Hospitals

(This post first appeared on the Altarum Health Policy Forum. In a future post I'll tie it into advanced medical homes and other aspects of health reform  that address the needs of  the chronically ill and the elderly.)

Transitions are one of the weak points in the U.S. health care system. Poor coordination and inadequate communication around transitions is particularly pronounced in the care of frail elderly people with multiple chronic diseases -- or maybe an acute illness or injury on top of a whole big bunch of chronic diseases.

Wishard Memorial Hospital in Indianapolis is a large urban safety net hospital serving largely low-income people, many of whom are “dually eligible” for Medicaid and Medicare. Led by geriatrician Dr. Steve Counsell, the hospital has been developing a multi-pronged strategy to improve care and care coordination for this at-risk population. The programs have a smart approach to the shortage of geriatricians, leveraging the skills of geriatricians and geriatric nurse practitioners to support, not supplant, hospitalists (inpatient) and the primary care doctors (outpatient) caring for at-risk patients.

Hospitals can be very hierarchical places, but patient safety and quality improvement is a top down, bottom up, everybody in this together task. The Agency for Healthcare Research and Quality (AHRQ)’s latest Innovations Exchange report spotlights how Chicago’s Northwestern Memorial Hospital. notably improved its patient safety culture. One key step was monthly meetings, including moderated panel discussions, where employees from all levels could hear or talk about adverse events that occurred, learn from them, and think through how to prevent mistakes from happening again.

We don't mean to overwhelm you with hospital readmission posts, but we have long been convinced that they are a barometer for a lot of what's wrong with health care quality and delivery. If you can reduce the very high readmission rates, you would have solved a lot of what's wrong with U.S. health care. So we were interested in this post by Josh Goldstein at his Philly Inquirer Check Up blog about a new initiative in southeastern Pennsylvania involving hospitals, doctors, nurses, nursing homes and Independence Blue Cross. The goal is to reduce admissions by 10 percent in 18 months. In late 2012, under health reform legislation, hospitals with high rates of preventable readmissions for specific conditions will be penalized by Medicare.

The collaborative, known as the Partnership for Patient Care, is looking in particular at the hospital discharge process -- the stage in which frail sick patients often fall between the cracks.

The latest Illinois Hospital Report Card and Consumer Guide to Health Care identifies nine hospitals that fell behind in keeping their hospital acquired infection (HAI) rates at or below the national average in 2009. Judith Graham of The Chicago Tribune followed up with each hospital, to ask them about the infection rates -- what happened, and what are they doing to fix the problem?

Many of the hospitals acknowledged the problem but blamed out of date, inaccurate, or overzealous reporting for the high infection rates. (In fairness, Pennsylvania’s experience shows that when reporting programs get off the ground, the hospitals that are aware, honest about, and working to solve the problem may start out with the highest numbers.) Illinois, along with 27 other states, requires that all hospitals report their rates of hospital acquired infections. Specifically, according to the report card, Illinois hospitals must use the Centers for Disease Control’s National Healthcare Safety Network (NHSN) reporting system to disclose their rates of central line associated bloodstream infections (CLABIs). The safety network also tracks HAIs and other adverse health care associated events.

Several weeks ago I heard two medical teams, one from New York and one from Minnesota, speak about their ongoing efforts to improve outpatient care of patients with congestive heart failure -- more specifically, about how to improve the transition between hospitalization and community-based care, so that the patient doesn’t boomerang right back into the hospital. Avoidable hospitalizations are common. They cost Medicare billions of dollars a year. I once interviewed a patient who literally could not remember how often he had been hospitalized within just a few months.

The new health reform law takes some steps to address the readmission challenge. Starting in 2012, hospitals with particularly high rates of avoidable readmissions will have Medicare payments reduced. That's the stick. On the carrot end, new models of care and payment systems (bundling, medical homes, accountable care) will create new pathways to improve care coordination and disease management. That would make it easier, for instance, to pay for a nurse practitioner to check up on a newly-released heart failure patient.

You read (and we link) all the time about people who end up in the Emergency Dept with serious (and expensive) conditions because they didn't have anywhere else to turn or couldn't afford to get the care they needed earlier. We get used to it. But when you witness it first hand, it becomes powerful. Because you realize it's not only about wasteful spending and inefficient use of resources. It's about people in pain.

I was in the Emory University Emergency Department in Atlanta one night last week, working on a magazine article (which I'll link to but I have to write it first). I wasn't writing about the uninsured and the underinsured on this particular night. And I wasn't writing about medical mysteries. But I came across an uninsured man with a condition that qualifies as a medical mystery. ("It's like a case from "House," one doctor said to another, at shift change.)

We often write about the early adopters in health care. Today, we will tell you about our recent encounter with some change resisters.

The early adopters (see our “What Works” website) are the ahead-of-the-curve crowd, the ones who are improving quality, often at lower cost, despite all the flaws and frustrations and disincentives in the system. They are the ones that allow us to be optimistic about health care reform.

The change resisters? Think Cassandra meets Chicken Little. Robert Garrett of the Dallas Morning News was at the same conference I encountered a few of them, and he reported on their “siege mentality.”

Reminders -- in the form of checklists -- have been on a roll lately. They can be the answer to how to guide an airplane through takeoff, whether your child is ready for kindergarten, patient safety in the UK, and surgery in the US. Checklists are mostly voluntary. Professionals want to improve, so they use a checklist as a reminder tool and are then less likely to forget steps. 

But what happens when the person in question doesn’t want to be reminded?

We get the promise of health IT, in the traditional, first life.

But what about in the SecondLife? It is a whole new world. An intriguing one.

“Dozens of patients, stricken with a debilitating flu, crowd the emergency room. Some slump mutely in chairs. Others wander, moaning or calling out for blankets. Just as the nurses begin triage, part of the hospital goes dark: a black out.”

Fortunately, as Stephanie Simon of the Wall Street Journal reports, “this chaotic scene isn’t real.” But it could be. Which is the rationale for online simulation courses to help doctors and nurses prepare for emergencies. (An aside -- speaking of health care emergencies... if you never read Sheri Fink's Pro-Publica/New York Times Magazine piece on Katrina, which won a Pulitzer this week, read it now.)

We’ve written before about the threat hospital-acquired infections such as MRSA pose to patients, and the burden they add to our health care system. Maryn McKenna's new book, SUPERBUG: The Fatal Menace of MRSA, examines where the deadly infection came from, what it is and where it’s going. Unless we take action now, McKenna explains in her highly-readable book, the future looks pretty grim.  (McKenna has guest blogged for us, and we link to her blog when we need some Super-expertise about Superbugs.)