| | | DATE: February 17, 2010
CONTACT: Bill Einreinhofer, Communications Director
PHONE: 732-238-5570, ext. 2120
E-MAIL: beinreinhofer@njqio.sdps.org MEDICAL EXPERTS OFFER ADVICE TO SENIORS:
“BE PART OF THE HEALTHCARE TEAM”
When we are sick, we usually think that it is up to our doctors to make us well. But we can play a major role in managing our own health, even if we have a serious illness that requires a hospital stay. Increasingly, health professionals are asking patients to be part of the healthcare team in order to speed recovery and avoid a reoccurrence of what put them in the hospital in the first place.
New Jersey is one of only 14 states chosen to participate in a pilot program to help identify the best ways to ensure coordination as patients move from one care setting to the next, such as hospital to home, to a nursing home, or within a hospital. These movements are referred to as “care transitions.”
“Our goal is to reduce unnecessary hospital readmissions, which can be extremely disruptive to patients and their families,” says Andrew Miller, MD, MPH. Dr. Miller is Co-leader of the New Jersey Care Transitions Project (NJCTP), which is focused on improving care coordination for seniors who are at high risk of re-hospitalization, in particular those diagnosed with heart failure, heart attack (acute myocardial infarction), pneumonia, and chronic obstructive pulmonary disease (COPD). The NJCTP focuses on 44 communities in Burlington and Camden Counties. The 30-day re-hospitalization rate for seniors in these communities is nearly 20% – roughly the national average. For some health conditions, 30-day hospital readmission rates in these communities can be 27% or higher. Many of these readmissions may be preventable.
To address these issues, the NJCTP team is working with a range of health professionals and institutions in the project communities, including Virtua—one of the largest healthcare networks in South Jersey. Other area healthcare providers are participating as well, for a total of 10 hospitals, 11 nursing and rehabilitation centers, six home health agencies, seven hospices, four dialysis centers, and a number of private physician practices. The project team is also reaching out to seniors and their caregivers through community-based organizations and facilities.
Becoming Part of the Care Transitions Team
The National Transitions of Care Coalition offers these tips for seniors being discharged from the hospital: Personal Health Records Help Patients Manage Their Own Care
Another way in which seniors can take more control over their healthcare and help ensure they receive the most appropriate care is by using a personal health record (PHR). A summary of a person’s overall health, the PHR also includes a list of all the medications an individual is taking. The very act of compiling PHRs gives seniors a deeper understanding of their own health, allowing them to make informed decisions. It also helps their doctors and other healthcare providers better coordinate their care.
A number of agencies and organizations, including senior centers, libraries, and local government agencies throughout Burlington and Camden Counties, are distributing PHRs. Some hospitals in the region are now providing PHRs to patients as well, and local groups are distributing PHRs to physician offices and at community events.
According to Susan Goldberg, of Delanco, New Jersey, “It’s very helpful, having everything in one place. That’s why we got about 75 PHRs to distribute to our neighbors. It’s a good place to write down all the questions you want to ask your doctor. As you get older, you sometimes forget things. We’ll jot questions down between office visits. That way, the next time we see the doctor, we’ve got everything organized.”
Scope of the Problem and Possible Solutions
Avoidable or unnecessary re-hospitalizations are too often the result of poor, uncoordinated care transitions. The reasons for these re-hospitalizations are many. According to data from the Centers for Medicare & Medicaid Services (CMS), 37% of Medicare patients who were readmitted to a hospital within 30 days had not seen a physician between their hospital stays. A recent study revealed many gaps between what patients think about their health status and the effort they put into managing a particular health condition. Fifty-seven percent of respondents to this survey indicated that they take one or more medications. Yet only four in 10 say they take their medications as directed.
Among the care transition approaches being piloted by the NJCTP is a method known as the Transitional Care Model (TCM), which is being implemented by Virtua’s home health agencies. Developed at the University of Pennsylvania School of Nursing, the TCM empowers, motivates and educates patients. It has been rigorously tested and is in use in a number of communities across the nation.
In Virtua’s adoption of the TCM, home health agency nurses identify in-hospital patients with chronic health conditions who are at high risk for re-hospitalization. The Transitional Care Nurse visits the patient shortly after discharge and is available for additional visits and by phone. In addition to helping patients and their caregivers understand their post-discharge care instructions, the Transitional Care Nurse also makes sure that patients make and keep the recommended follow-up appointments.
Additional steps have already been taken by providers participating in the NJCTP. These include an increased emphasis on in-hospital discharge planning and medication review; 9 of 10 hospitals are now calling patients after they have gone home to remind them to fill their prescriptions and to schedule and keep follow-up visits with their doctors; and one nursing home has increased the number of registered nurses on duty so that sicker patients can be treated there instead of being transferred to a hospital.
While these efforts by health professionals and facilities are encouraging, patients and their families must also become educated, and feel empowered as part of the healthcare team, if they are to avoid
re-hospitalization.
The NJCTP is a project of Healthcare Quality Strategies, Inc., (HQSI). For more information or to get a PHR, please visit http://www.hqsi.org or call 1-732-238-5570, ext. 2120. East Brunswick-based HQSI, under contract with the Centers for Medicare & Medicaid Services (CMS), is the nonprofit federally designated quality improvement organization (QIO) for New Jersey. We partner with healthcare providers, organizations, communities, and consumers to make healthcare safer, more efficient, more effective, and more accessible. Our methods include assessing opportunities for improvement, sharing best practices, and designing strategies with measurable and sustainable results. Our goal is for consumers to receive high-quality, patient-centered care with the best possible outcomes. | |
