MedicalResearch: What are the key points of your research?
Dr. Hall: Our study was designed to improve care transition from the hospital to home after coronary bypass surgery. The innovative program (Follow Your Heart), implemented at one of our system hospitals, involves sending cardiac surgery nurse practitioners (NPs) who cared for the patients in the hospital to the homes of discharged patients for at least two visits in the first two weeks after discharge. Their goal is to provide continuity of care for patients that they know from the hospital setting and to provide robust medication management, coordinate community services, and be a communications hub for hospital and community providers (primary care, cardiology, and community nurse home visit services). The nurse practitioners interact with community resources to ensure understanding and satisfaction of the patients’ needs prior to hand-off to those resources after two weeks. Our nurse practitioners utilize encrypted smart phones to provide reports to all appropriate providers and can even send pictures of incisions to the surgeon when necessary.
Their efforts resulted in a marked improvement in continuity in patient care and a reduction in 30 day readmission to 3.85% for the intervention group compared to 11.54% for the concurrent usual care group. The Follow Your Heart program was effective across all socio-economic groups. It resulted in a decrease in adverse events such as readmission within 30 days of discharge and provided a substantial cost savings in readmissions averted as well. It is clear that appropriately trained and experienced NPs can provide a transitional care service that is clinically and financially more effective. Hospital based NPs are better equipped to know the patients and their families since they typically spend most of their time at the bedside of the patients in the hospital.
MedicalResearch: What should practicing clinicians and the public take home from your study?
Dr. Hall: Unfortunately, simply having health insurance is not enough to guarantee high quality health care. The problem of fragmentation of health care delivery has to be solved. This program is one important step in that direction. Patients should consider the transitional care opportunities and continuity of care in their locale and seek care in hospitals that appreciate the need for better continuity across all potential care transitions. This new iteration of the doctor-patient relationship is a family affair provided by a team of hospital providers who can effectively deal with patients as individuals, not numbers, and provide them with safe and personal high quality transitional care back to their community.
MedicalResearch: Were any of the findings unexpected?
Dr. Hall: What we have learned is that all the training, instructions, office appointments, prescriptions and reams of sheets with directions and phone numbers provided by a hospital may not be enough if patients do not have adequate support systems in place at home. We found patients sometimes were not obtaining new medications because of cost issues, taking old meds with the mistaken belief that they were just as good and appropriate, failing to see community physicians because of lack of transportation, failing to follow appropriate diets because of lack of understanding or inability to go grocery shopping by themselves, or seeing community providers who did not have adequate communication from hospital providers who took care of the patient. All of these issues and more could easily be solved by our NPs.
MedicalResearch: What further questions remain to be answered and what further research is indicated?
Dr. Hall: This continuity of care with our NPs acting as the communications hub brought community-based providers up to speed and reinforced family responsibility to help the patient make the right health care decisions. The patient was more likely to feel capable of dealing with their health problems at the end of the day because their care was no longer fragmented. The current utility of the program in three system hospitals is helping us learn how to maximize benefits in a very diverse urban population. Further research is being done to expand the concept to other disease processes, such as congestive heart failure, pneumonia, chronic obstructive pulmonary disease, and cardiac arrhythmias, all of which were favorably impacted in our study group. Further research needs to be done with the concept in more rural areas, although use of NPs for home visits has already been incorporated into some rural family practices across the country.