The key to a high quality patient discharge is identifying post-discharge vulnerabilities.
Federal penalties for high rates of patient readmissions are compelling hospitals to dig into the causes of the re-hospitalizations, which frequently have more to do with socioeconomic factors than the healthcare provided.
This finding was the conclusion of a recent study in the Annals of Internal Medicine, indicating that economically disadvantaged patients and those living at home alone often are unable to attend to urgent post-care needs like taking their prescription medications on a regular basis.
Cognizant of this strong link, several hospitals are putting more effort into identifying different social and economic factors that may lead to a re-hospitalization event.
Tackling the problem
The key to a high quality patient discharge is identifying the vulnerabilities confronting the individual in the post-care environment. A study involving hospitals in Minnesota with the goal of collectively preventing 4,000 avoidable hospital readmissions exceeded this goal and prevented nearly 8,000 readmissions, resulting in more than 32,000 nights that patients could stay home in their own beds.
Essentia Health in Duluth, Minn., which operates 17 hospitals and 66 clinics in four states, participated in the RARE (Reducing Avoidable Re-Admissions) Campaign, as the project, which concluded in June 2014, was called.
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“As part of the study, we polled patients and their families regarding how well they understood the need for the discharged patient to take medications, how often these medications needed to be taken, and how they could replenish them when they were gone,” said Michael Van Scoy, MD, who is in charge of the patient readmission analysis program at Essentia Health. “The poll results were not very flattering. We were all sort of shocked.”
As an example, he provided the following: “We learned that an otherwise healthy 68 year-old with a laptop and cell phone and an able spouse to help her could easily take care of herself. But, a 68 year-old Norwegian bachelor who was hard of hearing and living in rural Minnesota was likely to forget to take his meds.”
The study findings led to the launch of a pilot program to examine the various factors that might cause a discharged patient to neglect his or her post-care needs. These barriers ran the gamut from transportation difficulties to having to make a decision between buying groceries or prescription drugs. The key is knowing these factors prior to patient discharge.
“Every single patient admitted to one of our hospitals now is given a clinical risk stratification score and social frailty score, both of which are driven by predictive data analytics,” said Van Scoy. “If this triggers a high risk of readmission, they cannot leave the hospital until they meet with one of our social work consultants.”
Previously, the hospital would contact a discharged patient within 48 hours to discover how the individual was handling his or her post-care needs. While well intentioned, this practice was too little, too late. “Most of our readmissions occur within seven days of discharge; we needed to have a more proactive approach,” said Van Scoy. “We now engage home health agencies to step in where there is an indication of readmission.”
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The MetroHealth System in Cleveland has a similar approach. “We’ve put in place transitional care coordinators to facilitate the patient’s discharge, managing the hospital system to focus on the transition from being a patient to being an outpatient,” said Alfred Connors, MD, chief clinical officer of The MetroHealth System.
The care coordinator meets with the discharged patient to ensure that they understand why they must take their medications and routinely have their prescriptions filled. Patients are further apprised that health conditions like swollen ankles or shortness of breath may indicate a need to immediately see their primary physician.
“Thirty to 35 percent of readmissions for heart failure are preventable,” said Connors. “These people simply aren’t taking proper care of themselves in the post-care environment. It’s up to us to identify when they are remiss or, more importantly, to ensure they are not remiss.”
Although post-care services like home healthcare and short-term nursing stays cost money, these alternatives are much less expensive than the expense of a hospital readmission.
“A 30-day stay in a nursing home is in the $8,000 range, compared with $15,000 for just a four-day stay in a hospital,” explained Sheryl Tiemeyer, head of the patient readmission team at Schneck Medical Center in Seymour, Indiana.
Schneck also has studied its readmission rates and put together a program to pare down the figure. One issue it had to overcome in the process was that many discharged patients did not want help with their post-care needs. “This was huge for us,” Tiemeyer said. “They could not afford their prescription meds and were too proud to admit it. Now when we identify this risk, we provide a free supply of meds for 30 days, and make sure they are hooked up with our patient assistance program once the meds run out.”
If the hospital determines the patient has not refilled a prescription, it sends another supply to the person. “The cost is significant, but it is a lot less than what it would cost to readmit the patient,” Tiemeyer explained. “We follow the same approaches with regard to home health services and nursing home care.”
These various hospitals are applying their own interpretation to the old saw, “An ounce of prevention is worth a pound of cure.” As more hospitals do the same, patient healthcare costs, at least those caused by hospital readmissions, will surely come down.
This article was originally published at Healthcare Finance.