Reducing avoidable hospitalizations: The low hanging fruit in Healthcare Reform

The debate over health reform has produced some really interesting moments this week.  On the one hand, we have Senator Arlen Spector at a town hall meeting being accused of promoting Socialism and, as one woman put it “… the systematic dismantling of this country,” and on the other we have a picture on the front page of the New York Times showing thousands of uninsured and under-insured people from around Los Angeles waiting in line for days for free medical care from a volunteer organization called Remote Area Medical.

The contrast could not be more profound.  The picture is reminiscent of the bread lines from the Great Depression, just as the accusations of encroaching Socialism hark back to similar accusations hurled at President Franklin Roosevelt in response to his Works Progress Administration and the Civilian Conservation Core.

But between these extremes, there is a middle ground, an opportunity, to effect change that will lower cost and improve the quality of life—if only we can get out of our own way for the common and individual good.

In our last post, we set forth a case that reducing avoidable hospitalizations could result in net savings of $10 billion or more while improving the quality of life for patients and their families.  In this post, we’ll consider some of the issues around the effort to reduce avoidable hospitalizations.

The basic idea is to improve communication with patients and their families once they are discharged from the hospital to help them take better care of themselves outside the hospital setting.  It’s a simple enough idea, but there are a few challenges along the way.

A rose by any other name…

What exactly is it we’re talking about anyway?  What should we call this service or function?  The concept is simple:  Nurses or other care givers communicate with patients and their families to accomplish basic tasks such as:

  • Make sure the patient understands the treatment regimen (medication, life style, testing, follow-up)
  • Help the patient adhere to the treatment regimen
  • Look for early warning signs that the condition is moving in a dangerous direction
  • Engage family and others in the care network to support the patient.

But what do we call it?

I’ve asked this question of various healthcare providers almost all of whom give me a rather disgusted look at my incredible stupidity before giving me a firm, concrete, absolute, obvious and different answer.  So far, I’ve asked about a dozen professionals and received about a dozen different absolute, obvious, only-an-idiot-wouldn’t-know-the-answer anwers.

Nurse Navigator.  That’s what they call it in the cancer center, where the objective is to coordinate care very quickly across many entities towards both diagnosis and treatment.  A quick search of the Internet supports this usage.  The term is common in the cancer world, but we found very little use of “Nurse Navigator” outside of the oncology setting.

Out-patient Support. This came from the anti-coagulation therapy unit of a major cardiovascular center.  Their objective is to help patients adapt to life taking Coumadin (generic name Warfarin), a truly amazing drug that requires careful management of many things to be safe and effective.

Patient-Centered Medical Home. This comes from one of the major insurance companies (as well as a bunch of other sources) that views PCMH as a consumer-friendly term that will engage and empower patients and their families across a broad range of chronic medical conditions, for the purpose of reducing cost and improving quality of life.

Telemedicine. This comes from an independent physician’s group associated with a major hospital.  In this discussion, we were talking mostly about recent on-set diabetes, where the focus is on the proper use of glucometers, insulin therapy as well as life style adjustments.   (This term is a bit problematic for me because “telemedicine” means different things to different people.  For some, it is a means to provide access to primary care for people in remote locations.  For others, it is a means of engaging specialists from around the world in the management of complex cases.)

Interactive Health Communication Applications (IHCA) Needless to say, this came from an academic paper.  You get the idea.

We could go on, but whatever you call it, it is essentially the same thing:  It involves the use of procedures and technology in some combination to improve communication upon discharge to extend the care given to patients in the in-patient setting to the home.

But where’s the proof?

In the last post, I cited the case of Park Nicollet Health in Minnesota which estimates it saved Medicare about $5 million in avoidable hospitalizations with an investment of $750,000 per year.  Unfortunately, that program was scaled way back because it was a losing proposition for the hospital.

A search of the literature shows a mixed bag of results with some reports suggesting big improvements while others show a net increase in cost, implying that the savings from the programs did not even recover their own cost (this is regardless of who pays and who is the beneficiary of the savings).

I had this discussion with one of the leading telemedicine doctors who commented “All this doesn’t prove anything.  It is all just anecdotal.  None of these reflect statistically valid, peer reviewed research.”

Of course he’s right, although there may be better research that neither he nor I have found.  But in the absence of such proper research, from his perspective that means we cannot have confidence in the expected result from implementing such a program.  However, as a vendor, and as a peddler, this is the perfect time to conduct the necessary research to figure out exactly what the best combination is of policies, procedures and technologies to yield the greatest savings.  Indeed, this is the opportunity of a life time.

The time is perfect

We are starting to see various programs undertake this important piece of the healthcare puzzle without waiting for the federal government to re-invent itself.  In May, 2009, the Institute for Healthcare Improvement, with grant support from The Commonwealth Fund, announced a new initiative to reduce avoidable hospitalizations by working across organizational boundaries in three states:  Washington, Michigan and Massachusetts.  The initiative, called “State Action on Avoidable Rehospitalizations (STAAR)” seeks to reduce 30-day rehospitalization rates while increasing patient and family satisfaction with transitions and coordination of care.

It is too early to know how this will roll out, but we are very encouraged and we applaud their leadership.  Indeed, we hope to participate in some of these communities towards this important goal.

As for the federal government, funding for solutions that reduce avoidable hospitalizations appear to be within the scope of the present proposals.  Let’s hope that this is one piece of middle ground that is elevated, not suppressed by the political hyperbole.

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