In hospital parlance, they are often called “frequent fliers,” those patients who, for whatever reason, come back to the hospital after discharge more often than others. Typically, these patients face chronic, serious health conditions. But health itself isn’t the only factor that leads some patients to be admitted to the hospital two or more times a month.
Although the hospital is a place for care and healing, staying out of it is the goal for patients dealing with chronic illnesses. Providers aim to help their patients remain healthy enough to manage their conditions at home, under the supervision of primary care physicians and other outpatient providers. But in order to do this more effectively, experts across UF Health have taken a closer look at what contributes to frequent readmissions and what can be done to prevent them.
Last fall, Peter Carek, M.D., UF College of Medicine Department of Community Health and Family Medicine chair, began taking a closer look at readmissions in the hospital. At the time, the readmissions rate was on the high side at 23 percent. He and his team also discovered that just 56 patients accounted for half of readmissions to the family medicine service.
There were several unit-specific projects already underway in the hospital, so Carek’s team took a different approach beginning in December 2014, analyzing the social determinants that affected the patients’ health. This included analyzing patients’ insurance status, their mobility, other illnesses, their transportation and support at home, and more. They established a weekly rounds session where a team of physicians, residents and staff discuss all of the patients who have been readmitted to the hospital. Here, they identify issues that could lead to more readmissions and troubleshoot them.
“A lot of times when patients are being discharged from the hospital, we do things that are important to us as care providers, but we have to think about what is important to them,” Carek said. “For example, we want patients to leave with a medication list, but what might be of more concern to the patient is ‘Can I afford this?’ or ‘How can I get this refilled?’ if they do not have a car.
“By identifying these hot spots, we look for patterns and find things we can help to change.”
Some of the changes the team has initiated included calling patients after discharge to ensure they have scheduled follow-up appointments and that they can get there. The team also collaborated In hospital parlance, they are often called “frequent fliers,” those patients who, for whatever reason, come back to the hospital after discharge more often than others. Typically, these patients face chronic, serious health conditions. But health itself isn’t the only factor that leads some patients to be admitted to the hospital two or more times a month.
Because many patients who lack insurance often come to the emergency room for care, the E.R. faces its own circumstances that UF Health leaders are trying to address. A unique clinic called the Care One Clinic was established at UF Health Shands Hospital in 2012 to help patients who made frequent visits to the emergency room, typically because they lacked insurance or were underinsured.
“We found we had 400 patients using the E.R. as primary care,” said Robert Leverence, M.D., a UF College of Medicine professor of medicine and vice chair for clinical affairs. “These patients were in the ER almost every month.”
As a hospital-based ambulatory clinic, the Care One Clinic, helps coordinate care for patients and gets them routed to specialists to address their health issues. A social worker is also on hand to help with other issues and barriers that affect patients’ health, as well as a pharmacist. Under the leadership of Deepa Borda, M.D., A UF College of Medicine assistant professor of medicine and Care One Clinic medical director, staff members aim to get patients the resources they need and help them “graduate” from the program into a primary care home.
“It’s transitional. We figure out what went wrong; frequently, we are diagnosing barriers to care, addiction, untreated mental health issues, pain, lack of insurance,” Leverence said. “For the patients we have touched, we have reduced their E.R. visits by 14 percent, reduced hospitalizations by 32 percent and reduced hospital costs by 40 percent.”
Another common issue that causes patients to return frequently to the hospital, specifically the E.R., is managing chronic obstructive pulmonary disease. COPD affects millions of people across the United States and is the third leading cause of death, according to the National Institutes of Health. Typically patients end up in the E.R. because they don’t seek care in the early stages of a health crisis.
“They tend to isolate themselves and they don’t want to be a burden,” said Tom Selig, R.R.T., UF Health Shands Hospital Department of Cardiopulmonary Services director. “They wait until they are in dire straits, then they require higher levels of care.”
To address this problem, the Cardiopulmonary Services team began providing education to COPD patients in October 2014. The educators look for barriers to care at home, help patients get scheduled for pulmonary function tests to assess the severity of their disease if they have never had one and follow up with them after they leave the hospital, ensuring they get to their first outpatient doctor’s appointment.
The team also ensures patients have their medications before they leave the hospital, said Lynnette Hildebrandt, R.R.T., UF Health Shands Hospital Department of Cardiopulmonary Services adult respiratory care coordinator.
“We started with select units,” Hildebrandt said. “We are slowly moving it out. Our goal is to have it housewide soon so we can catch all these patients.”
Another way to ensure patients aren’t readmitted is to offer them a variety of services right in their own homes. UF Health Shands’ HomeCare provides home care services, such as nursing, physical therapy, occupational therapy, speech therapy, social work services and home health aides. In addition, HomeCare has implemented a telehealth program.
“We can do a patient’s full set of vitals and check on five to seven disease-specific questions that tell us whether a patient is spiraling days before it happens. We are able to interrupt that readmission or preempt it by getting vitals and talking to physicians,” said Anthony Clarizio, executive director of UF Health Shands HomeCare and ElderCare of Alachua County.
ElderCare of Alachua County, operated by UF Health, provides meals to older adults, limited transportation assistance, personal care and respite services.
In addition, UF Health Shands has funded a study through Alachua County’s Elder Options examining social barriers to care, following patients for up to six months. The goal is to help pinpoint problems and develop solutions to everyday issues related to food, transportation and housing. A health care coach is assigned to each program participant to help coordinate the services being provided in the community.
Throughout UF Health, physicians, staff members and leaders are working more closely together to solve these issues and help patients manage their conditions at home.
“We do a really good job of taking care of patients in the hospital,” Clarizio said. “But there are these other factors out there and we are working on those. We are not used to dealing with these barriers outside the walls of the hospital.”
