Best Practices: Using volunteers to improve discharges

In early 2010, New York Methodist Hospital was, like most U.S. hospitals, searching for effective ways to curb its stubbornly high rates of preventable hospital readmissions.

Less than a year earlier, the New England Journal of Medicine published a landmark study reporting that one-fifth of Medicare beneficiaries ended up back in the hospital within 30 days of discharge, at an annual cost of $17.4 billion. That study and others like it led to a growing awareness of the problem and a call for changes that would eventually include financial penalties for excess Medicare readmissions.

At that time, New York Methodist's 30-day readmission rate among congestive heart-failure patients was above 25%, compared with the national rate of 24%. The hospital's troubling performance was the result of a number of factors, including a high percentage of patients from nursing homes, said Dr. John Heitner, director of noninvasive imaging and the cardiology fellowship program at the 591-bed Brooklyn hospital. “We knew we needed to do something,” he said.

The hospital had a successful program in place that used specially trained volunteers to improve patients' health literacy. Heitner and Mimi Makovitzky, the hospital's director of educational and volunteer resources, decided to test whether volunteers also could be used to improve the discharge process and reduce the number of patients unnecessarily returning to the hospital.

Heitner decided to conduct the project as a research study to determine what worked and what didn't. From June through December of 2010, he and his colleagues enrolled 137 patients with congestive heart failure. Half received standard care, and half received specialized dietary and medication instructions from student volunteers, along with a follow-up telephone call and weekly check-in calls for one month following discharge.

The results were striking, Heitner said. Only 7% of patients in the group who received volunteer help were readmitted within 30 days, compared with 19% in the control group. “It was a remarkable drop and we were just thrilled,” he said.

After the study concluded, New York Methodist received a one-year grant of $40,000 from the United Hospital Fund to continue the program. Makovitzky and her team made those funds stretch for two years, at which point the hospital made the program a permanent part of its volunteer services department.

From the first quarter of 2013 through the third quarter of 2014, the hospital's readmission rate for congestive heart failure fell from 25% to 21%, although that decline can't be reliably attributed to any single initiative.

Currently, New York Methodist's program has 16 volunteers who commit to stints of at least six months. They're trained to build rapport with patients, help them understand their condition and watch for red flags, said program manager Wendy Froede.

Makovitzky attributes much of the program's success to selecting high-quality volunteers. While the hospital uses non-medical lay volunteers to perform a wide range of general duties such as stocking supplies, the readmission program's volunteers are selected from a specialized pool of students interested in careers in medicine, nursing and public health. “We have hundreds and hundreds of applicants, and we look for the best and brightest people who are going into healthcare,” she said.

The student volunteers benefit because they gain patient-care experience, professional contacts and recommendation letters for their education and careers, Makovitzky said.

Dr. Eric Coleman, director of the Care Transitions Program at the University of Colorado and a recognized expert in care transitions, cautions against using lay volunteers without healthcare training to reduce readmissions. His model, used in hospitals across the country, prescribes the services of nurses, social workers or occupational therapists, all of whom have the expertise to teach patients the skills needed to manage their conditions.

But Coleman said New York Methodist's approach has merit because beginning healthcare students and workers have some degree of medical knowledge. And working closely with patients can help those volunteers better understand the patient experience and develop empathy, he said.

Despite the program's success, working with volunteers has its challenges, including frequent turnover and the need for more training. And nursing staff can be wary of volunteers walking onto their unit and talking to their patients. It's critical to get buy-in from nurses in the very beginning, Makovitzky said.

“But if I had my druthers, I would always work with volunteers,” she said. “They're here because they truly want to be here.”

Follow Maureen McKinney on Twitter: @MHmmckinney