Pro­gram fail­ing to curb re­peat hos­pi­tal stays

Antelope Valley Press (Sunday) - - Valley Life - By MARILYNN MARCHIONE

Re­searchers thought they had a way to keep hard-to-treat pa­tients from con­stantly re­turn­ing to the hos­pi­tal and rack­ing up big med­i­cal bills. Health work­ers vis­ited homes, went along to doc­tor ap­point­ments, made sure medicines were avail­able and tack­led so­cial prob­lems in­clud­ing home­less­ness, ad­dic­tion and men­tal health is­sues.

Read­mis­sions seemed to drop. The pro­gram looked so promis­ing that the fed­eral govern­ment and the MacArthur Foun­da­tion gave big bucks to ex­pand it be­yond Cam­den, New Jersey, where it started.

But a more ro­bust study re­leased Wed­nes­day re­vealed it was a stun­ning fail­ure on its main goal: Read­mis­sion rates did de­cline, but by the same amount as for a com­par­i­son group of sim­i­lar pa­tients not in the costly pro­gram.

“There’s real con­cern that the re­sponse to this would be to just throw up our arms” and say noth­ing can be done to help th­ese so-called fre­quent fliers of the med­i­cal sys­tem, said study leader Amy Finkel­stein.

In­stead, re­searchers need to seek bet­ter solutions and test them as rig­or­ously as new drugs, said Finkel­stein, of the Mas­sachusetts In­sti­tute of Tech­nol­ogy and the Na­tional Bureau of Eco­nomic Re­search.

Fed­eral grants and re­search groups at MIT paid for the study, which was pub­lished in the New Eng­land Jour­nal of Medicine.

Just 5% of the U.S. pop­u­la­tion ac­counts for half of health care spend­ing, and hos­pi­tal­iza­tion is a big part.

A decade ago, Dr. Jeff Bren­ner started work­ing with hos­pi­tals in Cam­den, a city with high poverty and crime rates, to iden­tify peo­ple who go to hos­pi­tals fre­quently and tar­get them with spe­cial ser­vices. He won a MacArthur ge­nius grant for the work, and fed­eral grants ex­panded the pro­gram to Aurora, Colorado; Kansas City, Mis­souri; Allentown, Penn­syl­va­nia; and San Diego. The govern­ment also paid for a study to see if it truly worked.

The study en­rolled 800 hos­pi­tal­ized Cam­den pa­tients with at least two other ad­mis­sions in the pre­vi­ous six months and at least two of th­ese conditions: home­less­ness, drug use,

a men­tal health prob­lem, trou­ble ac­cess­ing ser­vices, lack of so­cial sup­port or use of five or more medicines.

Half were given usual care when they left the hos­pi­tal. The rest were en­rolled in Bren­ner’s pro­gram with nurses, so­cial work­ers and oth­ers co­or­di­nat­ing their care for three months. Pa­tients re­ceived seven to eight home vis­its and nine phone calls on aver­age. The ef­fort cost about $5,000 per pa­tient.

Six months later, the read­mis­sion rate was 62% in both groups, and there was no dif­fer­ence in to­tal health care spend­ing.

Re­searchers don’t know what usual care was for the com­par­i­son group. If that sud­denly im­proved, it could ex­plain why the pro­gram failed to prove bet­ter.

How­ever, two key goals

of the pro­gram — a home visit and a trip to a health provider within a week of leav­ing the hos­pi­tal — were met for only 28% of par­tic­i­pants. Home­less­ness and lack of a tele­phone were big rea­sons, and the pro­gram more re­cently has worked harder to get peo­ple into sta­ble hous­ing.

“If you’re in a shel­ter or on the streets, it’s just not easy to help and that some­times leads to more hos­pi­tal­iza­tions,” said the Cam­den project’s leader, Kath­leen Noo­nan.

Three months of help also wasn’t enough, and there weren’t enough places to get help for men­tal health or sub­stance abuse prob­lems, she added.

“We’ve evolved a lot” since the pro­gram be­gan, said Bren­ner, who now is an ex­ec­u­tive work­ing on

sim­i­lar pro­grams at the insurance com­pany Unit­edHealth­care.

“The sys­tem is good at de­liv­er­ing care if you’re an aver­age pa­tient on an aver­age day,” but not for, say, a home­less per­son in a wheel­chair who is dis­ori­ented, Bren­ner said. “Th­ese pa­tients have com­plex prob­lems. If you don’t meet their needs, they’ll keep go­ing to the hos­pi­tal.”

The pro­gram was “clearly done with the best of in­ten­tions” and still may have pro­vided use­ful care to the peo­ple who re­ceived it even though it didn’t re­duce read­mis­sions, said Dr. Aaron Kes­sel­heim, a Har­vard Med­i­cal School health pol­icy ex­pert who had no role in the work. Prob­lems like read­mis­sion are much more com­pli­cated than they ap­pear to be, he said.


Cam­den Coali­tion staff mem­bers dis­cuss pa­tient en­gage­ment. Re­sults pub­lished Wed­nes­day in New Eng­land Jour­nal of Medicine show that af­ter six months, read­mis­sion rates were the same for those in the pro­gram and oth­ers given usual care. Re­searchers say more ef­fort must fo­cus on home­less­ness and ad­dic­tion, which com­pli­cate med­i­cal care.

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