Program shows how hospitals are working with rehab centers to keep patients from relapsing

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Keeping patients healthy after they leave the hospital is a challenge that hospitals have taken on — spurred by the financial penalties Medicare imposes if patients are readmitted within 30 days of discharge. Now, a collaboration between Robert Wood Johnson University Hospital Somerset and a rehabilitation center in Raritan demonstrates how…The program, “A Breath of Fresh Care,” was launched by RWJ Somerset cardiologist Dr. Mark Lebenthal nine months ago in a partnership with the rehabilitation facility Rehab at River’s Edge. Patients discharged from hospitals will often move to rehab facilities for a week or more of sub-acute care — and if the patient takes a turn for the worse and must leave rehab and return to the hospital, Medicare dings the hospital with a readmission penalty.

The for-profit Rehab at River’s Edge facility was acquired just over a year ago by 25-year health care veteran Judy Kushner. Her strategy: to develop clinical programs that support the hospital’s goal of avoiding unnecessary readmissions.

“If we do our job right, the patient will stay out of the hospital,” she said.

Lebenthal worked with Kushner to develop A Breath of Fresh Care for patients with congestive heart failure — a very difficult disease to control and one that often leads to hospital readmissions

Lebenthal said congestive heart failure patients typically spend three or four days in the hospital, followed by about 20 days in a rehab facility. He trained the nurses and therapists at River’s Edge to provide care aimed at preventing patients from relapsing. Before discharge, patients and their families are coached on proper diet, medications and exercise to keep the patient healthy at home. A program funded by a grant from the Robert Wood Johnson Foundation provides visiting nurses who deliver “transitional care”: making sure patients are ready for discharge, understand the medications and visit a doctor once they get home.

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Lebenthal designed an exercise program “that patients can safely do while in rehab and continue when they go home. We know that if people condition their muscles they are less likely to go back into heart failure.”

Last month, Robert Wood Johnson University Hospital in New Brunswick closed on its acquisition of Somerset Medical Center, which is now the Somerset campus of the hospital. Both hospitals had developed their own programs, now working in concert, where visiting nurses work with patients and families to avoid relapse, crisis — and readmission.

Alyssa Kizun is director of care management at the Somerset campus of RWJ, which she said has reduced its Medicare readmission rate for congestive failure from about 21 percent in 2011 to about 13 percent now.

“We are empowering the patient to be an active participant in their care,” Kizun said.

Lebenthal said health care reform is putting the spotlight on the care patients receive at rehab facilities: “Years ago, (rehab facilities) didn’t provide the extensive care to complicated patents that they are providing now.” But with the government looking to reduce health care spending by reducing hospital readmissions, hospitals are seeking out high-quality rehab programs.

Teresa DePeralta, who leads the transitional care program at Robert Wood Johnson University Hospital, said: “Medicine has improved so much and we are keeping people alive longer. The hospitals can’t do it alone: We need to develop efficient, community integrated programs that work with rehab facilities, nursing homes and home care.”

Kushner said she wants Rehab at River’s Edge to be a facility of choice for hospitals seeking rehabilitative care for their patients.

The Breath of Fresh Care program began nine months at River’s Edge, with the first six months devoted to intensive staff training. Three months ago, the program began admitting cardiac patients — and, Kushner said, so far there have been zero hospital readmissions.

“Eventually, hospitals are not going to want to do business with facilities” that don’t provide the kind of care that avoids readmissions, Kushner said.

Lebenthal said Rehab at River’s Edge has “kicked up” its cardiac care, essentially providing hospital-style care within a sub-acute facility. He said rehab facilities face competitive pressure to follow suit — and not all facilities will make the grade.

As high-performing sub-acute facilities emerge, “those are the places that hospitals are going to want to send their patients,” Lebenthal said.

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