In heart failure, a weakly pumping heart allows fluid to build up until patients gasp for breath. Spotting subtle early signs like swelling ankles or creeping weight gain is crucial. But at the Oregon Health & Science University, nurse practitioner Jayne Mitchell spied as patients were told what to watch for as they were discharged — and they barely paid attention.
The new plan: Learn by doing.
Every morning, hospitalized patients weigh themselves in front of a nurse, record the result and get quizzed on what they'd do at home. Gained 2 pounds or more? Call the doctor for fast help. Lots of day-to-day fluctuation? A weekly log can help a doctor tell if a patient is getting worse or skipping medication or having trouble avoiding water-retaining salty food.
Step 2: These patients need a check-up a week after they go home. The hospital makes the appointment with a primary care doctor before they're discharged, to ensure they can get one.
And for some high-risk patients who live too far away to easily track, Mitchell is pilot-testing whether a high-tech option helps them stick with care instructions.
During that first vulnerable month at home, those patients record their morning weight, blood pressure and heart rate on a monitor called the Health Buddy. It automatically sends the information back to Mitchell's team at OHSU and also will flash instructions to the patient if it detects certain risks.
In Sun River, Ore., Richard W. Pasmore's phone rang one morning. Nurses three hours away in Portland saw that his weigh-in was high and adjusted his medications over the phone.
The 67-year-old Pasmore thinks it prevented a return to the hospital: "It kept them totally abreast of everything that was happening with me." And by the end of the month, he says he'd gotten in the habit of his morning heart failure checks.
At the University of Utah, nurse Stephanie Wallace links high-risk patients to the outside care that could keep them from returning. And she's the one whose phone rings when that care falls through.
Consider the single mother who couldn't afford post-hospital blood tests to make sure her blood-thinning medication was working properly, or time off work to get them and didn't speak enough English to seek help. When the woman missed her lab appointment, Wallace pieced together the trouble, helped her enroll in a program for low-income patients — and stressed the importance of sticking with this care.
"It's not that they don't understand why they're sick. They don't grasp the importance of why they need follow-up," Wallace said.
The customized programs reflect the Dartmouth study's findings that there's great geographic variability in hospital readmissions.
In Miami, for example, more than a quarter of Medicare patients with heart failure returned to the hospital within a month in 2010, the latest data available. That's double the readmission rate for those patients in Provo, Utah.
In Dearborn, Mich., the readmission rate for pneumonia was 20 percent, twice that of hospitals in Salt Lake City.
"Every place is different and faces different challenges in terms of improving care after patients are discharged from the hospital," Goodman said.
Care About Your Care: http://www.careaboutyourcare.org
Dartmouth Atlas of Health Care: http://www.dartmouthatlas.org