Reducing readmissions and curbing excessive use of emergency services have become significant priorities for hospitals, made all the more urgent by provisions in federal health reform that are tying some funding to better patient outcomes. A project that has been launched by the Philadelphia-based Treatment Research Institute (TRI) and Temple University School of Medicine will zero in on unresolved substance use issues that often are at the heart of readmission for hospitalized medical patients.
A three-year award of more than $2 million from the Patient-Centered Outcomes Research Institute will allow Temple University Hospital to extend the duration of post-discharge intervention for some patients with substance use problems, adding two individuals with addiction-specific skills to its standard team. A study will compare the effects of the enhanced services with those of the hospital's usual disease management effort.
“The people at Temple said, 'We have more patients that we could serve with community disease management, and one group we can help is people with substance use issues, because [otherwise] we're going to readmit them,'” says Adam Brooks, PhD, senior research scientist at TRI.
This is the first award that either TRI or Temple University Hospital has received from the Patient-Centered Outcomes Research Institute, which was authorized by Congress in 2010 to fund research to help families and clinicians make informed healthcare decisions. It also is the first partnership between Temple and TRI, a leading research-to-practice entity serving the addiction treatment community.
Brooks says the award will allow for treatment team members implementing the enhanced post-discharge intervention to be in contact with a patient for at least 90 days after he/she leaves the hospital. A typical scenario for the hospital under usual care ranges from 30 to 45 days.
The kind of situation that the hospital encounters might involve a patient who was hospitalized because of congestive heart failure and informs a treatment team member that she has been drinking heavily at home and may be about to lose her housing, Brooks says.
Patients receiving the enhanced post-discharge intervention in the study will have access to the services of two new disease management team members: a social worker who can deliver evidence-based interventions over the telephone, and a peer specialist. Steven R. Carson, vice president for clinical integration at Temple University Health System, emphasizes the importance of the role of an individual in recovery on the enhanced team. “The peer-level coach is someone who has been there before,” says Carson.
He says that in general, the Temple University Hospital medical patients whose outcomes are compromised by substance use problems are individuals ages 45 to 55 with some type of cardiovascular diagnosis. Some may have received substance use treatment services at a point in their life, while others may never have seen the need for treatment.
Brooks adds that the new team members might explore with the patient whether he/she wants to get into formal treatment, while they would try to address other problems in the patient's life if the motivation to be admitted to treatment isn't yet there. “The goal is to keep the conversation active,” he says.
Carson says Temple generally works with patients who have faced challenges around having their substance use issues addressed sufficiently. “We are the de facto city hospital, even though Philadelphia doesn't have a city hospital,” he says. “Our patients do not have a whole lot of options.”
Under the Affordable Care Act (ACA), hospitals can face penalties in Medicare reimbursement if they maintain higher-than-average patient readmission rates. But while Carson says external forces certainly are at play in the overall move to reduce readmissions, this particular initiative targets a Medicaid or indigent population. “These are generally under- or unreimbursed patients who have no other way to get care,” he says.
Under this initiative, which has been under way for a month, the award supports the work of the disease management team members, while any addiction treatment services that the patient pursues would generally be reimbursed by Medicaid. More than 200 patients are expected to participate in the study.
In its work within general medical settings, TRI has learned that lengthy sessions with patients are not feasible. In this initiative, hospitalized patients who could benefit from enhanced post-discharge services will have to be identified at the bedside. TRI has created several tools to help providers initiate conversations with patients about substance use, including informational flashcards and written narratives about patients who have an alcohol or drug problem.
Carson says that a key measure of the enhanced intervention's success from the health system's point of view will involve patients' frequency of emergency-room use for follow-up care. All hospitals are trying to curb excessive and poorly targeted use of their emergency services.