The hospitals are among 751 nationwide that will lose 1 percent of their Medicare reimbursements in this fiscal year. The penalties are part of the Centers for Medicare and Medicaid Services’ (CMS) Hospital-Acquired Condition Reduction Program, which is part of the Affordable Care Act.

UConn John Dempsey Hospital has been penalized by Medicare all four years.

The program penalizes hospitals with the highest rates of patients who got infections from hysterectomies, colon surgeries, urinary tract catheters and central line tubes. It also tallies those who suffered from blood clots, bed sores or falls while hospitalized.

The 15 Connecticut hospitals penalized mark a slight uptick from the 14 that were penalized in the 2017 fiscal year, according to the data reported by Kaiser Health News.

“Any safety issue or hospital-acquired condition is one too many,” said Dr. Mary Cooper, chief quality officer and senior vice president for clinical affairs at the Connecticut Hospital Association. “Connecticut hospitals have always been dedicated to providing excellent quality care to patients. While we are making progress, we recognize that there is still work to be done, and are committed to continuously improving safety, quality of care and patient satisfaction.”

All hospitals in the state have adopted “high reliability” standards intended to reduce instances of preventable patient harm, which Cooper said “is changing the way healthcare is delivered and is saving lives every day.”

Of the 15 Connecticut hospitals that received penalties for 2018, six have been penalized in all four years since the program launched, according to CMS data. They are Bridgeport Hospital, Connecticut Hospice Inc. in Branford, Hartford Hospital, UConn John Dempsey Hospital in Farmington, Windham Community Memorial Hospital and Yale New Haven Hospital.

Five facilities on this year’s list also were penalized last year: Charlotte Hungerford Hospital in Torrington, Day Kimball Hospital in Putnam, Johnson Memorial Hospital in Stafford Springs, Masonicare Health Center in Wallingford, and St. Mary’s Hospital in Waterbury.

Others on the list for penalties in 2018 were MidState Medical Center in Meriden, Norwalk Hospital Association, Rockville General Hospital in Vernon and Waterbury Hospital.

While many hospitals are making progress when it comes to patient safety, more needs to be done, said Lisa Freeman, executive director of the Connecticut Center for Patient Safety.

Yale New Haven Hospital is among the 15 hospitals penalized.

“We’re not making any major strides,” she said. “There are certain hospitals that get penalized every year and there are certain hospitals that are not penalized ever. Unfortunately, money is a tremendous motivator for change. My hope is the hospitals that are being rated [in rankings like the CMS one] will use them as information to improve things.”

Cooper noted that by law the program must impose penalties on the lowest-performing 25 percent of hospitals ever year, “so even when hospitals are improving, one-quarter of all hospitals will still be subject to payment reductions.”

There are seven Connecticut hospitals that have never been penalized under the program. They are: Bristol Hospital,  Griffin Hospital in Derby, The Hospital at Hebrew Senior Care in West Hartford, Milford Hospital,  Sharon Hospital,  St. Vincent’s Medical Center in Bridgeport and William Backus Hospital in Norwich.

The CMS program is controversial and some hospitals have claimed in the past that it unfairly puts certain hospitals at a disadvantage if they treat certain populations or are “teaching hospitals.”

But, Freeman said, “Patient safety is patient safety. It shouldn’t matter what kind of hospital you are at.”

She hopes hospitals that have made improvements will share their successes and strategies with other hospitals.

“There is so much to learn from each other, and it can be done,” she said.

Glyphosate, the active ingredient in the world’s top-selling weed killer, Roundup, is a suspected carcinogen that’s used in agriculture, on golf courses, ballfields and other public venues, and for lawn care, experts said. It can be found in more than 750 products sold in the U.S., reports the National Pesticide Information Center.

Health concerns have been raised about Roundup for decades, concerns consistently disputed by its manufacturer, Monsanto. Earlier this year, a group of environmental health scientists called for the federal government to reassess whether glyphosate is a cancer risk.

iStock Photo.

Glyphosate can be found in more than 750 products in the U.S.

The New York- and Connecticut-based Citizens Campaign for the Environment supports glyphosate “restrictions or prohibitions,” said Connecticut program director Louis Burch.   Glyphosate poses a risk to young children “due to their rapidly growing bodies and developing immune systems,” he said. It also hurts aquatic life and can harm bees and other pollinators, he said.

The U.S. Environmental Protection Agency limits glyphosate residue content in food and in the amount workers can be exposed to. Calling the limits inadequate, critics say the U.S. Food and Drug Administration—which is mandated to enforce those limits on many foods—has failed to do its job.

The Government Accountability Office reported in 2014 that the FDA doesn’t test “for several commonly used pesticides,” including glyphosate, “the most used agricultural pesticide.”

FDA spokeswoman Megan McSeveney said that because of the cost of the tests, the agency “has not routinely” looked for glyphosate. In 2016, the development of a “streamlined” method allowed the FDA to start testing for residues in soybeans, corn, milk and eggs. The analyses were put on hold for a few months when testing was transferred to new laboratories but resumed this year, McSeveney said.

Preliminary results of the new tests, which were presented at a conference last year, showed no violations for glyphosate residues, but the testing continues. All results “must go through the FDA’s quality-control process to be verified,” McSeveney said.

Monsanto says glyphosate has been used by farmers, homeowners and others for more than 40 years and, if used properly, “does not present an unreasonable risk of adverse effects to humans, wildlife or the environment.”

In July, however, California added glyphosate to its list of chemicals known to cause cancer. The move follows a 2015 determination by the World Health Organization’s International Agency for Research on Cancer that glyphosate was “probably carcinogenic to humans.”

In Connecticut, a bill to ban the use of herbicides on highway medians and railroad rights of way won environment committee approval, but was not voted on by the end of the legislative session.

Lori Brown, executive director, Conn. League of Conservation Voters.

Glyphosate is a “dreadful substance” that has hurt consumers, applicators, wildlife and the environment, said Lori Brown, executive director of the Connecticut League of Conservation Voters. She said she supports action at every level of government to do “whatever it takes to get it out of the environment.”

U.S. Sen. Richard Blumenthal said he’s “concerned with the growing body of evidence linking glyphosate to serious health problems, including cancer.

“I would support a limitation or ban on the use of glyphosate and encourage further investigation into its potentially devastating effects,” he said.

The Northeast Organic Farming Association of Connecticut, referring to glyphosate as a “chemical poison,” says more than 100 million pounds are applied annually on U.S. food crops.

But the Connecticut Environmental Council, which represents golf course superintendents, pest control companies and groundskeepers, said if instructions on the product’s label are followed, it has no concerns about the safety of glyphosate.

“I consider it a valuable tool in controlling weeds such as poison ivy and grass along fence lines,” said Michael Wallace, the group’s president.

North Haven-based Environment and Human Health, Inc.,—a group of doctors and public health professionals—said glyphosate shouldn’t be sold to everyone who walks into a store to buy it.

“The public has been using this product for years and been told it was safe, but scientists are now finding out it is dangerous to human health,” said Nancy Alderman, the group’s president.

“Industry is still claiming, as they always have, that it is perfectly safe, and there is a whole population of people unaware of the product’s health hazards. Roundup should become a restricted pesticide that would require a pesticide permit to use it,” Alderman said.

NewsTimes Photo.

Nancy Alderman, president, Environment and Human Health, Inc.

Last year, scientists representing the Food and Agriculture Organization of the United Nations and WHO reported that “there is some evidence of a positive association between glyphosate exposure and risk of non-Hodgkin lymphoma,” but “the only large cohort study of high quality found no evidence of an association at any exposure level.” They also said “glyphosate is unlikely to pose a carcinogenic risk to humans from exposure through the diet.”

Monsanto, which says WHO’s cancer research agency “overlooked decades of thorough and science-based analysis by regulatory agencies around the world,” has also been hit with hundreds of lawsuits by individuals who say the multinational corporation failed to warn that exposure to Roundup could cause non-Hodgkin lymphoma, a cancer that starts in white blood cells.

Monsanto spokeswoman Charla Lord said, “No other pesticide has been more extensively tested than glyphosate.” Regulatory authorities in the U.S. and other countries “have publicly reaffirmed that glyphosate does not cause cancer,” she said, and “the “overwhelming conclusion of experts worldwide, including the Environmental Protection Agency, has been that glyphosate can be used safely according to label instructions.”

But Burch, of the Citizens Campaign for the Environment, said the group will continue to push for limits on the use of chemical pesticides and herbicides. “Our members continue to be concerned about [their] unintended effects.”

This initiative, which gives ex-offenders the opportunity to see a primary care physician on a regular basis and access critical mental health and drug-abuse treatment programs, exists because of the Affordable Care Act (ACA), and Medicaid pays most of the costs.

Recidivism data show that the initiative is working, state officials say. Yearly, the Court Support Services Division (CSSD) refers approximately 20,000 adults on probation to various behavioral health programs and tracks them for 12 months. In 2016, CSSD reported that 23.1 percent of adults who completed their referral program were rearrested, a five-year low since CSSD started tracking in 2012. For those who dropped out or were kicked out of the program, 41 percent re-offended within 12 months.

But the re-entry health care programs, which rely on generous reimbursements under Medicaid, are in jeopardy, as President Trump and the Republican-controlled Congress continue to discuss plans to replace the ACA and trim Medicaid funding.

In late March, a Republican repeal bill, which would have also converted Medicaid to a block grant program and cut state funding, was pulled from consideration in the House because it did not have the votes for approval. The House speaker announced that the ACA “was the law of the land.” But now, weeks later, replacing the ACA and cutting Medicaid are back on the agenda.

State officials are closely monitoring to see if the new administration will roll back policy changes that have made it easier for the state to connect ex-offenders to health care and drug treatment programs.

And community-based organizations that now bill Medicaid directly for behavioral health services are also worried that funds will disappear, and that former prisoners will be left without health coverage.

“Access to health care plays a critical role” in prisoner re-entry, said Jeff Grant, executive director of Bridgeport non-profit Family ReEntry. “All of these returning citizens who return to the street without adequate wraparound services are going to return to the behavior that got them in trouble in the first place.”

Nationally, studies of similar re-entry initiatives in other states have found that programs that link individuals to a health care system contribute to reduced recidivism. In Connecticut, Gov. Dannel Malloy’s administration credits access to community health services as part of the reason overall recidivism rates dropped slightly, from 32.9 percent in 2011 to 32.4 percent in 2014.

Leveraging Medicaid After State Cuts

A year ago, community-based mental health providers took a big hit in the state budget, when the state terminated $5.4 million in service contracts.

But following the lead of other states, some providers started billing Medicaid directly for ex-offender treatment—a move they said has allowed them to continue providing services to at least some of their clients. It is that backup plan that is in jeopardy as Congress works to cut Medicaid.

Non-profits such as Central Naugatuck Valley Help, Inc., which operates in Torrington, Danbury and Waterbury, were surprised at the severity of the state cuts. After losing a $1 million contract, Help, Inc. cut staff and employment programs, reduced the size of its space at each of its locations, and shifted behavioral health programming to Medicaid.

“We’ve been trying to hold on by billing Medicaid for the behavioral health services, and it’s challenging.” said Roberta Murtagh, executive director of Help, Inc.

Murtagh said the agency didn’t see a big change in the number of clients in Torrington and Danbury, but in Waterbury the numbers plummeted from 200 clients a year ago to about 70.

Those who get treatment say it is working. Ryan Puzinski, 29, of Torrington, said drug abuse treatment at Help, Inc.’s Watkins Center has helped him stay clean after serving 18 months for selling heroin.

Medicaid pays for Puzinski’s drug-abuse counseling sessions, as well as methadone, urine testing and LogistiCare transportation so he can get to medical appointments.

“I get a lot out of it,” he said. “It’s definitely helped me with identifying my triggers and my issues. Talking to people, hearing peoples’ stories, talking about my issues, getting feedback, stuff like that helps.”

Christina Brague, 42, of Torrington, said the drug-abuse treatment she gets at Help, Inc. through HUSKY D has been a “life saver.”

“It’s been a hard road, but I did it,” said Brague, who is on probation and has been enrolled in the program since September.

Derek Torrellas Photo.

Dr. Lisa Puglisi checks the blood pressure of Adrian Heggie at Transitions Clinic.

Not all non-profits had the resources to switch to Medicaid. Family ReEntry, which operates in Bridgeport, New Haven and Norwalk, lost its $1.9 million behavioral health state-funded contract. They cut their behavioral health programs but kept employment, housing and mentoring programs.

“A lot of eggs were in the Department of Correction budget basket. We didn’t want to … put all those eggs in a Medicaid basket only to find out that basket will be empty as well,” Grant said.

Access To Primary Care

Community workers say taking care of general health is part of a successful re-entry.

The Yale New Haven Hospital – Primary Care Center operates Transitions, part of a network of 17 clinics nationwide providing primary care “to promote healthy reintegration, improve health care utilization, and decrease prison recidivism.” The clinic, which has 700 patient visits each year across its two locations in New Haven, is partly funded through grants from the Centers for Medicare & Medicaid Services, a program created under the ACA that Trump’s Health Secretary Tom Price has vowed to eliminate.

“As a society, we tend to put health care on the back burner, but most of these guys never had a primary care physician,” said Jerry Smart, a community health worker for Transitions Clinic in New Haven. “If you get an illness that prevents you from working, how are you supposed to survive? Relapse is just around the corner.

“We are dealing with a population that is coming from an environment that’s plagued with violence, trauma, drugs,” Smart added. “There’s a lot of stress. I tell everybody who comes home, you may look good on the outside but you don’t know what’s going on the inside. Get some blood work, get a physical.”

Robert Nixon, 40, of New Haven, receives care at Transitions after serving 15 years in prison.

“Behind bars, it’s like a Motrin for everything,” he said. “When you come home, you start thinking where do I get the things that I need?”

After spending most of his adult life behind bars, Nixon said, he struggled in the outside world with simple things like crossing busy intersections in New Haven.

“It’s great you can go to a place where they know what you’re going through,” he said.

“Transitions is a community. They understand you. They explain everything to you. You walk out with a clearer head about how better to take care of yourself.”

Heidi Lubetkin, vice president of clinical and support services at Community Renewal Team, Inc., in Hartford, said many ex-offenders referred to the agency for mental health and drug abuse treatment were also in need of primary care. The agency connected with the University of Hartford’s Project Horizon to get its clients primary care help from volunteer registered nurses.

“I think it’s important to take care of the complete person,” she said. “You can’t take care of just one thing. Yes, take care of their substance abuse and mental health, but you can’t do that if they feel like crud.”

Reduction In Federal Funds

Since becoming the first state to expand Medicaid, Connecticut has relied more and more on federal dollars to pay for re-entry services and other programs.

In fiscal year 2017, $3.5 billion in federal Medicaid funds flowed into Connecticut, an increase of nearly $1 billion since the ACA was passed. Much of that increase is due to expanding Medicaid coverage to childless adults, aged 19 to 65, earning up to 138 percent of the federal poverty level, which Connecticut calls Husky D. Currently, 208,113 low-income residents are covered under HUSKY D, up from just 75,000 five years ago.

A significant number of those newly covered individuals are released prisoners. Numbers from the state Department of Social Services (DSS) show that 87.8 percent of new Medicaid sign-ups from January to November last year were HUSKY D.

Derek Torrellas Photo.

Daviana Contreras, case manager, meets with Jason Lerczak at the Community Renewal Team’s Hartford office. Lerczak started receiving services two years ago.

Until now, the federal government picked up 100 percent of costs under HUSKY D, which gave Connecticut a great incentive to sign up released prisoners for Medicaid. The federal share drops to 95 percent this year and notches down every year until it hits 90 percent in 2020. Still, that means Connecticut will pay just $32.1 million in fiscal year 2017 to make sure more than 200,000 low-income residents have health insurance, according to an estimate in the governor’s budget released in February.

According to the governor’s budget, the HUSKY D program will cost an estimated $1.46 billion in 2018. Under current law, the federal government will pick up 94 percent of that ($1.37 billion), while the state will pick up 6 percent ($87.5 million).

But if Republicans succeed in changing Medicaid funding to a block grant program, states would get a lump sum and less than what is given now. According to estimates from the state’s Office of Policy and Management, the GOP’s proposal from March would cut as much as $450 million in fiscal year 2020. This would force the state to make up the difference in funding or cut programs and reduce the number of people served.

A change in Medicaid funding “would shift money back to the state general fund and would likely mean reduction in services,” said Brian Hill, director of research, program analysis, and quality improvement at CSSD. If the state “continues to trim money [for those services] over the years, we don’t have that money sitting in a separate pot ready to supplant the Medicaid funds as they get cut,” Hill said.

“We’re talking about thousands of offenders who wouldn’t be getting the services they need,” Hill said.

Michael Lawlor, the state’s undersecretary for criminal justice policy and planning, said repealing Obamacare would lead to more crime and recidivism.

“Our goal is less crime. All the things we are doing, we believe, have the effect of reducing crime, and all the data we have show that it’s working,” Lawlor said.

Even after the Republican bill failed in March, Lawlor said, they were still concerned about changes to Medicaid — big and small.

“We have to be on guard with whatever proposals are being made,” he said.

In 2004, the Department of Health & Human Services encouraged states to suspend rather than terminate people on Medicaid when they are imprisoned, something Connecticut does. Lawlor said even without Congress, the new administration could roll back changes like this and add an obstacle for released prisoners getting help they need.

“Right now we’re concerned about the unintended consequences of even relatively minor changes that they could make that would have relatively large consequences,” Lawlor said.

“You could easily reverse all the progress that’s been made with a couple of minor changes to federal law.”

Multiple residents of Fernwood Rest Home, Inc., a 68-bed facility, told inspectors from the state Department of Public Health (DPH) that administrators would tell them they had to “go shopping to feed the monkeys,” a state DPH report says. A staff member of the home confirmed complaints from residents that administrators would put a chain across the dining room while the staff was making a “gourmet breakfast for themselves,” and would instruct staff members to “keep the monkeys out” of the room while they were eating.

At the same time, the facility, with a significant population of mentally ill residents, skimped on meals for residents, offering them eggs for breakfast only two days a week, with hot and cold cereal provided on other weekdays and donuts on Sundays, the report says. Residents told inspectors that the only snacks provided were granola bars, “with some residents indicating that they are still hungry and are told they cannot have any other snacks until the next day.”

The home was cited for eight violations, including failing to treat residents with dignity and respect; failing to give them quarterly statements or receipts pertaining to their personal financial accounts; and failing to provide “routine recreational activities” for them. In addition, no resident council was in place to allow residents to discuss their living conditions or push for improvements, the report says.

Under a consent order between the DPH and the home’s president, Raymond Adkins, Fernwood Rest Home will pay a $2,000 fine and hire a temporary manager, who will then bring on a new full-time director and make other staff and procedural changes. Adkins’ wife, Vivian, is listed as the home’s administrator.

Reached Thursday, Karen Adkins, daughter of Raymond and Vivian and a manager at the home, said some of the DPH findings were “exaggerated or outright untrue.” She said the rest home, first established by her grandparents, has struggled with “changes in the economy and a more demanding population” of residents, some who have mental illnesses.

“Our daily rate is a little more than $57 a day, and we have to do an awful lot with that money,” she said. “Where we’ve fallen down is, we’ve tried to keep this like a home, instead of an institution,” which contributed to some of the citations for inadequate procedures.

She said some residents have been at the rest home for more than a decade.

“I was flabbergasted at some of the things that were in (the report) – that anyone would take things like that out of context,” she said. “Who would come here and live here for years if we were like that?”

The inspection report cites a number of instances in which the home failed to ensure that residents’ special dietary restrictions were followed. Fernwood’s day-shift “dietary manager” told DPH inspectors that he did not have a list of residents with special diet needs, including diabetic residents.

Beyond food, the DPH report cites the home for failing to respect residents’ privacy by opening their mail, and for segregating male and female residents by gender in the dining room and lounge areas. The home also was cited for failing to properly secure medication or to keep track of narcotics, with inspectors finding missing Vicodin tablets, among other discrepancies.

Administrators told DPH inspectors that recreational activities were not consistently provided “due to staffing issues and the lack of finances.”

“Care coordination is especially important for children, as they benefit most when their needs are detected early and they receive intervention services,” the report says. “The primary care medical home is an ideal venue for detecting children’s problems at the earliest possible age and connecting families to helpful interventions and supports outside of the primary care site.”

The evaluation of the “Health Outreach for Medical Equality” project, dubbed “H.O.M.E.,” found that adding care coordinators to work with low-income children in the HUSKY insurance program boosted the percentage of Hartford children ages 2 and younger using dental services – 34 percent for those who received care coordination, vs. 25 percent of Hartford children overall.

In addition, children who received H.O.M.E. services accessed behavioral and mental health services at a significantly higher rate than the overall Hartford HUSKY population.

The increased access to dental and mental health care “pays off tremendously in the long run,” in terms of both health outcomes and cost savings, as problems are addressed earlier, said Lisa Honigfeld, vice president for health initiatives at the Child Health and Development Institute.

The H.O.M.E. project was coordinated by the Hispanic Health Council and the Connecticut Children’s Medical Center, which partnered to provide outreach and care coordination for patients in the Charter Oak Health Center at Children’s Medical Center (the Primary Care Center) who were insured by HUSKY. The project was funded by the Children’s Fund of Connecticut, the Hartford Foundation for Public Giving and the state Department of Social Services.

While project leaders expected that the coordinated care would cut down on the number of emergency room visits, the opposite was true: Children in H.O.M.E. in two age groups – 6 to 8, and 15 to 17 — were more likely to visit ERs than their counterparts.

Honigfeld said the finding was “surprising” and of concern, since a goal of care coordination is to decrease avoidable emergency room visits. But the evaluation suggests two reasons for the increased number of ER visits: H.O.M.E. participants tended to be a higher-risk population, and, because they received primary care services at Connecticut Children’s, they gravitated towards the medical center after-hours and on weekends when they needed care.

Honigfeld said that while national health care reform is “banking heavily on efforts to keep people out of emergency rooms, that really will not happen unless there’s an expansion of primary care capacity and access.”

Earlier studies have indicated that 40 percent of Connecticut children enrolled in HUSKY were seen in emergency care settings in 2006. A third of them sought ER care for conditions that could have been treated in primary care.

Fewer than 25 percent of Connecticut-based pediatric and family medicine practices report that they engage in formal care coordination activities, the report says. Almost half of all the practices said that care coordination is done on an as-needed basis, without a formal mechanism. Key barriers to providing coordinated care include a lack of time, reimbursement, staff, and integrated data systems that would support care linkages for patients.

The report advocates extra reimbursement to clinical practices for care coordination services, in both the public and private health insurance sectors.

Elements of the H.O.M.E project are being incorporated into ongoing efforts to coordinate care for Hartford area children that can be replicated in other communities, Honigfeld said. She noted that Connecticut has made significant progress in establishing a statewide “medical home” system through Medicaid that encourages coordinated care for children and adults. The state is using a medical home model for at-risk children enrolled in Children & Youth with Special Health Care Needs (CYSHCN) program.

Just recently, one of her female patients, who was switched to a new beta blocker for high blood pressure during an inpatient stay, landed back in the hospital after discharge because she had taken both the new medication and her old beta blocker – a combination that lowered her heart rate and blood pressure to dangerous levels.

“Every physician can tell you about these kinds of errors,” Horwitz said. “We do a relatively poor job of educating patients about their medications.”

As a researcher, Horwitz can now quantify those lapses.  A recent study she led looked at 377 patients at Yale-New Haven Hospital, ages 64 and older, who had been admitted with heart failure, acute coronary syndrome or pneumonia, then discharged to home. Of that group, 307 patients – or 81 percent — either experienced a provider error in their discharge medications or had no understanding of at least one intended medication change.

The findings that three out of four patients are going home with the wrong prescriptions or a lack of knowledge about their medications come as hospitals grapple with high readmission rates, and as adverse drug reactions post-discharge are exceedingly common.

“We’re talking about the vast majority of our patients going home at potential risk” of medication problems, Horwitz said. “That’s huge. Collectively, something is not right.”

The Yale study relied on interviews with patients after discharge, who were asked about their medication regimen. The researchers also reviewed patients’ admission and discharge medication records to see if all changes were intentional, or if any appeared to be errors. A total of 565 admission medications were re-dosed or stopped at discharge.

In all, the study found that 24 percent of the medication changes were due to provider error. In addition, the average patient had no understanding of 60 percent of all stopped, re-dosed and new medications. Errors and misunderstanding were more common for medications not related to the patient’s primary diagnosis than for those related to the main ailment being treated.

Horwitz said the findings highlight two key gaps – one a “systems” problem, the other an education problem. The electronic medical records system used at Yale and other hospitals makes it hard to track and reconcile medication changes, and discharge lists don’t flag which prescriptions are new and which have been stopped. Patients at many hospitals get a quick drug rundown from a nurse before discharge, but it’s not the kind of “teach-back” process that ensures they understand the medication list, Horwitz said.

“The solution is actually not to have a nurse sit with you for an hour and go over everything – it’s pretty much guaranteed that you’ll forget it by the time you get home,” she explained. “We’re talking about getting patients educated over the course of the hospital stay, in a way that assesses their understanding in real time.”

Yale-New Haven already has taken steps to improve patient education, Horwitz said, and is set to launch a new electronic records system in February that will allow for detailed medication tracking. Those changes are part of the hospital’s larger effort to cut down on patient readmissions—a factor that the federal government is now closely tracking.

Starting in October, new federal rules allow the government to cut Medicare funding to hospitals with high rates of patients who are readmitted within 30 days of a hospital stay for three conditions: pneumonia, heart attacks and heart failure. In Connecticut, 23 of the state’s 31 hospitals, including Yale-New Haven, are among more than 2,200 nationwide that face Medicare penalties this year for high readmissions.

Readmissions are counted no matter why the patient returns within 30 days – meaning, for example, that a hospital would be penalized if a pneumonia patient returns with unrelated kidney problems.

Horwitz said the study’s finding that errors are more common for drugs not related to the primary ailment causing the hospitalization underscores the need for clinicians to pay close attention to patient’s chronic and secondary illnesses.

“Most patients who get readmitted to the hospital are coming back for other problems,” she said. “Very often, we do a good job managing medications for the reason they’re in the hospital — what we do badly is managing the other stuff the patient was taking. . . We make mistakes in chronic disease management.”

Hospitals are trying a number of new measures to reduce readmissions, many of them related to better-equipping patients for the transition home. Yale-New Haven and its affiliated Hospital of St. Raphael have joined with the Agency on Aging of South Central Connecticut to have special care transition teams work with Medicare patients after discharge.

Nine other Connecticut hospitals are participating in a federally funded “ComPass2C” program, run by Connecticut Community Care, Inc., of Bristol, which assigns nurses and transition counselors to work with Medicare patients on managing their discharge care, through in-hospital coaching and follow-up home contact.

Dan Flynn, co-director of the program, said medication management is a “core piece” of the hospital-to-home intervention. Medication discrepancies were a key problem in a pilot program run by Connecticut Community Care at the Hospital of Central Connecticut, he said.

“The most prevalent issue at the patient level was non-intentional non-adherence” to a medication regimen, Flynn said, meaning patients wouldn’t know what drugs they were supposed to be taking. Many discharged patients lacked sufficient instructions on medications, he said.

While Connecticut Community Care provides the staff to serve as the “additional professional link” between hospitals and community care, Flynn said, the program’s goal is to educate and empower patients about their own medication needs, health status and health care scheduling.

“The goal is that patients will have their medication information in hand,” not only post-discharge but for subsequent hospitalizations or in other health care settings, he said.

The nine participating hospitals, in eastern and north central Connecticut, are: Bristol Hospital, Hartford Hospital, John Dempsey Hospital, Lawrence & Memorial Hospital, MidState Medical Center, Saint Francis Hospital & Medical Center, the Hospital of Central Connecticut, William W. Backus Hospital and Windham Hospital.

The decision represents a significant victory for Norwalk-based IMS Health, Inc., a leading drug data provider, and its co-respondents, data vendors Verispan LLC (now SDI Health LLC) and Source Healthcare Analytics, Inc., and PhRMA, a drug industry trade group. They had challenged the law on First Amendment grounds, asserting that it violated their Constitutional right to free speech.

The Vermont law takes aim at a practice known as “prescription data mining,” in which pharmacies sell electronic prescription records (with patients’ names encrypted) to medical data providers. These companies extract data such as physicians’ identifying information and prescribing habits, and sell them to pharmaceutical firms, which use them to tailor sales pitches to individual doctors. Vermont sought to curtain this practice to protect physician privacy and to reduce spiraling health care costs.

Writing for the court majority, Justice Anthony Kennedy said that the Vermont law violates the free speech rights of data providers and drug companies. “Vermont may be displeased that detailers with prescriber-identifying information are effective in promoting brand-name drugs, but the state may not burden protected expression in order to tilt public debate in a preferred direction.”

Mixed Reactions

IMS Health senior vice president and general counsel Harvey Ashman hailed the decision as essential to improving patient care.

“Transparency is vitally important to advancing healthcare,” he said in a company statement. Access to doctors’ prescribing practices, he said, “enables communication about new medicines, best practices, and safety updates.”

The ruling was a setback for consumer health advocates and physician groups that support the Vermont law, and for legislators in other states seeking to enact similar laws. Existing laws in Maine and New Hampshire are likely to be challenged in view of the court’s decision.

Vermont Attorney General William Sorrell said the court’s decision was a disappointment, but not a defeat. “Our challenge now will be to continue to work to protect medical privacy and reduce health care costs without violating the Supreme Court’s ruling,” he noted. “This is a step back, but not the end of the story.”

Sweeping Implications

Legal experts expect the results of this case – Sorrell v. IMS Health, Inc. – to influence far more than the promotion of prescription drugs.

Constitutional attorney Cheryl Hanna, a professor at Vermont Law School in South Royalton, said the court’s decision “advances the rights of corporate speech,” making it harder for state and federal governments to regulate commercial messages in the name of consumer protection.

Many existing regulations are likely to be challenged in the wake of the new ruling, she said, such as the Food and Drug Administration’s ban on advertising drugs for non-approved (“off-label) uses.

In a dissenting opinion, Justice Stephen Breyer, joined by Justices Ruth Bader Ginsburg and Elena Kagan, wrote that the court wrongly applied the highest standard of free speech, opening “a Pandora’s box of First Amendment challenges to many ordinary regulatory practices that may only incidentally affect a commercial message.”

To read the previous story on drug data mining click here.