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Preventing Hospital Readmission
Tracy Lanoza, DNP, APN, FNP discusses which patient populations are at greatest risk of readmission, post acute care management (including working with nursing homes) to prevent patients from being readmitted to the hospital and how receiving quality home health care can help keep a patient from being readmitted to the hospital.
Featured Speaker:
Tracy Lanoza, DNP, APN, FNP
Tracy Lanoza, DNP set out to improve the care delivered in the skilled nursing setting and sub-acute care.Transcription:
Melanie Cole (Host): Hospital readmissions after release are widespread, costly and often avoidable. My guest today is Tracy Lanoza. She’s a nurse practitioner with Lourdes Health System. So Tracy let’s start by the prevalence of hospital readmission. If someone’s been released from the hospital, tell us about what kinds of conditions would typically send them back to the hospital whether they’ve gone home or gone to rehab?
Tracy Lanoza (Guest): So the biggest problematic diagnosis would be heart failure, pneumonia, COPD, and sepsis. Sometimes even acute renal problems will send them back to the hospital. Those are the top problems that we see when the patient has been going home with those diagnoses and they end up back in the hospital, and that’s often at a rate of about 25% of the time if they’ve gone home. If they go to a rehab, it can up between 30% to 40% of the time that they will return to the hospital within the next 30 days.
Host: Why? Why are the rates so high?
Tracy: So a lot of the times it comes because these patients have a lot of things wrong with them. It’s not just that one problem that sends them back to the hospital. When the centers for Medicare and Medicaid measure this, they do a readmission rate and they base it on the basis of heart failure readmission, but they may have had another problem. Say they were in the hospital for heart failure and they go back to the hospital because they develop a fever and pneumonia or they fell and they go back within the 30 days; any reason they go back, it’s called a heart failure readmission. So they could go back home and for any reason they go back for frailty, it’s within that 30 days. These people tend to not recover very well so they have problems, and as you age, especially over the age of 65 and older, they take longer to recovery. They’re not as resilient, so they have issues so it’s harder for them and they need more time and I think – if you think about it 50 years ago people would go in the hospital and they would stay in the hospital for two or three weeks. Now we tend to get people out of the hospital in two or three days. So it’s much easier for them to end up back in the hospital than it was in the past.
Host: So then Tracy, what are some common issues that can arise during transition of the patient, whether it’s to post-acute care and rehab or if they’re going straight home, what’s involved in the planning policies and what kind of providers are involved?
Tracy: So Melanie I’m glad you asked me that. So the biggest problems that we have is that transition time and usually those readmissions happen in the first seven days up to 40% of the time. It’s because that transition home is actually frightening and problems happen at that time. Whether it’s difficulty getting the meds or confusion in the meds or the family gets nervous when the patient first comes home or the patient gets nervous when they first go home. It’s frightening when they first come home and they can be overwhelmed. So that transitioning home is a key point. We try to make sure that those patients get home and to their primary care, so that any questions that they may have or any concerns they maybe have can be addressed because they get home and they become afraid. You just came out of the hospital and you have heart failure or it could be a new diagnosis or an old diagnosis and there’s three new medications and you have questions, and you’re anxious, and you start feeling short of breath, what do you do? You go back to the hospital because you’re afraid and the family’s afraid or you’re just not breathing right. You just go back to the hospital. It’s a safety net for a fear factor and that’s what ends up happening many, many times and there is only one recourse because people are afraid to just stay at home and wonder what’s going to happen because as you age, that fear increases, that looming fear of death is there and they end up there because there’s no other way to make sure that nothing’s going to happen to them.
Host: What an important point that you’re making because you know as people get scared about going home and the family members as well – so when someone is transitioning, what are some of the things that you look for to prevent that readmission when they’re in the home? Do you educate the families? Do you educate the patient themselves? How is medication adherence involved? Speak about how these providers might help with that.
Tracy: There has been a lot of initiatives put in place to try to address that transition home especially with the medications. Number one, there has been blister packing from the pharmacy where the hospital sends the medications to the pharmacy and the medication is then put in blister packs where each day are set up where the patient doesn’t have to think about what they’re taking. They open up blister packs like morning, noon, and night so that there’s no confusion about what the medications have to be. Unfortunately there’s an additional cost attached and some of the patients will decline that type of administration help because if you’re on five, ten medications it could become confusion. Other initiatives would be that they send a home health nurse to the home to make sure that within 24 hours somebody comes to the home to make sure that they reconcile those medications from the hospital and that the family has picked them up from the pharmacy and that they are the correct medications and that there’s an understanding and an education piece that takes place in the home. When you’re in the hospital and somebody says to you these are your medications, do you understand them? That ability to understand and learn when you’re sitting there trying to go home is difficult, but when you’re back home and you’re sitting in your own home and you’ve had time to rest, you have more ability to understand and retain the information. So it’s better to have it given to you once you’re home and you have family members there to help you listen and retain it. So those two things help with the big problem which is medication administration.
Host: The blister packs are a great idea and is the education in the home because you’re right people do pay closer attention when they’re there in their environment. So what’s the importance of follow up care with their primary care provider? Are they supposed to – especially if they have a chronic disease like congestive heart failure, are they supposed to really keep track of their primary care provider and see them often because they run to the emergency room if they think something’s wrong.
Tracy: CMS, which is the center for Medicare and Medicaid has put in an initiative, what’s called transitional care management and they have actually approved an appointment that’s a higher rate and higher billed because they want to encourage patients to see their primary care within three days of going home from the hospital because they know that’s an important visit and it’s a higher billed visit because there’s so much more information to ingest after a hospitalization. That going home visit has so much more information from the testing and any of the results that have come through for that primary care to share with that patient and for everyone to have an understanding. That job for that primary care doctor is to make sure that all of those follow up visits have been scheduled, are in place, and that the patient is going to be guided through whatever has to be done now that they’re in the outpatient setting. So that is key, especially if there’s more care in a chronic care condition like heart failure where they’re going to need to see their cardiologist or if there’s a heart failure clinic they have to attend or if there’s more testing that has to be done, and that is key to make sure that we’re not just treating that readmission for that same problem because unfortunately in our healthcare system, we tend to work towards the sickness instead of the prevention or even healthy care instead of sick care.
Host: Wow Tracy you make so much sense. Now I’m going to ask you a question you might not have expected and it’s strictly your opinion, but how might you see in the future things like telemedicine help with reducing readmissions? Do you see that as a factor for patients?
Tracy: So I have actually done multiple investigations into telemedicine. It was part of my doctorate for heart failure because I have my doctorate in nursing and I did it in heart failure studies and I found that telemedicine does help but it doesn’t actually have the impact that we want unless it’s combined with the actual eyes on the patient. So by that it means that somebody actually has to be able to follow up and see the patient. It’s not enough to just get numbers back on a patient because the patient has to feel like there is somebody that’s caring about them. The actual data itself is not helpful. It actually just generates more visits or unnecessary visits because sometimes we’re treating numbers instead of a patient. The patient needs to feel that somebody cares. So even though there is an impact that can be done from telehealth, it’s better that they have a human component in it. So telemedicine where somebody’s calling and talking to them and they see a human being in that exchange, I think has more impact than just say data that’s being sent back from monitoring. That make sense?
Host: Wow what a great assessment. It does and you know it’s a wonderful explanation too of how telemedicine can work and possibly not be as effective. Wrap it up for us Tracy. You’re very, very good at this. I can tell – I can hear your passion and you know what you’re talking about. Please tell us what you would like the listeners to know about preventing readmission back to the hospital after they’ve been released and what education might be available for the families to help promote that self care and to know before they go to post-acute or rehab or home what you want them to know?
Tracy: I think you said it Melanie. I think that self care is the biggest piece. That we have to stop thinking about our healthcare system as sick care. We have to start taking it upon ourselves to try to be healthy and that if we can focus on putting the money of our healthcare system into keeping our population as healthy as possible and putting our money into nutrition management, diet management, measures that keep our patients moving, we’re going to make the impact that we need. Instead of trying to fix them when they’re sick, keeping them healthy is going to be the way of the future because that’s what’s going to keep them out of the hospital.
Host: Such important information and so well spoken and beautifully put. Thank you so much Tracy for being with us today and sharing your expertise and explaining how we can prevent and reduce some of these hospital readmissions. This is Lourdes Health Talk. For more information, please visit lourdeset.org, that’s lourdesnet.org. This is Melanie Cole. Thanks so much for listening.
Melanie Cole (Host): Hospital readmissions after release are widespread, costly and often avoidable. My guest today is Tracy Lanoza. She’s a nurse practitioner with Lourdes Health System. So Tracy let’s start by the prevalence of hospital readmission. If someone’s been released from the hospital, tell us about what kinds of conditions would typically send them back to the hospital whether they’ve gone home or gone to rehab?
Tracy Lanoza (Guest): So the biggest problematic diagnosis would be heart failure, pneumonia, COPD, and sepsis. Sometimes even acute renal problems will send them back to the hospital. Those are the top problems that we see when the patient has been going home with those diagnoses and they end up back in the hospital, and that’s often at a rate of about 25% of the time if they’ve gone home. If they go to a rehab, it can up between 30% to 40% of the time that they will return to the hospital within the next 30 days.
Host: Why? Why are the rates so high?
Tracy: So a lot of the times it comes because these patients have a lot of things wrong with them. It’s not just that one problem that sends them back to the hospital. When the centers for Medicare and Medicaid measure this, they do a readmission rate and they base it on the basis of heart failure readmission, but they may have had another problem. Say they were in the hospital for heart failure and they go back to the hospital because they develop a fever and pneumonia or they fell and they go back within the 30 days; any reason they go back, it’s called a heart failure readmission. So they could go back home and for any reason they go back for frailty, it’s within that 30 days. These people tend to not recover very well so they have problems, and as you age, especially over the age of 65 and older, they take longer to recovery. They’re not as resilient, so they have issues so it’s harder for them and they need more time and I think – if you think about it 50 years ago people would go in the hospital and they would stay in the hospital for two or three weeks. Now we tend to get people out of the hospital in two or three days. So it’s much easier for them to end up back in the hospital than it was in the past.
Host: So then Tracy, what are some common issues that can arise during transition of the patient, whether it’s to post-acute care and rehab or if they’re going straight home, what’s involved in the planning policies and what kind of providers are involved?
Tracy: So Melanie I’m glad you asked me that. So the biggest problems that we have is that transition time and usually those readmissions happen in the first seven days up to 40% of the time. It’s because that transition home is actually frightening and problems happen at that time. Whether it’s difficulty getting the meds or confusion in the meds or the family gets nervous when the patient first comes home or the patient gets nervous when they first go home. It’s frightening when they first come home and they can be overwhelmed. So that transitioning home is a key point. We try to make sure that those patients get home and to their primary care, so that any questions that they may have or any concerns they maybe have can be addressed because they get home and they become afraid. You just came out of the hospital and you have heart failure or it could be a new diagnosis or an old diagnosis and there’s three new medications and you have questions, and you’re anxious, and you start feeling short of breath, what do you do? You go back to the hospital because you’re afraid and the family’s afraid or you’re just not breathing right. You just go back to the hospital. It’s a safety net for a fear factor and that’s what ends up happening many, many times and there is only one recourse because people are afraid to just stay at home and wonder what’s going to happen because as you age, that fear increases, that looming fear of death is there and they end up there because there’s no other way to make sure that nothing’s going to happen to them.
Host: What an important point that you’re making because you know as people get scared about going home and the family members as well – so when someone is transitioning, what are some of the things that you look for to prevent that readmission when they’re in the home? Do you educate the families? Do you educate the patient themselves? How is medication adherence involved? Speak about how these providers might help with that.
Tracy: There has been a lot of initiatives put in place to try to address that transition home especially with the medications. Number one, there has been blister packing from the pharmacy where the hospital sends the medications to the pharmacy and the medication is then put in blister packs where each day are set up where the patient doesn’t have to think about what they’re taking. They open up blister packs like morning, noon, and night so that there’s no confusion about what the medications have to be. Unfortunately there’s an additional cost attached and some of the patients will decline that type of administration help because if you’re on five, ten medications it could become confusion. Other initiatives would be that they send a home health nurse to the home to make sure that within 24 hours somebody comes to the home to make sure that they reconcile those medications from the hospital and that the family has picked them up from the pharmacy and that they are the correct medications and that there’s an understanding and an education piece that takes place in the home. When you’re in the hospital and somebody says to you these are your medications, do you understand them? That ability to understand and learn when you’re sitting there trying to go home is difficult, but when you’re back home and you’re sitting in your own home and you’ve had time to rest, you have more ability to understand and retain the information. So it’s better to have it given to you once you’re home and you have family members there to help you listen and retain it. So those two things help with the big problem which is medication administration.
Host: The blister packs are a great idea and is the education in the home because you’re right people do pay closer attention when they’re there in their environment. So what’s the importance of follow up care with their primary care provider? Are they supposed to – especially if they have a chronic disease like congestive heart failure, are they supposed to really keep track of their primary care provider and see them often because they run to the emergency room if they think something’s wrong.
Tracy: CMS, which is the center for Medicare and Medicaid has put in an initiative, what’s called transitional care management and they have actually approved an appointment that’s a higher rate and higher billed because they want to encourage patients to see their primary care within three days of going home from the hospital because they know that’s an important visit and it’s a higher billed visit because there’s so much more information to ingest after a hospitalization. That going home visit has so much more information from the testing and any of the results that have come through for that primary care to share with that patient and for everyone to have an understanding. That job for that primary care doctor is to make sure that all of those follow up visits have been scheduled, are in place, and that the patient is going to be guided through whatever has to be done now that they’re in the outpatient setting. So that is key, especially if there’s more care in a chronic care condition like heart failure where they’re going to need to see their cardiologist or if there’s a heart failure clinic they have to attend or if there’s more testing that has to be done, and that is key to make sure that we’re not just treating that readmission for that same problem because unfortunately in our healthcare system, we tend to work towards the sickness instead of the prevention or even healthy care instead of sick care.
Host: Wow Tracy you make so much sense. Now I’m going to ask you a question you might not have expected and it’s strictly your opinion, but how might you see in the future things like telemedicine help with reducing readmissions? Do you see that as a factor for patients?
Tracy: So I have actually done multiple investigations into telemedicine. It was part of my doctorate for heart failure because I have my doctorate in nursing and I did it in heart failure studies and I found that telemedicine does help but it doesn’t actually have the impact that we want unless it’s combined with the actual eyes on the patient. So by that it means that somebody actually has to be able to follow up and see the patient. It’s not enough to just get numbers back on a patient because the patient has to feel like there is somebody that’s caring about them. The actual data itself is not helpful. It actually just generates more visits or unnecessary visits because sometimes we’re treating numbers instead of a patient. The patient needs to feel that somebody cares. So even though there is an impact that can be done from telehealth, it’s better that they have a human component in it. So telemedicine where somebody’s calling and talking to them and they see a human being in that exchange, I think has more impact than just say data that’s being sent back from monitoring. That make sense?
Host: Wow what a great assessment. It does and you know it’s a wonderful explanation too of how telemedicine can work and possibly not be as effective. Wrap it up for us Tracy. You’re very, very good at this. I can tell – I can hear your passion and you know what you’re talking about. Please tell us what you would like the listeners to know about preventing readmission back to the hospital after they’ve been released and what education might be available for the families to help promote that self care and to know before they go to post-acute or rehab or home what you want them to know?
Tracy: I think you said it Melanie. I think that self care is the biggest piece. That we have to stop thinking about our healthcare system as sick care. We have to start taking it upon ourselves to try to be healthy and that if we can focus on putting the money of our healthcare system into keeping our population as healthy as possible and putting our money into nutrition management, diet management, measures that keep our patients moving, we’re going to make the impact that we need. Instead of trying to fix them when they’re sick, keeping them healthy is going to be the way of the future because that’s what’s going to keep them out of the hospital.
Host: Such important information and so well spoken and beautifully put. Thank you so much Tracy for being with us today and sharing your expertise and explaining how we can prevent and reduce some of these hospital readmissions. This is Lourdes Health Talk. For more information, please visit lourdeset.org, that’s lourdesnet.org. This is Melanie Cole. Thanks so much for listening.
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