A North Carolina study on reducing costly hospital visits cut readmissions by 20 percent among the sickest and poorest patients who are most prone to relying on hospitals for their medical care.
The project, believed to be the largest of its kind in the nation, was conducted by Community Care of North Carolina, a Raleigh-based physician-led program that focuses on helping poor people get health care and avoid hospitalization.
It involved some 800 nurses and social workers doing intensive follow-ups with Medicaid patients. They sometimes shadowed patients for months to make sure they took their medications, kept their doctors appointments and followed all instructions.
The study was written up by three CCNC officials and a UNC-Chapel Hill medicine professor and published in the August issue of Health Affairs, a peer-reviewed policy and research journal based in Bethesda, Md.
More than 21,000 Medicaid patients and 120 North Carolina hospitals were involved in the project, which took place over the course of a year in 99 of the states 100 counties.
What was unique and gratifying was that we were able to replicate this all over the state of North Carolina, said lead author C. Annette DuBard, a senior vice-president of informatics and evaluation at CCNC. Its not specific to any one hospital or any health care system.
Cutting hospital readmissions is seen by many as a major component of controlling runaway health care costs. The nations new health care law, the Patient Protection and Affordable Care Act, includes penalties for hospitals that have excessive readmissions of Medicare patients.
In 2008, CCNC launched a Transitional Care Program, which was designed to cut hospital readmissions for N.C. residents on Medicaid, the federal insurance program for the poor. The organization, which oversees 14 regional community care networks, then undertook a study to measure the effectiveness of the program, looking at a 12-month period from July 2010 to June 2011.
The study demonstrates the effectiveness of intensive follow-up efforts, even with the most challenging patients. But it also shows the challenges ahead for a healthcare approach that requires patients to be closely monitored for months because they have problems taking care of themselves.
About a quarter of Medicaid patients are deemed frequent flyers because of their frequent return visits to hospitals. A number of these patients are homeless, live in shelters, in subsidized housing or share accommodations with family members. About 40 percent of this group has mental health problems, such as schizophrenia, bipolar disorder and chronic depression, DuBard said.
The benefits of early intervention and follow-ups resulted in averting one readmission for every six patients over the course of a year.
Care managers typically talked to high-risk patients in the hospital and followed up with a home visit within 72 hours after discharge, DuBard said. At the patients home, the care manager reviewed the patients prescriptions with the patient and family, making sure the patient kept doctors appointments. In some cases, the manager arranged transportation, even accompanying the patient to the doctors office.
In the absence of this kind of support, the majority of these highest-risk patients will be rehospitalized within three months, DuBard said. We can be confident this is a positive return on investment because so many readmissions were averted.