Eric Weil, MD, and Colleen Macauley, RN, BSN | hospital discharge
Eric Weil, MD, and Colleen Macauley, RN, BSN

After a heart attack and surgery to keep clogged arteries open with a stent, a 57-year-old man is discharged from Massachusetts General Hospital with prescriptions for medications to prevent another heart attack. Three days later, he still hadn’t filled them. A woman advised to take Lasix to control high blood pressure was taking only half the dose prescribed after she left the hospital.

Had Mass General’s Colleen Macauley, RN, BSN, not been making follow-up calls and discovered these medication issues, these patients could have ended up back in the hospital. Ms. Macauley is part of a post-discharge initiative at Mass General, an effort to coordinate and improve the transition from inpatient to outpatient care, and ultimately prevent patients from ending up back in the hospital shortly after discharge.

“Post-discharge follow-up reinforces instructions patients receive when they leave the hospital,” explains Sally Iles, RN, associate vice president for Medicine and Primary Care Services.

“Because so much happens at discharge, patients frequently miss or misunderstand the plan. We’ve discovered just how important it is to connect with them shortly after they are home.”

Focusing on Vulnerable Medicare Patients

Eric Weil, MD, who is associate chief for clinical affairs in Mass General’s General Medicine Unit and an internist at MGH Revere Healthcare Center, designed the pilot project in 2011. Although all MGH primary care practices have nurses who call patients after a discharge, the idea is that one person whose job is solely to make these calls can do it more effectively and efficiently. Ms. Macauley is responsible for calls to patients from four of Mass General’s 20 affiliated primary care practices: MGH Back Bay, MGH Revere Adult Medicine, MGH Revere Broadway and the Bulfinch Medical Group.

Dr. Weil based the pilot on lessons learned from the six-year Medicare demonstration project that he directed at Mass General. Nationwide, roughly one in five Medicare patients return to the hospital within 30 days after discharge. This costs Medicare an estimated $17.5 billion. The federal government has begun fining hospitals it deems to have too many Medicare patients readmitted within 30 days of discharge.

The Mass General demonstration project, known as the Care Management Program, was funded by the U.S. Centers for Medicare and Medicaid and focused on the most vulnerable Medicare patients, those with chronic diseases and multiple health problems. These patients were assigned nurse care coordinators, who made sure nothing fell through the cracks — medication discrepancies, follow-up appointments and community services, if needed. The project succeeded in reducing overall admissions by 20 percent. Emergency visits fell by 13 percent. The demonstration program itself ended in 2012, but Mass General has expanded the effort to other groups of patients, not just those on Medicare.

“Transition care is important for all patients, not only those whose care is very complicated,” Dr. Weil explains. “Any patient leaving the hospital is at a vulnerable time in their lives. Discharge often occurs in a chaotic environment and people don’t hear, remember or understand everything they are told to do.”

“I do a lot of teaching,” explains Ms. Macauley, whose calls last from 15 minutes to an hour. “When patients get home and settled, they often have many questions, but their first doctor’s appointment may not be for a week or so. More often than not, they wouldn’t otherwise call in with questions.”

Comprehensive Care Through Collaboration

One woman she called reported that she had red rashes all over her body, but thought they were related to a new medication prescribed after her hospital discharge. She was adamant that she didn’t need to be seen by her physician. Ms. Macauley, as is standard, reported this to the patient’s nurse contact in the practice, so they could arrange a same-day urgent care appointment. It turned out the patient had full-blown Lyme’s disease.

“If we want to care for a patient comprehensively, we have to work collaboratively,” says Ms. Macauley, who has been a nurse for more than 20 years. She has a nurse contact at each of the four practices. Those nurses worked together with her to develop a template of standard questions to ask during the calls. The questions cover such clinical information as the patients’ current condition, medications they are taking, and tests or labs that require follow-up.

Post-discharge follow-up calls began in July 2009 and the pilot Ms. Macauley now works on has been in operation since November 2011. “Trends in readmission rates for 2010 and 2011 are promising,” Ms. Iles says. “We’ve slowed the rate at which readmissions were increasing.”

Dr. Weil explains that there are other signs that post-discharge follow-up is having an impact. “We have lots of anecdotal information about improved patient care and prevention of bad outcomes,” he says. “Our data also show that having one person do the post-discharge follow-up work is extremely productive and translates into time saved by each of our practices.”

When calling patients after their hospital discharge, Ms. Macauley lets them know that she is calling on behalf of their MGH primary care doctor. They are reassured to know that their personal doctor is coordinating all of their care. “They are also grateful to have someone to talk to about their experience at MGH,” she says.

Recognizing Patterns of Problems

One man she spoke with was in his 90s and lived alone outside of Boston. Ms. Macauley ascertained that because of extreme pain in his legs due to shingles, he was at risk of falling. He was very appreciative after she communicated with his practice and they arranged a visiting nurse. Her role requires her to function as part of the primary care team.

Because Ms. Macauley’s attention is devoted solely to these calls, she can recognize patterns of problems and find solutions that will ultimately become a “best practice” for other nurses in Mass General primary care practices who are making these calls. For example, it became clear to her that she needed to be more exact in the questions she asked patients who are on warfarin (Coumadin), a drug taken to prevent blood clots. It can have dangerous side effects like bleeding. She now routinely asks about bleeding and the color of the pill they are taking to make sure the dosage matches what they are prescribed.

Ms. Macauley has also identified a patient population that needs more comprehensive follow-up: those with substance abuse problems. She reports that a significant number of the patients she encounters have problems related to substance abuse. She is working with addiction specialists at MGH to develop a discharge packet tailored to such patients, including information on health effects, medication interactions, a Motivation to Change self-assessment and information about rehabilitation programs and community resources.

Dr. Weil thinks the jury is still out about whether the benefits of having a centralized person like Ms. Macauley making calls outweigh those of entrusting the follow-ups to someone at the practice who knows the patient and treats them regularly. Either way, he adds, Mass General’s efforts so far show there are viable ways to better control readmissions. “I think there is a sizable number that are clearly preventable,” Dr. Weil says.