Hospital readmission prevention programs, such as the one my Accountable Care Organization (ACO) conducts, try to make sure the patient coming home from the hospital fully understands their discharge instructions and removes any roadblocks that would prevent the patient from following those instructions.

With our program one of our nurse Care Coordinators contacts the patient within two days of discharge from the hospital.  They make sure the patient sets up an appointment to see their physician within 1-2 weeks and, most importantly, review the Discharge Instructions the patient was given upon discharge from the hospital.  Basically, there are 4 areas that are covered:

• New Or Worsening Symptoms (NOWS) – The Care Coordinator  asks the patient how they are doing to determine whether they may be feeling worse than when they were in the hospital, either due to worsening of known symptoms or the development of new ones.  In my experience, it never ceases to amaze me how often patients minimize such worsening in their condition and delay contacting their physician.  Directly asking about NOWS helps identify their occurrence and teaches the patient their importance and the need to inform their doctor immediately when they are present.
• Medication Reconciliation – Have there been changes made to the medications the patient was taking before entering the hospital?  The Discharge Instructions that the patient was given before discharge include a list of the medications they should take, but often questions arise once the patient is home.  The Care Coordinator   goes over the discharge medicines with the patient and compares those to the ones the patient was taking before.
• Appointment Adherence – Has the patient made follow-up appointments that have been recommended so they continue to recover?  These could be with specialists seen in the hospital as well as the primary care physician.  In addition, certain testing may have been recommended as well.  These are usually specified in the Discharge Instructions, too.
• Self-Management – Are there things the patient was instructed to do to help their recovery?  If they had surgery, how do they manage the dressings of the surgical site?  If they are a diabetic, do they need to check their blood sugars more frequently than before the hospitalization?  What about their activity level and diet?

In each of these areas, the Care Coordinator makes sure that the patient knows what to do and has no obstacles to carrying out their discharge instructions.  Each day our 22 Care Coordinators reach out to dozens of Medicare beneficiaries who have been discharged from the hospital and, thanks to their efforts, miscommunications are corrected and problems solved on a daily basis to help these patients complete their recuperation at home.

For Your Health – Dr. Bob

As I noted in my first post about exercise and weight loss, most weight loss programs recommend that you work on both sides of the equation, eat fewer calories and burn more off.  Now that we’ve covered some topics about implementing an exercise plan, I wanted to close with some key points to consider as you start to increase your activity:

• Depending on your age and health, you may need to check with your physician before you start an exercise program.
• Plan to gradually increase your activity, especially if you usually don’t exercise.
• As you exercise more, you may notice an increased appetite.  Avoid eating more calories by drinking more water or choosing healthy, low-calorie foods.
• Recommendations for an exercise plan of moderate intensity include cardio exercises 3 to 5 days a week and weight training 2 days a week.
• Moderate intensity is the equivalent of a brisk walk.
• Your age & health may prevent your engaging in too vigorous an exercise program.

I hope these last few posts about exercise and weight loss help you to improve your health and weight.

For Your Health – Dr. Bob

How does all this relate to losing weight? The key point to remember is that the MET level associated with an activity does not directly equate to the number of calories expended. The weight of the individual performing the activity will determine how many calories are expended at a given MET level of activity. So, a person who is 220 lbs. performing the same activity for the same amount of time as someone weighing 110 lbs. will burn twice as many calories as the lighter weight individual. Since it is true that no matter what a person’s weight, to lose 1 pound they need to have a weekly caloric deficit of 3,500 calories, the heavier person will lose the 1 pound faster! This also means that as they continue to lose weight, they will not lose weight as quickly with the same amount of exercise! To continue the rate of weight loss they must increase the amount of energy expended by increasing the number of METs or the duration of the activity. These are important points to bear in mind as you progress towards your weight loss goals.

So from this we can see that a progressive exercise program can help us lose weight throughout the weight loss and maintenance phases. But it can do more than that. Perhaps its greatest value is to prevent chronic medical conditions and help treat many conditions. All great reasons to exercise!

In my next post I’ll review some of the important things to remember about starting your exercise program.

For Your Health – Dr. Bob

So how can a hospital readmission prevention program actually work?  Over the next few posts I’ll look at each of the three components.  In this one I’ll cover Patient Identification & Prioritization.

It’s important to identify patients as close to the time of their discharge from the hospital as possible.  When a physician cares for his patients in the hospital, he clearly knows the discharge date so he can communicate it to the Readmission Prevention Program.  But it has become more and more common that the primary care physician does not see his patient in the hospital when they have been admitted.  In his place, a hospitalist does the inpatient management.  In this situation, how do the physician and Readmission Prevention Program learn about the patient’s hospitalization and discharge?

• The hospitalist could call or e-mail them, but that’s not very efficient.
• Sometimes health insurance companies have Readmission Prevention programs for non-Medicare patients.  They may have a staff person at the leading hospitals to identify patients that are being discharged.
• Alternatively, the health plan may call discharge planners at the hospitals to learn about their health plan members who have been discharged.
• In more and more locations, Health Information Networks (HIN) are being set up to enable one health care provider to share information with another. The patient needs to authorize the HIN to share their information with the health care providers that care for the patient.   But once that’s done, the hospital’s information can be passed to the PCP’s office and the Readmission Prevention Program.
• In our ACO, one of our hospitalists has developed a hand held application that automatically sends e-mails to the PCP and the Care Coordinator with the Readmission Prevention Program when the hospitalist sends a patient home.

As far as Patient Prioritization or Stratification, some of these Readmission Prevention Programs use clinical criteria, such as the reasons for the hospitalization to determine which patients should be contacted after hospital discharge.  Sometimes a scoring system is used, but that depends on someone at the hospital scoring the patient and that score getting transmitted to the Readmission Prevention Program.  A very popular readmission risk scoring tool is the LACE Tool which calculates a score based upon,

• Length of stay – how long the patient was in the hospital.
• Acuity – whether the patient was a hospital inpatient or not.
• Co-morbidities – how many other diseases the patient has.
• Emergency room visits – the number of these visits in the past 6 months.

A score over 10 indicates that the patient has a high likelihood of readmission and should be contacted promptly after he is sent home.

In the next post I’ll talk about what is covered in the Outreach component of these Readmission Prevention Programs.

For Your Health – Dr. Bob

What about the risks of physical activity? As
you might expect, physically active adults do experience a higher rate of leisure
time and sports related injuries than those who are less active. Despite this,
those that engage in moderate intensity aerobic activity have a similar overall
injury rate when compared to the more sedentary people. It seems that the
more active individuals may have more activity related injuries, but the
nonsport and nonleisure injuries are less. The reverse is true for their more
sedentary counterparts. As the intensity level increases, so does the risk of
injuries. The risk of cardiac arrest or heart attack is low for healthy adults
at the moderate intensity levels, but it increases as the intensity level
increases especially for those who exercise infrequently. This underscores the
importance of getting a medical clearance from one’s physician before starting
any exercise program. It is recommended that, “Symptomatic persons or those
with any cardiovascular disease, diabetes, other active chronic disease, or any
medical concern, should consult a physician prior to any substantive increase
in physical activity, particularly vigorous intensity activity.” (1)

In the next post we’ll revisit the relationship between MET levels and weight loss.

For Your Health – Dr. Bob

Footnotes: 

(1) W. L. Haskell, et al. Circulation. 2007;116:1089; originally published online Aug. 1, 2007