Keeping patients from coming back

PHILADELPHIA ― It took more than a week for doctors and nurses to get Pierre Trombert’s congestive heart failure under control and send him home from Thomas Jefferson University Hospital.

But the trickier part, in some ways, was making sure he didn’t come back.

Enter Joanne Heil, professional nudge.

She gave him a scale, then called his home to ask if he was weighing himself. She reminded him about doctor’s appointments, then followed up to see if he went. She pestered him about his diet.

Heil is an advanced-practice pharmacist at Jefferson, but in the changing tide of 21st-century medicine, her charge went well beyond advising the 71-year-old man on his prescriptions.

Hospitals nationwide have been striving to reduce the rate at which their patients are readmitted. Both the federal government and private insurers are tired of picking up the tab. In a 2009 study in the New England Journal of Medicine, researchers estimated that a year’s worth of unplanned hospitalizations cost Medicare alone $17.4 billion.

Congestive heart failure is a particularly big target, as one in four patients end up back in the hospital within 30 days of discharge. Starting in the fall of 2012, the government will cut Medicare reimbursements for hospitals with higher-than-expected 30-day readmission rates for heart failure and two other conditions: heart attack and pneumonia.

Private insurers, meanwhile, are splitting the savings with hospitals, such as those in the University of Pennsylvania health system, that have figured out ways to keep patients from getting sick again.

Such efforts put hospitals on the hook for what happens outside their walls. So now, if Pierre Trombert forgets to take his medicine, is it the hospital’s responsibility?

Heil is game for the challenge, leading an effort that started at Jefferson in November. She and colleagues have managed the cases of several hundred Pierre Tromberts since the program began.

There is just one problem.

Like some others of advancing years, her patient is kind of stubborn.

Trombert is a lively spirit, gaily telling a visitor that he is “71, going on 49.”

A retired interior designer with an abundant thatch of gray hair, he is a native of France who lives in Philadelphia’s Northern Liberties neighborhood and took up fencing at age 69. He does not always like being told what to do.

Months ago, when he started to feel weak and short of breath, he did not seek help.

“My girlfriend screamed at me,” he recalled. “My son screamed at me. I thought it was only a passing thing.”

His legs began to swell, and eventually he couldn’t walk 20 feet without leaning on the wall for support. These are classic signs of congestive heart failure, meaning that the heart muscle is too weak to maintain proper circulation, leading to fluid buildup in the legs.

Trombert finally called his doctor and was admitted to Jefferson in late May. He was given diuretics to reduce the fluid, and gradually he got his strength back, first walking the hospital hallways and then around the block.

In early June, Heil came to his room. Besides the scale, she gave him a pill organizer and a detailed booklet that described what to do each day after he left the hospital. And she told him she would call his home five times over the coming month.

Hospitals have tried a variety of methods for easing patients’ transition to home or a nursing home. Some use patient “navigators,” who can help with making doctor’s appointments, sticking with a diet, or sorting through a complex regimen of drugs. These helpers can be nurses, pharmacists, or social workers.

In a recent issue of Archives of Internal Medicine, two studies found that such interventions are useful at reducing readmissions, though one of them, at Baylor Medical Center Garland, in Texas, found they did little to reduce costs, at least in the short term.

In the April issue of Health Affairs, Penn nursing professor Mary Naylor and colleagues identified nine interventions that were most successful at reducing readmissions. Some of the best practices included home visits, follow-up for months after discharge and daily telephone access for patients with questions.

At Penn’s three hospitals, nurses start working with high-risk inpatients, then continue to do so after discharge ― visiting them at home and even accompanying them to the doctor’s office.

Meanwhile, one start-up company is even planning to offer reward points to patients who take their meds and get prescriptions refilled. MedRewards, based in New York, is in talks with several insurers, chief executive officer Dean Margolis said.

To spur more innovation, the 2010 health care overhaul provided $500 million for training and technical assistance to improve readmission rates and reduce harm in hospital settings.

Philadelphia’s temperature hit 97 degrees June 8, and it was two degrees higher the next day.

When Trombert went in for a follow-up doctor’s appointment that day, his lab results revealed that his kidneys were starting to shut down.

Instead of his body retaining too much fluid, he was not getting enough. Back to the hospital he went.

Heil was convinced that the heat played a role in his dehydration. Trombert, whose home has air-conditioning, maintained that he did not feel hot. But some older people have an impaired sense of thirst, and have trouble recognizing when they need water.

The patient was discharged again after a few more days, and Heil restarted the 30-day clock for her phone calls.

When she called on day two, Trombert said he had no time to talk: “I must go out!”

Heil was frustrated, yet his obstinacy was a good sign. At least he did not feel weak.

On day seven, she had more luck. She made sure he weighed himself at the same time every day. She verified that he had the proper doses for his drugs, and asked about his energy level. He said he felt short of breath when climbing stairs.

“How about your ankles?” the pharmacist asked.

“No!” he cried. “I have beautiful legs now. I can walk around in a tutu. People have to pay 10 bucks to look at them.”

Heil reminded him that Jefferson had a 24-hour pharmacy hotline if he had questions.

Trombert was fortunate in that his heart failure, unlike most, could be alleviated with surgery. His heart muscle was not weak at all. The poor circulation had arisen because the pericardial sac surrounding his heart was stiff with scar tissue, the aftereffect of a bypass surgery years earlier, said David Wiener, his cardiologist.

So once again he went back to the hospital, this time by choice. The operation was performed earlier this month, and he is once again back home, telling Wiener he feels like a new man.

Heil, the pharmacist, has resumed her calls once again, and she is ready to be surprised. In one conversation before the surgery, she was concerned to learn that Trombert was busy plastering walls in his house.

Don’t overdo it, she advised. He agreed.

Ultimately, she realized, there was only so much she could do. Her program seemed to be helping Pierre Trombert, but only as long as he agreed to listen.

By Tom Avril, The Philadelphia Inquirer

(McClatchy-Tribune Information Services)