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.

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.

Research Brief: How Do Nurses Influence Discharge Teaching?

This week, we introduce you to the INQRI project conducted by Marianne Weiss, Olga Yakusheva, and their team.

Improving how patients are discharged from the hospital to reduce unnecessary readmissions is a critical issue now being debated at the national level. With one in five elderly readmitted to the hospital within 30 days at an annual cost to Medicare of $17 billion, policymakers are seeking cost-effective solutions to better transition patients from hospital to home. Researchers at Marquette University, led by Weiss and Yakusheva, have been studying what hospital-based nurses do to influence outcomes 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 have 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.

Access the research brief.

This post is part of a series to provide the public with research briefs on INQRI-funded projects across a range of interests.

Hospitals Need Clear Discharge Processes

A new article in JAMA Internal Medicine demonstrates that hospitals need clearer discharge processes for older patients. Researchers suggest that patient satisfaction with the discharge process doesn't explain how well they actually understood the reasons for hospitalization and the care goals following hospitalization. You can learn more about this study on FierceHealthcare.com.

In thinking about designing an effective discharge process, it's important to involve the right partners.  INQRI researchers at Marquette University, led by Marianne Weiss and Olga Yakusheva, would tell you that nurses should be involved.  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.

For more information about the INQRI study, please click here.

Nurses Save Patients Time and Hospital Money

The local CW affiliate for the Dallas Fort-Worth area, KDAF-TV, detailed how a group of nurses tasked with obtaining detailed history for patients has helped improve care and patient satisfaction. The team of five full-time nurses, better known as DART (discharge, admission, resource, transport), also play a crucial role in the discharge process, ensuring patients understand the medications and instructions given to them by hospital physicians.

To read more about the DART team, click here.

Northeast Florida Hospitals Reducing Readmissions With Nurse Intervention

Yesterday, the Florida Times Union reported on the implementation of a new discharge intervention at St. Vincent’s HealthCare. The intervention, which includes an educational component for patients in the health system, utilizes follow-up phone calls and care in an effort to reduce readmission rates among high risk patients. The intervention also includes a dedicated nurse practitioner who provides transitional care for heart failure patients, which includes home visits and follow-up calls as previously noted.

Click here to read the full news article.

Click here to read other blogposts related to readmissions.

INQRI's Five Most Read Blogposts of 2011

On behalf of the INQRI program staff and leadership team, we would like to wish all of you a safe and happy holiday & New Year.

Below you will find the five most read blogposts from 2011.

Please feel free to comment and share your favorite post from this year!

Interdisciplinary Pilot Study Suggests Nurses Can Help Chronically Ill Patients Properly Manage Medication after Being Discharged from Hospital Nurses Bridged Gap Between Leaving Hospital with Prescriptions and First Visit with Primary Health Care Provider

New Study Shows Higher Nurse Staffing Levels in Hospitals Can Reduce Rates of Infection, Improve Outcomes for Patients

INQRI Project Featured in Health Services Research

Expanding Nurses' Scope-of-Practice in the News

The Future is Now for Nurse Practitioners

Nurses Key to Reducing Readmissions

Yesterday's article on HealthcareITNews.com, "Readmissions have hospitals stymied," discussed a recent Dartmouth Atlas Project report which indicated that little progress has been made in reducing hospital readmissions for Medicare patients over a five-year period. In addition, the report demonstrated that readmissions for patients with some conditions are actually increasing.

The work of INQRI researchers at Marquette University suggests that increasing the number of nurses involved with discharge might reduce some of those readmissions. Marianne Weiss, Olga Yakusheva and their team found that having more registered nurses working on a hospital unit and reducing the amount of nurses' overtime hours are correlated with fewer patients being readmitted or visiting the emergency department within the first 30 days after hospital discharge. They also found a positive correlation between the number of nurse staffing hours and patients’ satisfaction with the quality of discharge teaching and subsequent readiness to go home.

Click here to learn more about the Marquette study.

Look Who Made it to the Human Capital Blog

Check out this new entry on RWJF's Human Capital blog... congratulations to INQRI researchers Marianne Weiss, D.N.Sc., R.N.; Olga Yakusheva, Ph.D. and Kathleen Bobay, Ph.D., R.N., N.E.A.-B.C. on all the terrific coverage given to your study lately!

In their INQRI project, "A Quality and Cost Analysis of Nurse Practice Predictors of Readiness for Hospital Discharge and Post-Discharge Outcomes," this team from Marquette University broke new ground by linking the unit-level nurse practice environment and nursing care processes with patient outcomes at discharge and post-hospitalization. Specifically, the study examined direct and indirect causal relationships between the nursing practice environment, the discharge teaching process and readiness for hospital discharge with hospital readmission and emergency department utilization.

Medication Discrepancies: The Problem and the Solutions

Check out this awesome video created by an INQRI grantee team led by Cindy Corbett and Stephen Setter.

In their INQRI project, they used information technology to help home care nurses more efficiently and effectively identify and resolve medication discrepancies as patients transitioned from the hospital to home. Researchers evaluated whether the intervention had an impact on patients' emergency department visits during the first month after hospital discharge. The intervention group participants had fewer emergency department visits during the first 30 days after the index hospitalization. These findings demonstrate both the importance and the complexity of medication information transfer during care transitions from hospital to home.



Medication Discrepancies (3 Minutes) from Washington State University on Vimeo.

INQRI Project Featured in Health Services Research

Health care experts often consider it a failure of the system when patients use emergency departments or are readmitted to the hospital within 30 days after being discharged. Patients who are inadequately prepared for being discharged are more likely to visit the emergency department or be readmitted than patients who are well-prepared. In many hospitals, the responsibility for discharge teaching and preparation lies with staff nurses.

A new study published in the current issue of Health Services Research, finds that having more registered nurses (R.N.s) working on a hospital unit and reducing the amount of R.N.s’ overtime hours are correlated with fewer patients being readmitted or visiting the emergency department within the first 30 days after hospital discharge, and also reduced costs. The study also found a positive correlation between the number of R.N. staffing hours and patients’ satisfaction with the quality of discharge teaching and subsequent readiness to go home.

Marianne Weiss, D.N.Sc., R.N., associate professor and Wheaton-Franciscan Healthcare/Sister Rosalie Klein professor of women’s health at Marquette University College of Nursing is one of the lead investigators of the study, which was funded by the INQRI program. She led an interdisciplinary team that included Olga Yakusheva, Ph.D., assistant professor in the Department of Economics at the Marquette University College of Business Administration and Kathleen Bobay, Ph.D., R.N., N.E.A.-B.C., associate professor at Marquette University College of Nursing and Research Scientist at Aurora Health Care. The team studied nurse staffing levels, patients’ reports on quality of the discharge teaching process and their readiness for discharge, along with post-discharge readmissions and emergency department visits for sixteen medical surgical units at four hospitals in a single Midwestern health care system. The final sample included 1,892 patients.

Researchers found that when R.N. non-overtime staffing was higher, the odds of patient readmission were lower and when R.N. overtime hours were higher, emergency department use was also higher. In addition, a cost-benefit analysis estimated that increasing non-overtime staffing by .75 hours per patient per day increased hospitals’ cost by $197.92 per hospitalized patient but saved payers $607.51 per patient. Reducing R.N. overtime staffing by .07 hours per patient day resulted in hospital savings of $8.18 per hospitalized patient and $10.98 in savings per hospitalized patient to payers. Using a cost analysis projection for the 16 nursing units in the study, the researchers estimated an annual net savings of $11.64 million associated with increasing non-overtime hours and an annual net savings of $544,000 associated with decreasing overtime hours. However, in current payment models, payer savings accruing from reduction in readmissions or Emergency Department use would not be applied to offset hospital costs for increased nurse staffing.

“We know that patients who aren’t properly prepared to be discharged are more likely to be readmitted to the hospital and we also know that if nurses have more hours allocated to work with patients, they have more time to perform critical functions that require R.N.- level expertise, like discharge teaching,” said Weiss. “This study shows us that investing in nursing care hours could potentially be offset by the savings that could be realized in reductions in readmission and emergency department use.”

The study’s authors write that their findings support recommendations to: monitor and manage unit-level nurse staffing to ensure optimal post-discharge results; implement assessment of the quality of discharge teaching and patients’ readiness for discharge as part of the discharge procedure; and realign payment structures so that the cost of nurse staffing is offset by the savings that result from reductions in unplanned readmissions and Emergency Department visits after discharge.

Coverage of the study:

• The American Nurses Association Smart Brief's top story
• The Business Journal - Milwaukee
• Modern Healthcare
• Health Behavior News Service

The Impact of Health Literacy on Readmission

A recent article in the Washington Post, "Improving Health Literacy Will Decrease Hospital Readmissions, Costs," details the effect that patients' knowledge of health information can have on hospital readmissions.  In fact, the article states that "under health reform, measures to improve patients' ability to obtain, understand and use health information are expected to decrease costly hospital readmissions and complications."

An INQRI team found that nurses are key to the educational efforts that happen at discharge and help prevent readmissions.  Researchers at Marquette University have been studying what hospital-based nurses do to influence outcomes that occur after discharge from a hospital. Specifically, they looked at identifying the contributions that nursing staff make to the quality of discharge teaching on patient outcomes, readiness and readmission rates of patients who are discharged home. They have found that when units had more RN hours per patient day, less 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 team published some of their study results in the May 2010 edition of Medical Care.

• Read the abstract on the Medical Care website.
• Read the recent article in the Washington Post.

With Upcoming Medicare Changes, Hospitals Need to Reduce Readmissions

Improving how patients are discharged from the hospital to reduce unnecessary readmissions is a critical issue now being debated at the national level. With one in five elderly readmitted to the hospital within 30 days at an annual cost to Medicare of $17 billion, policymakers are seeking cost-effective solutions to better transition patients from hospital to home. INQRI researchers at Marquette University have been studying what hospital-based nurses do to influence outcomes that occur after discharge from a hospital. Specifically, they are looking at identifying the contributions that nursing staff make to the quality of discharge teaching on patient outcomes, readiness and readmission rates of patients who are discharged home. They have found that when units had more RN hours per patient day, less 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.

This works comes at a critical time.  New Medicare rules are coming soon that will cut payments for return visits.  Therefore, hospitals across the nation are doing what our researchers know to be important - they are spending more time focusing on discharge instructions with patients and caregivers.

Click here to read about these efforts in an article for MarketWatch.

Reducing Readmissions

This week INQRI's director, Mary Naylor, joined more than 200 hospital administrators, doctors, nurses and national experts for a discussion centered around developing strategies to reduce hospital readmissions in the five-county Philadelphia area.

Naylor described her transitional care model (TCM) which uses advance practice nurses to target the chronically ill elderly. This population accounts for 75 percent of Medicare costs. Using their intervention, Naylor's team reduced rehospitalizations through three months with a savings of more than $2,000/month/participant.

Click here to learn more about the event in the Philadelphia Inquirer.

Click here to read about the findings of INQRI researchers at Marquette University. This team has been working to prevent unnecessary readmissions by studying what hospital-based nurses do to influence outcomes that occur after discharge from a hospital.

Nurse Assessments Key to Understanding Discharge Readiness

Although the prevention of hospital readmission and use of emergency departments is a vital strategy in reducing health care costs, there has been little research on nurse assessment and patient perceptions of discharge readiness in relation to postdischarge outcomes.  However, a new study published in Medical Care can shed some light on this issue.  INQRI's team at Marquette University conducted a study with 162 adult medical-surgical patients and their discharging nurses from 13 units in four hospitals.  They found low correlations between nurse assessment and patient perceptions of discharge readiness.  In fact, nurses rated patient readiness higher than did the patients.  The team concluded that since nurses' assessment was more strongly associated with postdischarge utilization, formalizing nurse assessment could help identify patients at risk for readmission.

Click here to access the article on the journal website.

How do you reduce hospital readmissions?

Louisiana Governor Bobby Jindal's administration plans to launch a program aimed at reducing hospital visits for patients with chronic disease, the Baton Rouge Advocate reports. During the 2009 legislative session, the state Department of Health and Hospitals (DHH) received $10 million in state and federal appropriated funds to curb escalating Medicaid costs. The administration plans to use the funding to begin soliciting proposals from contractors to implement a disease management program that will target Medicaid beneficiaries with diabetes, asthma and congestive heart failure (CHF), which the DHH secretary notes are the leading causes of high-cost and frequent emergency department visits throughout the state. For more information, click here.

Several Michigan hospitals will soon begin participating in a three-state collaborative project aimed at reducing hospital readmissions, the Livonia Observer reports. The 15 Michigan health centers participating in the State Action on Avoidable Rehospitalizations (STAAR) project will seek to reduce 30-day rehospitalization rates by 30 percent. For more information, click here.


For information on INQRI-related work involving discharge, please click here.

Transitional Care Cuts Hospital Re-Entry Rates, Costs

The NPR story featuring Mary Naylor's Transitional Care Model is now available online at NPR.org:

Here's a number that tells you a lot about what's wrong with the American health care system: When older patients get discharged from a hospital, 1 out of 5 of them will come right back within a month. Medicare pays $17 billion a year on these hospital readmissions. And in many cases, coming back should have been avoidable.

Mary Naylor is trying to change that. She started the Transitional Care Model at the University of Pennsylvania Health Care System in Philadelphia. A nurse with advanced training in geriatrics is assigned to an elderly patient while he is in the hospital and then follows the patient, with frequent visits and contact, over two or three months to help him manage his own care.

"Every time an older adult is hospitalized, it generally results in changes in their plan of care," says Naylor. Some of the instructions from a doctor can be hard to follow, like new prescriptions. "So they would go home and 24 hours after discharge have a set of prescriptions, drugs already in their cabinet and wonder, 'Should I be taking these plus these?'"

For the rest of the story and to hear the clip from Morning Edition, click here.

***

The INQRI program is very invested in ensuring good patient care quality at each stage of the health care journey. An INQRI team at Marquette University has been working for the past two years on discharge preparation.

Hospital readmission and emergency department utilization within the first 30 days following hospital discharge represent adverse, potentially avoidable, and costly outcomes of hospitalization. For their project, "A Quality and Cost Analysis of Nurse Practice Predictors of Readiness for Hospital Discharge and Post-Discharge Outcomes," Marianne Weiss and Olga Yakusheva, worked on linking the unit-level nurse practice environment and nursing care processes with patient outcomes at discharge and post-hospitalization. Specifically, the study examined direct and indirect causal relationships between the nursing practice environment, the discharge teaching process and readiness for hospital discharge with hospital readmission and emergency department utilization.

Dr. Weiss has published extensively regarding discharge readiness. To read her article, "Patients' Perceptions of Hospital Discharge Informational Content," co-authored by Lynn Maloney, click here.