RN Researching Communication Tool that could Reduce Readmissions

A nurse researcher is exploring whether or not hospital readmissions among elderly patients in assisted living could be reduced through improved communications between medical providers, the Lubbock Avalanche Journal reports.

Alyce Ashcraft, associate dean for research at the Texas Tech University School of Nursing, is conducting a study with a customized Situation, Background, Assessment and Recommendation (SBAR) tool that gathers additional patient information and forces more transparency in nurse-provider communication.

Over a 16 week-period, Ashcraft instructed nurses at a retirement community in Lubbock, Texas, to document all of their consultations with health care providers, including phone and fax communications, on SBAR forms. The intent is to eliminate repeats tests and create more efficient care by recording when nurses contact other providers about a patient’s condition, and the actions taken. The data is still be collected and analyzed.

“I don’t care if you’re here in long-term care, or the hospital or home health, it doesn’t matter,” Ashcraft, told the Journal. “Communicating the right information and getting the residents’, the patients’, the clients’ story right so that decisions can be made that are good for them; [t]hat’s what we hope to do.”

INQRI researchers at Marquette University, led by Marianne Weiss and Olga Yakusheva, studied what hospital-based nurses do to influence outcomes, including readmission rates, after a patient is discharged from a hospital. Specifically, they identified the contributions that nursing staff make to the quality of discharge teaching and the impact of that teaching on patient outcomes, readiness and readmission rates of patients who are discharged home. They found that when units had more RN hours per patient day, fewer overtime hours and fewer vacancies, the discharge teaching was of higher quality, patients reported greater readiness for hospital discharge, and post-discharge utilization of readmission and emergency room visits was lower.

Hospitals May Get Funds Cut for High Readmission Rates

Hospitals could see their Medicare payments docked as a result of Affordable Care Act (ACA) reforms that aim to reduce patient readmissions. As a result, more hospitals are focusing on patient and caregiver education to reduce re-hospitalizations.

Under ACA, reductions in Medicare payments for inpatient care will be imposed on hospitals that readmit too many patients within a month of discharge. Cuts could range from a few thousand to hundreds of thousands of dollars depending on the circumstances, the article states.

A Medicare Payment Advisory Commission study estimates that approximately 12 percent of Medicare patients readmitted to the hospital may not need to be. The Commission also found that reducing preventable readmissions by 10 percent could save Medicare $1 billion annually.

For 2014 only three types of readmissions will be penalized under ACA: pneumonia; heart attack; and heart failure. Two more types, chronic obstructive pulmonary disorder and hip and joint replacements, will be factored in next year.

INQRI grantees Dr. Marianne Weiss and Dr. Olga Yakusheva have conducted research examining how the hospital discharge process affects readmission rates. Learn more about their work:

Read "Nurse and patient perceptions of discharge readiness in relation to postdischarge utilization."
Read "Age-related differences in perception of quality of discharge teaching and readiness for hospital discharge."
Read "Quality and cost analysis of nurse staffing, discharge preparation, and postdischarge utilization."

Good Communication Is Just as Important As Good Care

In an opinion piece for the New York Times, Theresa Brown, an oncology nurse and author, discusses the importance of clear communication between doctors, nurses, and patients to ensure that patients comprehend diagnosis and treatment, and have a positive experience. These factors can ultimately improve patients’ health outcomes.

“A growing body of literature suggests that these clinical miscommunications matter, because the success of physician-patient interaction has a real effect on patients’ health,” Brown writes. “In a 2005 article … researchers at the University of Washington, claim that treatment outcomes are better when doctors show more empathy and take the time to make sure patients understand what’s going on.”

Brown, who authored Critical Care: A New Nurse Faces Death, Life, and Everything in Between, has often seen situations where even when quality care is provided, a patient feels that they received poor care because the process of diagnosis and treatment was not handled properly and they became confused.

“Interestingly, patients in hospitals report more satisfying interactions with physicians when doctors sit down during rounds instead of standing,” Brown writes, citing a 2012 article co-written by nurse practitioner Kelli J. Swayden in Patient Education and Counseling. “Sitting gives the message ‘I have time,’ whereas doctors who stand communicate urgency and impatience.”

Hospitals are very busy and focused on “volume and flow” and billable procedures, however providers need to remember that taking time for the “human” element can ultimately improve patient outcomes, Brown concludes.

An INQRI-funded study “A Quality and Cost Analysis of Nurse Practice Predictors of Readiness for Hospital Discharge and Post-Discharge Outcomes” looked at how improving the hospital discharge process can improve patient outcomes and reduce unnecessary readmissions. Researchers at Marquette University, led by Marianne Weiss and Olga Yakusheva identified the contributions that nursing staff make to the quality of discharge teaching and the impact of that teaching on patient outcomes, readiness and readmission rates of patients who are discharged home.

They found that when units had more RN hours per patient day, fewer overtime hours and fewer vacancies, the discharge teaching was of higher quality, patients reported greater readiness for hospital discharge, and post-discharge utilization of readmission and emergency room visits was lower. The project findings are presented in a research brief on the Robert Wood Johnson Foundation's website.

Bread, Milk, Pneumonia Shot: How Retail Clinics are Changing the Landscape of Healthcare

By Olga Yakusheva, Marquette University

When your child gets a sudden fever, it’s bad enough. When your child gets a sudden fever on a Friday night, it can be downright terrifying. You calm yourself with the thought that it is most likely nothing serious and can wait until Monday, all the while trying hard to push away the memory of that recent Sunday family trip to the ER for what turned out to be a simple ear infection.

Thankfully, these situations are becoming less frequent as more and more people get access to retail health clinics. Retail clinics, also called convenient care clinics, are small clinics located in pharmacies, grocery stores, and supermarkets, where a nurse practitioner (NP) or physician assistant will see you for a range of simple conditions (ear infections, cuts and small burns, and such), preventive care, or vaccinations. The clinics accept patients on a walk-in basis and are typically open after hours and on weekends. Most visits last about 15 minutes and prescriptions can often be purchased before leaving the store. Many clinics accept insurance, and some insurers now cover retail clinic services. Although a relatively new phenomenon in the US health care landscape, close to six  million patients visited retail clinic visits in 2009 alone, and an estimated 6,000 retail clinics or more will be operating in the US by the end of the year.

Along with convenience, retail clinics provide care at a lower cost. A study funded by INQRI and recently published in Health Affairs found that choosing a retail clinic for the initial visit can reduce the overall cost of care over the next two weeks by as much as $160-$220 per patient, and that these cost saving are greater where NPs are allowed to practice independently without a physician’s supervision. In addition to direct cost savings, having access to convenient care could lower costs by averting complications that may otherwise result when patients delay seeking care.

While currently accounting for less than 5% of all outpatient primary care visits, the share of visits to retail clinics is projected to increase more than two-fold by 2015. If the cost savings continue into the near future, the projected expansion of the retail clinic market could save our economy over $2 billion, and potentially much more if it were accompanied by a uniform expansion of NP scope of practice laws. Joanne Spetz, the lead author of the study, says that these findings “underscore … that when NPs practice to the full extent of their training, they can deliver highly efficient high-quality primary care.”

Critics of retail clinics bring up a number of potential drawbacks to wide adoption of retail clinics. These concerns include the possible erosion of existing patient-physician relationships, diminished continuity of care, over-prescription of medications (particularly antibiotics), and overall reduced quality of care. While existing studies show the quality of care provided at retail clinics to be similar to conventional primary care settings, the Spetz study did find that when NPs were allowed to prescribe, payments for prescription medications were slightly higher.

These concerns notwithstanding, the rapid growth of the retail clinic sector over the last decade tells us that they are meeting a growing consumer demand for convenient, high-quality affordable care. As health care policy changes under the Affordable Care Act continue to roll out, retail clinics will play an increasingly important role in alleviating growing pressures on our primary care system. In the meantime, we may all need to start getting used to the idea of putting routine tests and vaccinations on our grocery lists.

The Importance of Nursing in Achieving the "Best Care at Lower Cost"

by Richard C Lindrooth and Olga Yakusheva

The Institute of Medicine (IOM) released the findings of its Committee on the Learning Health Care System in America in a report entitled "Best Care at Lower Cost: The Path to Continuously Learning Health Care in America"[1] in early September, 2013.  The report recognized that the complexity of clinical decision-making is rapidly increasing and that clinicians need to continuously update their skills in order to keep up with:

(1) rapidly expanding diagnostic and treatment options; and
(2) the increasingly complex and chronic clinical condition of patients.

Given the growing external demands placed on nurses, the IOM reports that a critical determinant of the success of an organization in dealing with these demands is how "a learning health care organization harnesses its internal wisdom—staff expertise, patient feedback, financial data, and other knowledge—to improve its operations."   Nurses in particular are in an excellent position to play a central role in creating a virtuous feedback loop such that it is feasible to continuously adjust and incrementally improve systems in response to rapidly changing external demands.  The report, supported by the results of a growing and increasingly robust body of academic research, stresses the important role of leadership and management in fostering and maintaining an environment within which continuous learning could take hold.

The recommendations highlight the critical importance of continuing investments in the human capital necessary to enable clinicians' (nurses) to thrive in the dynamic health care market.  Bachelors of Science in Nursing (BSN) programs teach nurses the critical communication skills and analytical tools and that can be harnessed by a well-managed organization in creating an environment that fosters and rewards continuous learning. 

The good news is that employers will increasingly recognize the value of a BSN and reward staff for the additional cost and effort required for the degree.  The IOM Future of Nursing report documents the value of an advanced degree and knowledge of the value of a BSN is reflected in recent hiring trends.  Standard economic theory predicts that the value of a BSN - and human capital in general - depends upon the ability of an organization to put those skills to productive use.  Well-managed organizations will be apt to reward advanced training precisely because the organization can harness the human capital to increase productivity. 

The IOM report documents the experiences of many organizations that have successfully fostered the skills and experience if their staff to improve outcomes and productivity.  While the case studies are encouraging, there are even more organizations that still have not adopted the management practices necessary to facilitate continuous learning.  An organization's future success hinges on its ability to keep up with rapidly changing treatments and the increasingly complex needs of patients. Those organizations that are successful in doing so will thrive and grow market share at the expense of organizations that fail to keep up. 

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[1] Smith, M; R. Saunders, L. Stuckhardt, and J.M. McGinnis, Editors. 2013. ""Best Care at Lower Cost: The Path to Continuously Learning Health Care in America." Available at: http://www.nap.edu/catalog.php?record_id=13444, accessed on September 20, 2013.

How Can An iPod Reduce Hospital Readmissions?

The Cullman Regional Medical Center in Alabama is using handy technology to reduce readmissions by recording discharge instructions, as well as videos, pictures and documents on iPods which they give to patients or their caregivers. Nurses use a program called "Good to Go" which allows patients, families and other care givers  to review the discharge instructions and other important information related to a patient's care whenever they need to.

The Medical Center is beta-testing the program, but so far is reporting great success. They have seen a 15 percent decrease in 30-day readmissions.

Read more about this initiative here.

An INQRI-funded study on discharge teaching and patients' readiness conducted by Marianne Weiss and Olga Yakusheva found that the quality of nurses' discharge teaching is affected by RN hours per patient day, overtime hours and vacancies. They also found that higher quality discharge teaching was correlated with patients reporting a higher level of readiness to be discharged, lower readmission rates, and fewer emergency room visits.

New Survey Shows Nurse Practioners Spending More Time on Patient Education and Medication Adherence

A survey of nurse practitioners (NPs) and physician assistants (PAs) conducted by Manhattan Research reveals that NPs are playing a central role in helping patients adhere to their medication regimens and also spending more time on patient education - both of which are crucial in improving quality of care and patient outcomes.

According to the survey of 909 NPs and PAs, nearly nine in ten NPs provide resources to patients that help them with medication adherence (including three in ten who have referred patients to digital tools to help with adherence, and almost half of NPs report spending more time on patient education in the last two years.

The survey findings are highlighted in a new infographic.

Several INQRI research teams have examined the role of nurses in medication management, including ways home healthcare nurses can help with adherence; the impact of nursing processes on medication errors; and ways nurses and pharmacists can collaborate on medication reconciliation. And an INQRI research team led by Marianne Weiss and Olga Yakusheva identified the impact of nurses' discharge teaching on patient outcomes, discharge readiness, and readmission rates. A brief on that study was recently posted.

Will Dr. Robot Open New Doors for Nurses?

By Olga Yakusheva, PhD and Richard C. Lindrooth, PhD

Olga Yakusheva, PhD, is an associate professor of economics at Marquette University. Richard C. Lindrooth, PhD, is an associate professor at the University of Colorado Anschutz Medical Campus. Both are INQRI grantees.

Technological innovation is rapidly transforming patient care. A new generation of innovations will potentially change the most fundamental aspect of the patient experience – patients’ interactions with physicians and nurses. The FDA recently approved the first autonomous telemedicine robot for use in acute care hospitals. Even more advanced technologies, some capable of processing up to tens of millions of pages of plain medical text per second, are being tested and may soon be used to diagnose conditions and recommend treatment, with limited input from clinicians.

This new technology has the potential to perform several tasks more efficiently than clinicians, albeit with some limitations. It can quickly and effectively sift through large amounts of information and, based on a complex set of guidelines, create a probability-weighted list of diagnoses and recommendations. The result will be purely evidence-based and free of human cognitive decision-making biases.  The technology can drastically speed diffusion of new research and guidelines through electronic dissemination, similar to automatic software updates, and make most novel treatment regimens instantly available to patients.

However, even the smartest technology may not perform well when guidelines require information that is not easily quantifiable, nor when decision-making requires patient-specific judgment. Furthermore, technology is unlikely to supplant humans in direct patient care, including procedures and tasks that require empathy and emotional support.

New JAMA Study Underscores Why the Business Case for Nursing Is Problematic

A new study to be published tomorrow in the Journal of the American Medical Association (JAMA) finds that hospitals profit when patients have complications during surgery. According to a report in the Washington Post's Wonkblog, this counter-intuitive finding is a function of the payment structure in our nation's health care system. Hospitals earn money for every procedure done, even if that procedure is necessary to correct an error that occurs during surgery.

It's for just this reason,according to Olga Yakusheva, Douglas Wholey and Kevin Frick, that it has been so difficult to make a business case for investing in nursing care. In their article in the INQRI Medical Care supplement published last month, the INQRI researchers point out that because investments in nursing care improve patient outcomes, they hurt hospitals' bottom line. The authors go on to suggest that the roll out of the Affordable Care Act, which includes penalties for high rates of hospital acquired infections among, will help to address this confounding issue. They, like the authors of the JAMA study, also encourage taking more aggressive steps to make health care payments outcome-based, rather than service-based.

According to the Post blog, the JAMA study found that a hospital's profit margin jumped from $16,936 to $55,953 when there was a surgical complication.