By Roberta Holley, Rabbi David Keehn, and Jess Geevarghese
Myth: Chaplains are nice to have in hospitals but not essential. Chaplains are a luxury, not a necessity.
Fact: We live in a healthcare environment that’s driven to deliver higher quality care while lowering costs. Without the data and evidence that chaplains contribute significantly to these goals, some hospitals might be unwilling to have paid chaplains on staff, and fewer people would get the expert help that chaplains provide.
The Need: Chaplains can develop and manage pilot programs to begin building the case that chaplains contribute significantly to higher quality care and an improved patient experience – both of which contribute to an organization’s bottom line and reputation.
The American healthcare system exists in a state of flux. The Affordable Care Act has put increasing pressure on hospital administrators to provide high-quality care more efficiently. What can we do to assist our administrators? While keeping to our core mission of providing spiritual care, we can strengthen chaplaincy’s contribution to the overall goals of the hospital.
Hospital administrators are concerned about hospital readmissions and patient experience. The ACA in 2012 authorized the Federal Centers for Medicare and Medicaid Services to penalize higher-than-expected 30-day readmission rates for heart failure, heart attacks, and pneumonia by decreasing those hospitals’ Medicare payment rate across all discharges.
Numerous studies have indicated that hospital readmissions are a significant problem, both for patients and the healthcare system in general. At the national level, among older Medicare beneficiaries, 20% of hospitalized patients are readmitted within 30 days and 56% are readmitted within a year. A 2009 study estimated the cost of these unplanned rehospitalizations at $17.4 billion a year. Many of those readmissions are due to unanticipated change in a patient’s condition or a planned follow-up treatment. But some result from patient confusion over new drug regimens, inadequate follow-up with primary care physicians, anxiety, and isolation.
“Can Chaplains Lend Their Talents to Readmission Reduction?”
HealthCare Chaplaincy Network asked the question, “Can chaplains lend their talents to readmission reduction?” With a grant from the New York Community Trust, we partnered with New York Hospital Queens to seek an answer. Initially, the project focused specifically on patients suffering from heart failure, heart attacks and pneumonia, as studies have shown that these are the three populations with the highest likelihood of readmission to hospitals within 30 days of discharge (and the three groups that the Centers for Medicaid/Medicare Services tracks). Then, as the pilot continued, we expanded the patient population to Medicare fee-for-service patients with a high risk for readmit status.
Every discipline has a role to play, and concurrently, NYHQ had a social work intervention for the same population. We worked closely with the hospital team to ensure smooth communication between the two groups. Ultimately, the patients we saw were older adults who had been readmitted after the social work intervention, or those who refused the social work intervention and who were not seen by social work due to distance, but were considered high-risk patients with any diagnosis.
What Did the Pilot Involve?
Roberta Holley, an experienced hospital chaplain, visited patients over a six-month time frame in the hospital to conduct a chaplaincy visit. Then, she would describe the program and ask if the patient would participate. If the patient consented, Chaplain Holley visited the patient while in the hospital, once or more depending on length of stay. Once he or she was discharged, Chaplain Holley would call twice in the first week and once a week for the next three weeks to follow up on their transition home, conduct a chaplaincy visit over the phone to address any spiritual/emotional concerns, and ask specific questions regarding care. If the patient expressed any medical concerns or questions, Chaplain Holley would connect the nurse case manager to the patient.
What We Learned To Date
While the project was aimed at patients, caregivers need just as much care, if not more than the patients. Caregivers were anxious, needed someone to hear them out, and often had no one to talk to about the situation. The importance of chaplaincy support of the family caregiver seemed a critical finding that has not yet been reported in a science of chaplaincy paper.
Most patients welcomed the spiritual, emotional and practical support given in the hospital and post-discharge. Men were less likely to get into deep meaningful conversations. The practical support included Chaplain Holley working as a liaison to care management and being a sounding board about difficulties procuring prescriptions, medical equipment, need for palliative care, and advance directives. Chaplain Holley could see the effect of chaplaincy with angry patients or caregivers, whose feelings would ease with dialogue. While this was a chaplaincy intervention, Chaplain Holley was part of an excellent interdisciplinary team comprising chaplaincy, care management and patient experience departments.
Chaplain Holley has worked with 158 patients, of whom 16 were discharged to a facility, five died and one refused the program after consent. The program is still under way. To date, 20 patients were readmitted, which is slightly lower than NYHQ’s average readmission rate for the core measures. While the results are preliminary, we don’t expect to be able to draw definitive conclusions of the effect on readmissions. However, we anticipate the insight of the qualitative findings has created a new space in the existing literature. Our findings have set the foundation for designing empirical studies in this realm of chaplaincy research and quality improvement programs nationally. We will report on results when final.
Chaplain Holley says, “As the chaplain, I realize that it is a privilege to take the time to hear the patient or caregiver out, to discuss the issues and concerns that are affecting quality of care and recovery, and to have the ability to take action of their behalf. This action may range from praying to interceding with the the multidisciplinary team that affects the patient’s care.”
Roberta Holley is the chaplain dedicated to the New York Hospital Queens’ readmissions reduction project. Rabbi David Keehn is director of pastoral care at New York Hospital Queens. Jess Geevarghese is senior director of business development and initiatives at HealthCare Chaplaincy Network.
