After launching a program that enables patients to self-administer antibiotics, Parkland Health & Hospitals cut readmissions for participating patients by almost 50 percent, saved $40 million in unreimbursed costs—and spotlighted a new way to meet the 'triple aim' of health care.
Parkland launched its self-administered Outpatient Parenteral Antimicrobial Therapy (S-OPAT) program in 2009. The program primarily serves uninsured patients, as insured patients can receive nurse-administered therapy at home or elsewhere.
How Parkland's program works
The program's staff—a team that includes a case manager, social workers, pharmacists, and transitional care nurses—assesses which patients are eligible for the program, trains them, and monitors them.
To participate in the program, patients have to:
- Be able to be trained to complete the treatments at home;
- Have access to a refrigerator and a telephone;
- Be able to visit Parkland weekly; and
- Not have a history of injection drug misuse.
Patients are then referred to a pharmacist to assess whether an appropriate antibiotic can be administered at home, as some antibiotics necessitate a level of monitoring that is best provided in an inpatient setting. According to Hospitals & Health Networks' Lola Butcher, the pharmacist sets the dose, frequency, and overall length of treatment.
Transitional nurses then train eligible patients in English or Spanish, or in another language via phone-based translation services. Before patients can begin the program at home, they must demonstrate at least three times that they would be able to complete the process successfully.
Participating patients are sent home with a week's worth of antibiotics as well as a box of supplies to administer the medication. According to Butcher, patients receive a card that includes the date of their next appointment and a number to call if they need assistance. In addition, each IV bag includes a QR code that patients can scan with their phone to download a YouTube video demonstrating how to self-administer the drugs.
The patients are required to visit the clinic each week for blood tests and to have a nurse change the PICC line dressing and address any concerns.
Between 2009 and 2013, researchers collected data to compare the outcomes of patients in the program with those of patients whose medications were administered by a nurse.
They found that patients who administered the medication at home had similar or better outcomes than patients who had a nurse's assistance with the medication. For instance, S-OPAT patients had a 47 percent lower 30-day readmission rate than patients who had nurse assistance. According to the researchers, there was no significant difference in the groups' one-year mortality rates.
Moreover, the program saved nearly 6,000 days of patient hospitalization and $7.5 million each year. Over the course of eight years, the hospital saved 27,666 bed days and $40 million. And while many hospitals would see that as a revenue loss, for Parkland—an 800-bed safety net hospital that's typically at capacity—that meant $40 million in unreimbursed care went to other individuals who needed inpatient services, Butcher reports.
According to Kavita Bhavan, an infectious disease specialist at Parkland, said, "Tying up a number of beds for patients who could otherwise be home didn't make sense," she said. "By opening those beds up for the acutely ill who are coming into our [ED] every day, we are doing better with our resource utilization."
Now, Parkland is challenging other physicians to consider self-care initiatives. Cardiologists, for instance, are looking at whether patients who need continuous IV support for late-stage heart failure might be able to receive it at home, Butcher reports.
"When you draw upon the OPAT experience, it tells you that patients are probably capable of more than we give them credit for," Frederick Cerise, Parkland's president and CEO, said. "So, that is going to make us more willing to stretch the conventions a bit and trust that patients can assume more of their care if they have an engaged team [who is] working with them."
A culture change
While self-care initiatives are beginning to take root in the health care industry, Butcher writes, "the concept of patient-administered care is still somewhat radical in the United States, where patients and providers are accustomed to a specific power dynamic."
Separately, Alex Anderson, a research associate for innovation at IHI, said that patient-administered self-care requires a culture change in how health care professionals view their roles. "There are many providers who really do believe that they are the authority figures and that is how our health system has worked for a really long time, and they are probably not the best champions for getting this kind of work started."
Separately, Britt-Mari Banck, a nurse who came to the United States to teach a nephrology practice about developing a self-care program, noted that some of her colleagues were resistant to the idea at first. To that, she replied, "I said this is the future" (Butcher, Hospitals & Health Networks, 5/16; Butcher, Hospitals & Health Networks, 5/17; Minemyer, FierceHealthcare, 5/17).
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Stage 2: Discharge education
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