Decreasing preventable hospital readmissions is at the front line of the Affordable Care Act's (ACA) effort to eliminate unnecessary care and curb Medicare's growing spending. Recently, Medicare identified 2,225 hospitals that will have payments reduced for a year starting on Oct. 1, totaling approximately $227 million in penalties.
As a result of these penalties in addition to providing the proper care that patients deserve when they are discharged, hospitals have been realizing that reducing unnecessary hospital readmissions requires integrated, intelligent technology that empowers patients and families in their own medical care. However, that proper care cannot be possible if patients aren’t following their post-discharge instructions.
This has become a recurrent issue in healthcare; the Centers for Disease Control and Prevention (CDC) reports that 9 out of 10 adults who receive medical advice find it incomprehensible and do not know what to do to take care of themselves, creating a revolving door for healthcare institutions.
To help combat this, in October 2011, the 145-bed Cullman Regional Medical Center (CRMC) in Cullman, Ala., became a beta site for the San Jose, Calif.-based Vocera's Good to Go technology, which records discharge instructions for patients, families, and other care providers to review any time using any device.
Using Good to Go on an Apple iPod device, CRMC caregivers capture “live” audio instructions as well as educational videos, pictures, and documents that are specific to the care of each patient. After hospital discharge, patients can listen to or review their personal care instructions anytime using any phone, mobile device, or computer to clarify follow-up appointments, medication information and more. Family members and other caregivers can also access the recorded instructions using the patient’s unique ID number and login information, says Cheryl Bailey, R.N., chief nursing officer of CRMC.
Bailey says that when the nurse goes in to provide the discharge teaching to the patient, he or she will stop by the charge nurse area and obtain an iPod device. “I keep two or three of these devices in each nursing unit. Nurses will then tell their patients they will record their discharge teaching, so when patients go home they, along with their families, can log in or call and read about their diagnosis. We have an ADT feed that comes from our electronic medical record (EMR) into the solution, and when the nurse logs on with her secure password and pin, she’ll choose the patients name, which is loaded in there. And this is all cloud-based technology, so nothing is residing on the iPod device. It’s all HIPAA-regulated,” Bailey says.
Cheryl Bailey, R.N.
Nurses choose from several templates, which each contain a specific diagnosis. For example, explains Bailey, there will be a template for congestive heart failure (CHF), which will include educational information, such as constructing a low-sodium diet or learning the importance of weighing yourself every day. And this in addition to the nurse’s discharge instructions, so there is a wealth of information, Bailey says. The nurse also has the option to include an e-mail address and cell phone number of a family member, so they get the same secure access. “We utilize this system for a multi-disciplinary approach to help better inform our patients and help them understand if they possibly forget something when they get home. They can log on the internet or can phone in and listen to this information as many times as they need,” Bailey says.
Depending on which unit it is, Bailey says she can see anywhere between a 50 to 80 percent pickup rate of patients getting that information. That information is picked up 60 percent by phone and 40 percent by internet, while patients access it more than once 30 percent of the time. “I can see which patients received the discharged recording, which nurse gave it, if patients have access to the information, and how they accessed it, as well as how often.”
And so far, the results have been there, boasts Bailey. “With 30-day readmissions, we have seen a 15 percent decrease. And we have also seen an increase in patient satisfaction. Two questions on the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey focus on the discharge process. We have seen increases of 62 and 63 percent, respectively, on improvement of satisfaction. Our initial goal was to reduce 30-day readmissions, but patient satisfaction has also increased.”
Bailey says she attributes that to the accountability factor. “The staff knows we randomly listen to these recordings, as we want to make sure they are doing a great job providing the teaching. So they do a better job teaching, knowing we are listening. We have heard patients or family members tell the nurse on the recording, ‘You did a great job with that information. Thank you.’”
And just as importantly, Bailey says she sees an accountability improvement in regards to the patient. “When the nurse says the discharge teaching is being recorded, the patient is more likely to really listen, thinking that if it’s being recorded, it must be important. Rather than focus on the door to go home, the patient is now focusing on the teaching the nurse is giving.”
A COMMUNICATION IMPROVEMENT
Previously, says Bailey, patients weren’t really listening, and that has become a common problem in hospital. “They are just ready to get home, not listening to what we’re saying. Now, we are finding that most patients do comply and go back and re-listen to the instructions. When it’s over, the nurse encourages the patient to log on and ask any follow-up questions, too. Listening to it immediately helps with that comprehension, since we flood patients with information. To be honest, it’s hard to remember everything, and this system really helps with that.”
Communication between medical staff and patients has undoubtedly deteriorated over the years, but an under-talked about aspect of that is simple listening, says Bailey. “We communicate every day, but we often fall flat on our face. When people talk, there are so many other things we’re thinking about. You have the young patient who might have their head elsewhere, and you have the elderly patient who’s sick and just wants to be back home. I think it’s a problem for people of all ages, everywhere. Everyone I talk to about this solution can relate to this—it’s a common problem.”
And with factors like HCAHPS and value-based purchasing hovering over the industry, hospitals are paying real close attention to their readmissions rates, says Bailey. “If hospitals can streamline technology to help, all the better.”
Bailey recalls one instance when a physician called her about a nurse giving a patient certain discharge instructions for when he or she got home. When the patient did that, he or she ended up being readmitted because of that very thing the nurse said to do, causing the physician to repair the damage.
“The physician came to me suggesting to write up the nurse for this mishap,” remembers Bailey. Fortunately, though, because of the recordings given, Bailey was able to compare the nurse’s discharge instructions with the physician’s orders. As it turned out, they were exactly the same, absolving the nurse of all blame, as she just followed the physician’s instructions verbatim. So despite the patient being readmitted, Bailey says “it turned out to be a home run for us. The nurse did her job perfectly and used this technology for its purpose, which is as a backup resource for patients.”