Keeping frequent flyers safe at home – with good detective work

by Jay Berry on March 4, 2011

Photo: PhylB/Flickr

Jay Berry is a pediatrician and hospitalist within the Complex Care Service at Children’s Hospital Boston. He leads the multi-institutional Complex Care Quality Improvement Research Collaborative (CC-QIRC). This is the final post in a 3-part series.

Imagine a child and family going through four hospital readmissions in a row — one right after the other — and how disruptive those hospitalizations are to their lives. I recently was involved in a study that demonstrated that patients experiencing frequent, potentially avoidable readmissions – so-called “frequent flyers” — are a major driver of pediatric healthcare costs. These children often have very complex, chronic health conditions.  It’s now our duty to take action on these findings.

So how can we help prevent these repeated readmissions?

We could start by identifying and tracking children who are frequently readmitted. Currently, such tracking is hindered by a lack of patient accountability. Which provider is ultimately responsible for a child who’s been rehospitalized four times within the last year? The primary-care doctor in the community? The specialist? The inpatient doctor? The hospital in general?

I sometimes see finger-pointing in this situation, without a champion who steps up and takes charge of the patient and their healthcare utilization patterns. Lack of accountability for frequent-flyer children may be one of the greatest contributors to their repeated hospitalizations.

So any solution has to begin with collective accountability shared by all providers who deliver health services to a particular child: specialists, home nurses, primary care clinicians and hospital providers. Once these providers become better integrated, we can start to find the root causes of the child’s frequent readmissions.

The experiences of clinicians who are deep in the trenches caring for complex, high-resource-utilizing patients have a lot to teach us. Dr. Jeffrey Brenner, highlighted in Atul Gawande’s recent article, “The Hot Spotters,” has been tracking high-resource-utilizing patients in Camden, New Jersey, one of the poorest, most crime-ridden cities in the nation, for the last decade. He’s actively sought to provide care for these patients and has done a great job – improving their health, keeping them out of the hospital and reducing healthcare costs.

Brenner talks about the “light switch” – the eureka moment when detective work uncovers an actionable root cause for a patient’s poor health and high resource use. Dr. Robert Master from the Commonwealth Care Alliance in Boston describes the same kind of moment during repeated home visits to adults with severe physical disabilities. I experienced it first-hand as a medical student with my first “frequent flier,” Jim: We found that that the wrong setting on his feeding pump contributed to his being hospitalized four times in one year.

If you do a root cause analysis, you may find medical reasons for a child’s readmissions – the child’s seizure management may not be optimized. Sometimes you’ll find social reasons – the parents’ caregiving burden is too immense and they need respite care. Sometimes you’ll find health-services reasons – the primary-care physician feels uncomfortable caring for the complex child for an urgent illness and sends him to the emergency department every time he’s sick.  Other times, you may not find a true root cause – but in the process of searching, you may arrive at a care plan that, when implemented, is enough to prevent a child with a complex chronic health condition from requiring hospital care during his next illness.

Whatever the reason, we as pediatricians need to merge our preventive medicine skills with our detective skills to uncover and attack the problems behind multiple hospital readmissions. The more we share our ideas and personal stories, the more apt we’ll be to prevent these hospitalizations and enable these children to remain healthy at home and in the community.

What are your experiences and ideas of breaking the readmission cycle in children who are hospitalized over and over again?  What’s worked?  What hasn’t worked? Your input may help another child and family become an infrequent flyer to the hospital.

4 comments

  • http://twitter.com/MauraCrabassMcG Maura CrabassMcGonkl

    In the case of my family, as a single Mom to 2 kids with trachs and another child with airway and apnea issues, I have seen the direct correlation between home nurse services and frequency of hospitalizations. When I have nursing support and back-up within a reasonable “awake care” interval, I am able to maintain my children in the home environment even when they are very sick. Our last hospitalization occurred just as we were entering a 3-day span without nursing and my twins began taking a turn for the worse- after I had covered four empty overnight shifts already the past week. With snow coming and very high oxygen requirements, as well as near constant hands-on care needs for both, we took transport into CHB. The last week of December of 2010, we faced a similar illness. Nearly daily we were in contact with our pediatrician or specialists from Childrens via phone, but with nursing support and antibiotics called in after a phone order for a trach culture, I was able to maintain my kids at home for both Christmas & New Year’s. I know without my access to doctors via phone, I would have had to pack all 3 kids into the car and drive in to the ER. Having home nursing care at a high amount of coverage enabled me to get the rest I needed to continue adequate care when I had no shift available.

  • http://twitter.com/MauraCrabassMcG Maura CrabassMcGonkl

    In the case of my family, as a single Mom to 2 kids with trachs and another child with airway and apnea issues, I have seen the direct correlation between home nurse services and frequency of hospitalizations. When I have nursing support and back-up within a reasonable “awake care” interval, I am able to maintain my children in the home environment even when they are very sick. Our last hospitalization occurred just as we were entering a 3-day span without nursing and my twins began taking a turn for the worse- after I had covered four empty overnight shifts already the past week. With snow coming and very high oxygen requirements, as well as near constant hands-on care needs for both, we took transport into CHB. The last week of December of 2010, we faced a similar illness. Nearly daily we were in contact with our pediatrician or specialists from Childrens via phone, but with nursing support and antibiotics called in after a phone order for a trach culture, I was able to maintain my kids at home for both Christmas & New Year’s. I know without my access to doctors via phone, I would have had to pack all 3 kids into the car and drive in to the ER. Having home nursing care at a high amount of coverage enabled me to get the rest I needed to continue adequate care when I had no shift available.

  • bettyd

    I completely agree with Maura above. Home nursing services are essential to keeping our complex kids out of the hospital. It is a difficult task to be a 24/7 provider when even the child’s sleep cycles require interventions for meds, repositioning, feeding pump or other devices alarming during the night. We want to keep our kids at home – imagine the enormous cost of pediatric nursing home care – but we can’t be a parent and nurse 24/7. Please send this study to the State, who is looking to reduce nursing coverage for the most needy.

  • Jay

    I also agree. We are supposed top have nursing every night and have never had it. We have limited day hours but it is a continuous fight to keep it. The agency that provides RN support has already decreased the services due to state finances and pressure to reduce costs. Yes, we have done well keeping her healthier and out of the hospital but if the services continue to be decreased will this be the case?

Previous post:

Next post: