Preventing cardiac patients from boomeranging back into the hospital was one reason the North Shore-Long Island Jewish Health System hired psychologist Kristina J. McGuire, PsyD, to launch its behavioral cardiology service in 2011. Hospitals now face hefty fines from the Centers for Medicare and Medicaid Services if they have above-average 30-day re-admission rates for heart failure and acute myocardial infarction patients, says McGuire, who is based in the system's Zucker Hillside Hospital in Glen Oak, N.Y.
Of course, says McGuire, helping cardiac patients avoid re-hospitalization isn't just a matter of finances. It's also about improving their health. Before the North Shore-Long Island Jewish Health System created its behavioral cardiology service, "there really was no system in place for cardiac patients to have their complex psychosocial needs met," says McGuire, who worked on her own until the system hired another psychologist at a different site last year. (A psychiatrist who devotes half her time to behavioral cardiology provides psychiatric evaluations and medication management.) Yet those needs were often what contributed significantly to patients — especially heart failure patients — ending up back in the hospital.
Heart failure can be an especially challenging disease for patients to manage, says McGuire. Patients must monitor their salt intake and diet carefully to reduce fluid buildup in the lungs and the rest of the body, for example. They're often on a lot of medications. And they can be depressed or anxious about their diagnosis, something that makes juggling those kinds of practical matters even more difficult.
"Often patients don't know where else but the hospital to turn in order to get their needs met," says McGuire.
McGuire's job is to prevent those unnecessary re-hospitalizations through intensive case management: helping with discharge planning, identifying support services and following up to make sure patients adhere to treatment regimens and get to appointments. For some patients, case management may make up 50 percent of her work, she says.
In one case, that meant providing a suitable scale for a patient with heart failure to take home from the hospital. "Buying a scale sounds very minor, but weighing yourself can mean the difference between re-admission to the hospital or not for some patients," says McGuire.
What she does is above and beyond normal psychotherapy, says McGuire, who also screens patients for depression, anxiety and other problems and provides brief psychotherapy interventions to those who need help. "It requires targeting the highest-risk patients and using an individualized 360-degree approach," she says, explaining that she assesses patients' perceptions and management of their disease, support system, logistics and any psychological problems that may be interfering with their medical treatment. Interventions may include coordination with treatment providers, telephone support, individual or group therapy, referrals to community resources and caregiver support.
Given the nation's aging population, McGuire believes such work will become increasingly common. She's not the only one.
"Kristina McGuire is the wave of the future," says psychologist Robert Allan, PhD, co-editor of APA's "Heart and Mind: The Practice of Cardiac Psychology." "The Medicare fines represent a watershed opportunity for psychologists to go to the nearest hospital and see if they can sign on in some way to reduce hospital readmissions."
—Rebecca A. Clay
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