Hospice of St. Lawrence Valley, hospitals working together to cut readmissions
Wednesday, July 14, 2010 - 9:09 am


A new program is underway designed to reduce the number of patients who return to the hospital shortly after their release.

Hospice and Palliative Care of St. Lawrence Valley is participating in the program with Canton-Potsdam Hospital, Claxton Hepburn Medical Center in Ogdensburg, and Massena Memorial Hospital.

The program “provides medical case management, nursing consultation and social work services to qualifying patients with a serious illness who were recently hospitalized,” said Brad Catling, Hospice’s director of development and community relations.

“This care will be given for a period of 45 days from discharge from the hospital. The goal is to increase the quality of each patient’s life and reduce the need for rehospitalization.”

And the service can help patients’ as well as medical providers’ bottom line, said Hospice Executive Director Brian Gardam.

“Hospitals have a strong interest in patients who have chronic illnesses and don’t have those illnesses well managed at home and are frequently readmitted” after a hospitalization, Gardam said.

Dovetails With Healthcare Reform

“The program is notable,” Gardam said, “because this is a project where three hospitals and our organization are all working together to put a model of care together that can be of real benefit to people in our area who have chronic illnesses, and where we can demonstrate a way to keep health care costs down.”

“We might be able to help these patients decrease their admissions and stay at home if they can get care there,” said Canton-Potsdam Hospital Vice President for Patient Care Services Nancy Rutledge. “These are patients who don’t qualify for other home health programs.

“It’s a very creative program,” Rutledge said. “It represents great cooperation among health care agencies to try to meet the needs of people who are trying to stay in their homes.”

Gardam explained some incentive for hospitals to make the program work comes from the new health care program adopted by the federal government this year.

“Some of the reforms under the health care program make it less likely that there will be reimbursement if someone with a chronic illness who has been hospitalized has to be readmitted with the same diagnosis within 30 days. That’s the plan for Medicare.

“The goal is better care, so there is a strong financial incentive to provide services to help prevent patients from returning to the hospital.”

Chronic diseases are conditions that are treatable but might not be curable, such as diabetes, heart disease and cancers, which according the U.S. Centers for Disease Control are the leading causes of death and disability in the U.S. “Chronic diseases account for 70 percent of all deaths in the U.S., which is 1.7 million each year. These diseases also cause major limitations in daily living for almost 1 out of 10 Americans or about 25 million people,” CDC says.

Under the Hospice program, a nursing and social work team can “help a patient deal with medications and reconnect with the attending physician” for continued guidance, Gardam said, while helping with “the emotional, psychological and spiritual issues that come along with having a chronic illness” that can inhibit a patient’s progress.

Helping Patients Understand

Catling said that typical services under the program include “helping patients understand and manage their medications and treatments, on-going nursing assessment of the symptoms associated with their chronic illness, collaboration with medical providers and accessing community resources.

“The Home Support Program team will also promote timely follow-up by patients with their primary physician or treating specialist,” Catling said. “In addition, they will provide short-term counseling to help strengthen the patient’s ability to deal with psychological and social stressors that may impact their health.

“The program will provide 24 hour on-call assistance which will include the services of a registered nurse, if necessary, to help alleviate symptoms such as anxiety.

“It’s still early in the program,” Gardam said. “We’ve been having meetings with discharge planners and case managers at the hospitals, to see which cases should be referred to us, to review them, and see if the program is appropriate for them. The goal is to see if we can keep people from being readmitted to a hospital in the first 30 days after discharge.”

No Charge to Patients

The Home Support Program is provided as a post-discharge service of the participating hospitals, Catling said. There is no charge to patients enrolled in the Program.

The program is supported by grants from The Northern New York Community Foundation and The Edward Moses Walk/Run Corporation. If the program can show results, more grant funding is possible.

“We had done a pilot program with Claxton Hepburn with a grant from the Alcoa Foundation a few years ago. With the new provisions in health care reform, it made sense to use what we learned in the pilot program and extend it to the three hospitals.”

So far, Gardam says, there have been about a dozen referrals and a handful of people brought into the program.

“If it works, it will reduce costs to the health care system, and fewer people will be taking up beds in the hospital that might be needed by other patients.

“We’ll be sitting down with everybody involved in about two months to take stock, to see if there’s improvement, see what’s working and what’s not.”