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Outreach to DHMC Patients Lowering Readmission Rates

  • Caron Bronstein nearly died from a weak heart and DHMC doctors found a way to get her healthy again and stay out of the hospital.Bronstein is a dog trainer , she was working at home with one of her dogs.  Valley News - Jennifer Hauck

    Caron Bronstein nearly died from a weak heart and DHMC doctors found a way to get her healthy again and stay out of the hospital.Bronstein is a dog trainer , she was working at home with one of her dogs. Valley News - Jennifer Hauck Purchase photo reprints »

  • Trainer Caron Bronstein works with one of her dogs at home in Lebanon.<br/>(Valley News - Jennifer Hauck)

    Trainer Caron Bronstein works with one of her dogs at home in Lebanon.
    (Valley News - Jennifer Hauck) Purchase photo reprints »

  • Caron Bronstein nearly died from a weak heart and DHMC doctors found a way to get her healthy again and stay out of the hospital.Bronstein is a dog trainer , she was working at home with one of her dogs.  Valley News - Jennifer Hauck
  • Trainer Caron Bronstein works with one of her dogs at home in Lebanon.<br/>(Valley News - Jennifer Hauck)

Lebanon — Two years ago, Caron Bronstein’s heart nearly stopped beating, and yet she survived without ever being hospitalized.

Much of the care she received from her cardiologist was over the phone.

“Just making sure of what I could do diet-wise and activity-wise to make sure I wasn’t inflicting any further damage on my heart,” Bronstein, 58, said one recent morning.

Mundane conversations about what she had for breakfast, whether she’d had any weight gain or experienced any dizziness lately might not seem like the kind of sophisticated treatment you’d expect from heart specialists. But as Bronstein’s doctor, Alan Kono at Dartmouth-Hitchcock Medical Center, has realized, reaching out to patients beyond doctor visits and coaching patients on how to treat their illnesses go a long way toward ensuring people are staying healthy and out of the hospital.

It is also reason why DHMC has outperformed its peers on a key measure within federal health reform efforts — readmission rates.

The Lebanon hospital is among the best in the country when it comes to the proportion of heart patients that have to be readmitted within 30 days of being discharged, ranking in the top 1 percent of hospitals in the country between July 2008 and June 2011, according to Medicare data.

Of the 542 heart failure patients discharged from the hospital in that time, only 93 were readmitted, according to George Blike, DHMC’s chief quality officer. That ranks the hospital eighth out of 3,110 providers evaluated by the Centers for Medicare & Medicaid Services.

DHMC’s performance in this area not only has earned Kono, the director of the hospital’s congestive heart failure clinic, pats on the back from co-workers, but also helped the hospital avoid potentially $1 million in penalties from the federal government as it cracks down on hospitals that have high rates of patients who return too soon after getting treated.

The strategies that Kono’s team has been using offer lessons for other doctors within Dartmouth-Hitchcock and elsewhere as providers focus on coordinating care in order to reduce costs and improve overall health, Blike said.

“We think the learning on this model will translate to other high-risk groups,” Blike said.

The strategies Kono has developed over nearly a decade all point to ways of coordinating care, via a team of different nurses and doctors, and empowering patients to play a more active role in their own care. They are similar to steps being taken by primary care doctors, but Kono’s success shows that they can be used in specialty practices as well.

Kono gives a lot of attention to patient education, which is not in itself novel. Plenty of doctors and nurses spend time instructing patients on how to take care of themselves at home. But where Kono and his team have gone above and beyond is in what they do after someone has left the hospital.

The first 24 hours after a patient is discharged is a critical factor in determining whether they end up back in the hospital, Kono said. In studying patient readmissions, Kono said he realized a lot of people return to the hospital within the first three days. So, all heart patients who are admitted to the hospital get a follow up phone call within the first day to see how they are doing and answer any questions. They follow up again at the two-week mark, and again after one month.

Kono’s team has also used a new electronic health records system to its advantage. Anytime one of their heart patients shows up for an appointment in another area of the hospital, regardless of whether it has anything to do with a heart issue, then a cardiology nurse uses it as an opportunity to see how the patient is doing, Kono said.

“We’ll look at our patient population and say, ‘Oh, Ms. Smith is here for a defribillator change. Let’s say hello,’ ” Kono said.

These kinds of check-ins with patients might appear to be simple, but the foundation for implementing them into practice results from years of poring over patient data, looking at demographics and studying how people were being treated to develop a program to keep people healthy once they’d left the hospital.

“This is not just something we worked on in a year,” Kono said.

A challenge has been making this approach work in a fee-for-service world, where doctors are paid according to the treatments they provide. The meetings among Kono’s staff, when they are planning together over lunch or after work, can’t be billed to insurers. Yet this coordination among doctors and nurses is crucial, Kono said, even if they’re not getting paid to do it.

Dartmouth-Hitchcock has comitted itself to improving coordination among doctors, not only in cardiology but throughout the hospital, Blike said. Dartmouth-Hitchcock is one of 32 hospital networks that have agreed to roadtest the concept of accountable care by becoming an “accountable care organization,” or ACO. Passed as part of the Affordable Care Act in 2010, the ACO program calls on hospitals and doctors to make themselves accountable for the total cost and quality of patient care, regardless of where someone gets treated. If a hospital is able to lower costs for certain patients while maintaining high quality care, then the hospital shares in the savings.

Kono’s strategies, such as discharge procedures and coaching patients about treating their illness, could gain wider use within Dartmouth-Hitchcock as it seeks to become more efficent and prevent costly readmissions.

“Some of this is where we want to move to,” Kono said.

Bronstein’s experience suggests that Kono’s innovations are working. Her heart is as strong as it was before it nearly failed in December 2010. She’s stuck with her medication regimine and never had to undergo surgery.

Her lifestyle has returned to the level she enjoyed years ago. A dog breeder, Bronstein can go outside and play with her Labradors. She even talks about indulging in riskier fun.

“Now I can go back to doing all the other things I love to do,” she said, “like riding roller coasters.”

Chris Fleisher can be reached at 603-727-3229 or cfleisher@vnews.com.