It’s the return visit nobody wants.
Patients are happy to stay away from hospitals as much as possible. Hospitals face financial penalties for excessive readmissions. Even so, many people with challenging health conditions leave the hospital only to reappear in the emergency room, sicker than ever. Some readmissions are unavoidable, but others are preventable. A return to the hospital shortly after discharge can be a sign that patients weren’t adequately prepared to go home. Other patients may fall through the cracks because follow-up care or community resources are lacking. Curbing rapid readmissions is a thorny issue for hospitals. Health care experts are trying to tease out causes and discover how to keep discharged patients from turning back into inpatients. Here’s where hospitals are starting to see glimmers of success.
Congestive heart failure is one of the highest-risk diagnoses for early hospital readmission. Heart failure patients who see a doctor for a clinic appointment soon after discharge — or receive a follow-up phone call from a nurse or pharmacist within the health care system — are less likely to be rehospitalized, according to a large study. Researchers evaluated records of about 11,000 heart failure patients in the Kaiser Permanente Northern California health system discharged over a 10-year period. “What we found was that timing of follow-up matters,” says Dr. Keane Lee, a cardiologist and research scientist with Kaiser Permanente and study co-author. “Specifically, it should be done within seven days of hospital discharge to be effective at reducing readmissions within 30 days.”
Clinicians trained in empathy skills may better relate to and communicate with patients getting ready for discharge. Encouraging two-way discussions instead of one-way lectures may help patients reveal their expectations, worries and potential barriers to keeping up with the treatment plan at home. At Cleveland Clinic, for example, health care providers undergo empathy training to more fully engage with and really listen to patients and family members. When doctors seem unhurried and offer their undivided attention, patients are more willing to open up. That’s when they disclose that they don’t have access to a local pharmacy for prescription refills, or transportation to medical appointments. It’s a perfect opportunity to pull in health team members, like clinical social workers, to connect patients to community resources.
Treating the whole patient
“Comorbid conditions” is a fancy way of saying a patient has more than one health problem. Patients are more than just their “main” condition, such as heart failure or chronic obstructive pulmonary disease, or COPD. When a patient has both diabetes and heart disease, for example, catching and treating symptoms of either condition early may stave off a trip to the emergency room. Older patients and those in frail health are more vulnerable to being readmitted for secondary infections like pneumonia, or complications like sepsis. Integrated care models make it easier to provide all-encompassing, continuous care, says Dr. Alan Go, director of comprehensive clinical research at the Kaiser Permanente Division of Research and study co-author. “It becomes a more seamless experience for the patient and the provider across the different care settings: outpatient, emergency department and the hospital, across and throughout the patient’s lifetime,” Go says.
Bewildered patients who leave the hospital overwhelmed by lengthy medication lists and overtasked with multiple outpatient appointments may be ripe for another admission. A patient navigator team, consisting of a nurse and pharmacist, may help reduce hospital readmissions for heart failure. Early findings suggest that these navigator teams, an initiative of the American College of Cardiology, are working. One study looked at results at the Montefiore Medical Center in New York City. By providing patient education, scheduling follow-up appointments and focusing on issues such as patient frailty or lack of understanding of discharge instructions, the navigator team contributed to reducing 30-day readmission rates among patients.
Diabetes home monitoring
Home-monitoring programs for high-risk patients with both diabetes and coronary artery disease can help them avoid the revolving hospital door. That’s the finding from a July 2010 study looking at a Medicare Advantage program of telephonic diabetes disease management. Registered nurses conducted regular comprehensive phone assessments including patients’ diabetes symptoms, medication-taking and self-monitoring of key test results like glucose levels. Nurses worked with patients to improve their understanding of diabetes care, foot care, nutrition and physical activity, reminded them about vaccinations and eye exams and probed for indications of mental health issues like depression. Hospital admissions for any cause whatsoever were reduced for patients on the program, as were diabetes-related admissions.
The transition from hospital to home represents a critical juncture for patients. Understanding the care plan at the time of discharge — medications to be taken, physical therapy requirements and follow-up appointments with outpatient physicians — is really important, says Andrew Ryan, a professor of health care management at the University of Michigan School of Public Health. “Patients don’t want to be readmitted, either,” Ryan says. “They can take an active role in coordinating their care. Ideally, they wouldn’t have to be the only ones to do that.” Discharge is a key time for patients and families to speak up. “If you don’t know, make sure to ask questions,” Ryan says. “Engaged patients are the best patients.”
Proactive nursing homes
Nursing home residents who are hospitalized may soon make a U-turn back from their long-term care residences. “There are very high readmission rates from skilled nursing facilities,” Ryan says. Traditionally, he says, if a recuperating resident developed any sort of health problem, he or she was immediately referred to the hospital with an ambulance soon on the way. “Now, hospitals are doing some creative things, like putting physicians in nursing homes, where they [make rounds] and try to figure out what could be treated there and what really requires another admission,” he says. “It speaks to this interest in engaging in care in a broader sense than hospitals historically have.”
Nurses on board
A program embedding nurse practitioners and registered nurses in about 20 Indiana nursing homes is showing success in reducing preventable hospitalizations among residents. Launched in 2013, the OPTIMISTIC, or Optimizing Patient Transfers, Impacting Medical Quality and Improving Symptoms: Transforming Institutional Care, project reduced hospitalizations by one-third, according to a November 2017 report. OPTIMISTIC, a demonstration project funded by the Center for Medicare & Medicaid Innovation, enables on-site nurses to give direct support to patients, many with complex medical and cognitive conditions, as well as to train and educate nursing home staff members. By their doing so, frail older adults were spared the disruption and upset of hospital admissions and readmissions.
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