Catching patients on the rebound

While working as an inpatient case manager, Tami Woodrum, RN, often saw the need for a way to help ease the transition of patients from hospital stays back to their homes and primary care providers.

Greenville Health System (now Prisma Health) wasn’t alone. Hospitals across the nation face the daily challenge of ensuring patients return home successfully from an inpatient stay. The National Institutes of Health reports roughly 20 percent of recently discharged, older patients are readmitted within 30 days of discharge.

The Care Coordination Institute (CCI), a Greenville Health System affiliate that centers on anticipating medical needs through data analysis, recognized a problem in need of a solution while reviewing health care data tracked from a provider network in which GHS participates.

Leaders of CCI began meeting with GHS representatives in late 2015 to discuss their findings and consider how they might address the issue. Together, they set the goal of creating a program focused on reducing readmissions for patients who are at high risk for being readmitted or needing emergency department services. GHS' Transitional Care Program (TCP), the first of its kind in the state, launched in December 2017.

TCP, which has served more than 180 participants to date, closely follows patients during the critical month after a hospital discharge, when they are most at risk for readmissions. Misuse of medications and hospital-related complications often play a role in early readmissions.

“The idea of transitional care programs is becoming more popular nationwide,” noted Thad Tuten, MD, GHS hospitalist and TCP co-director. “But GHS saw a potential benefit and was willing to make the investment needed to innovate early on.”

Thad Tuten, MD, reviews the plan of care with patient Mike Dollfus.

So-called “bridging” strategies similar to the TCP model appear to be the most successful approach to good outcomes for many health systems. Bridging involves a series of interventions aimed at lessening the challenges patients face in taking the information they receive while in the hospital and putting that into effective use at home.

For 72-year-old, twice-retired Greenville resident Charles “Mike” Dollfus, TCP was a revelation. “What a surprise it was for me,” said Dollfus, who entered the program on Sept. 14. “They don’t just cut you loose after a hospital stay; they give you all the time you need.”

Dollfus had been admitted to Greenville Memorial Hospital in early September after being diagnosed with community acquired bacterial pneumonia and running a temperature of 104. When offered TCP before discharge, he was at first leery, but decided to participate after learning he could drop out of the program at any time.

TCP is a voluntary program created to fill the gap between a patient’s discharge and first follow-up visit with the primary care provider. Providers are notified when a patient elects to enter the program. Upon completion of the program, the patient’s doctor receives detailed reports about progress.

“By meeting with patients like Mr. Dollfus in the critical time period immediately after discharge,” said Stanley Coleman, MD, with Travelers Rest Family Medicine, “TCP helps enhance our care.”

Providers affiliated with GHS have ongoing access to the patient’s medical information through the GHS electronic health record. For providers outside GHS, medical information is regularly shared via fax.

Hospitalized patients first receive information about the program from nursing staff. Those who wish to participate are contacted after discharge by Woodrum, who walks them through the program and sets up their first appointment. Woodrum stays in touch with patients and their families throughout the process and works with patients and physicians to see that appointments are set up and kept and to identify any additional needs to be addressed.

“It’s amazing to see people during their initial appointment with the program,” commented Woodrum, who now works as ambulatory care manager for TCP. “A lot of hospital information causes them to be confused about what they are to be doing. But understanding that information is the key to good outcomes for patients.”

Putting patients in touch with a team of specialists devoted to improving outcomes is the heart of the program. Specialists include hospitalist physicians, a dedicated pharmacist, dietitian, social worker, care manager and financial counselor.

The team approach is one key to the program’s success because it addresses every aspect of the patient’s health needs and provides services (such as IV fluids, IV steroids and nebulizers) not usually found in the primary care setting. The program also builds in more time for visits than is allotted in a typical follow-up appointment.

“Patients in the program love that we have time to spend with them,” observed Dr. Tuten. “That’s true not only during the office visits, but also during the contacts between their weekly appointments.”

Adverse drug events (ADE) are a major cause of readmissions, and account for the hospitalization of nearly 100,000 patients per year. TCP addresses this concern through the dedicated pharmacist team member, who reviews the patient’s drug plan and spends the time needed to ensure the patient understands which medications are prescribed, along with how and when to safely take those.

“Some patients pointed out they didn’t understand their medication instructions,” reported Josh Almaroad, CPA, TCP manager. “Because the dedicated pharmacist spends the time needed, patients walk away confident in knowing what they should and shouldn’t take.”

Patients are evaluated for the program using a scoring system called LACE. LACE looks at the length of stay in the hospital, how much care the patient likely will need (acuity of admission), whether the patient has multiple health issues (comorbidities) and the number of emergency department visits by the patient within the previous six months.

During the program, patients are seen once each week for four weeks. The first appointment is scheduled within two to five days of discharge. Patients ask questions, and receive counseling and education regarding their diagnosis and medications. They also receive information and assistance regarding diet and nutrition, connecting with any needed community resources, and financial counseling to help with affording their medications.

For Dollfus, the bond that develops between the patient and the team is what makes the program special. “You get close to these people and they get close to you,” he shared. “I can’t tell you how impressed I was with the program and how much they helped me.”

“To see the improvements in them at the end of the program,” remarked Woodrum, “tells me we are doing the things that need to be done.”

Family members and other caregivers also play an important role in good outcomes. Woodrum considers it highly important that the patient has someone involved who understands what is going on. For patients without family, program specialists go the extra mile to ensure all needs are met.

When patients finish the program, they are assigned an ambulatory care manager who continues follow up. The manager works to reinforce program information and make sure any barriers to care are moving toward resolution.

Dollfus was discharged from TCP on Oct. 2, but the team continues to stay in touch and monitor his progress. ”Even though I am finished with the program, if I need them, I call Tami Woodrum and she takes care of it,” he said.

GHS leadership and TCP staff are encouraged by the results they are seeing in the early days of the program and anticipate confirmation of the program’s effectiveness when they begin reviewing data later this year.

For Dollfus, there is no question about the program’s effectiveness. Because TCP addresses all medical issues for patients, he was treated for more than just the infection for which he was hospitalized.

“The care I received was not just for the pneumonia,” he summarized. “Now I’m walking farther, my balance is better, and I’m not falling like before. They give you self-confidence that you just can’t put a price tag on.”

Update: In February, Mr. Dollfus returned to the hospital for reasons unrelated to his earlier visit. After a brief stay, he returned home—and enrolled again in TCP.