Prevent readmissions with nurse intervention

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Rebecca Hendren for HealthLeaders Media, September 27, 2011

Changing reimbursement incentives are forcing hospitals to focus on preventing readmissions. However, hospitals are stymied when patients fail to take the medications that may keep them out of hospital.

Hospitals routinely have nurses follow up with discharged patients by telephone to monitor their recovery and ask about medications, but even that can be problematic.

"We couldn't tell on the telephone that they were not taking medications," says Linda L. Costa, RN, nurse researcher at The Johns Hopkins Hospital, and assistant professor at Johns Hopkins University School of Nursing.

Adding a home visit from a nurse soon after discharge may provide a beneficial and cost-effective option to keep the most complex patients out of the hospital. A study by an interdisciplinary research team that included two nurses and a pharmacist based at The Johns Hopkins Hospital has shown promise for increasing nursing involvement and helping patients stay on track and out of the hospital.

The study, funded by the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative, took a group of chronically ill patients taking multiple medications and examined whether a simple, early intervention could make a difference in the patients' post-hospital progress and prevent readmissions. The study sent nurses on home visits to discuss medications and solve problems that prevented patients from sticking to their regimens.

Costa, the lead researcher, says the study was launched because nurses were getting calls from patients post discharge to clarify medication orders. Costa says many patients with chronic illnesses are faced with complicated medication regimens that they may not understand, have prescriptions that need to be filled, and are frequently left wondering what to do about prescriptions they had been taking before hospitalization.

"We had to go to the home and see it," Costa says. "It was the only reliable way to really know what medication management is."

By seeing what was going on in the home, the nurses could determine patients' understanding about managing their medications. The study enrolled patients with multiple chronic conditions who had been prescribed four or more medications. Nurses called patients two days after they went home to talk about their medications. They visited them at their home two weeks after leaving the hospital.

"We found that was really the way we could see what was going on as far as medication went," says Costa. "We could look at the bottles, see how they organized medications, filled prescriptions, if they understood what medications they were supposed to be taking."

The nurses identified discrepancies between treatment plans and what patients were doing post-discharge. "Many discrepancies were not intentional," says Costa. "Patients were just confused with the instructions and weren't realizing things."

Each patient in the study was taking about 10 medications on average, so instructions were plentiful and complicated. The nurses were surprised to learn that money was not the barrier to medication adherence. "A lot of patients did have supplemental help because they were lower income," Costa says. "The problems were mostly not understanding or deciding not to take a medication."

The nurses learned that they could work with patients and their families to improve their understanding of their medication regimen, and improve compliance. But they also struggled with patients discontinuing a medication because of side effects.

"It confirmed that if they felt a med was not helping them or made them feel worse they stopped taking it," she says. "How they identified which medication was random. It could be a blood pressure pill or a blood thinner pill. They would select one or two and they would stop taking them if they felt it was affecting them. It wasn't related to particular side effects and it was pretty random as to which one they didn't take."

In some cases the most important nurse intervention was counseling patients to tell their doctors that they were not taking or had problems with particular medications.

Costa ran the pilot study on a small budget and hopes to examine the larger implications of the findings with further research. She says the initial results indicate that the home visits provide a good return on investment.

"If you look at the costs that hospitals will spend to reduce readmissions, the cost of this program is not that significant," Costa says. "We're seeing patients in our local area, so it's feasible to do. There is value to be had and I don't think it's exceedingly costly."