
Readmission rates cut by half
Rush doesn’t yet have complete results on whether its program is reducing hospital readmissions. Other studies, however, have shown this kind of out-of-hospital help can cut readmissions by about half. At a University of Pennsylvania hospital, where nurses made home visits and arranged follow-up visits and community services, just 28 percent of patients were back in the hospital within 26 weeks. In the control group, 56 percent had to be readmitted.
This fall, Rush will offer the same sort of assistance before people even leave the hospital. Doctors and social workers will spend more time with the patients and their families or caregivers, going over their medications and discharge instructions and contacting their personal doctors to provide medical updates and arrange appointments. All this attention to the patient is part of a pilot program that involves Rush and 29 other hospitals across the country. It’s called Project BOOST—Better Outcomes for Older adults through Safe Transitions—and is sponsored by the Society of Hospital Medicine.
Fixing a fragmented system
Rooney, the Rush social worker, says better care doesn’t require a lot more people or money. What’s needed are better, more effective ways to use the people, programs and money already there.