Troy Brown

April 05, 2012

April 5, 2012 (San Diego, California) — Reducing the incidence of hospital readmissions for Medicare patients is one of the provisions of the Affordable Care Act, and hospitalists are being asked to develop innovative ways to accomplish this, according to a presentation at the Hospital Medicine 2012: Society of Hospital Medicine (SHM) Annual Meeting.

Eric Coleman, MD, MPH, professor of medicine and head of the division of health care policy and research at the University of Colorado in Denver, and Mark Williams, MD, FACP, FHM, professor in medicine-hospital medicine and chief of the division of medicine-hospital medicine at Northwestern University Feinberg School of Medicine in Chicago, Illinois, discussed strategies that hospitalists can use to reduce readmission rates.

Asking patients who have been readmitted several times about the factors that they believe contributed to their readmission can be illuminating.

It is not necessarily organ-system dysfunction that is driving their readmission, said Dr. Coleman. Other factors contribute to a patient's ability to remember their instructions and to follow through with them.

Literacy, cognition, education level, socioeconomic status, and level of social support all contribute to a patient's adherence to discharge instructions, he noted.

Communicate With Primary Care Providers

In an interview with Medscape Medical News, Dr. Williams said: "I think that just as hospitalists need to talk to the primary care providers as they're transitioning patients from the hospital home or to a skilled nursing facility, at the time of admission, they need to connect with patients' primary care providers, as well as patients' caregivers, so they can have a better understanding of what was happening prior to the hospitalization. What factors triggered the need for hospitalization beyond just the medical illness? That'll help them quite a bit as they then establish planning for the hospital discharge process."

Opportunities exist for community-based organizations to be part of the solution, helping patients with socioeconomic needs like transportation and paying for medications, Dr. Williams added.

Discharge Planning Should Begin at Admission

The process of planning care transitions — formerly called discharges and transfers — should ideally begin at the time of admission, they said. Many times nurses complete lengthy admission assessment forms that languish in the patient's chart, never to be referred to again. These documents often contain valuable information about the patient's home environment and their caregiver situation, which can be used to develop individualized discharge plans.

Patient Education Is Vital

Patients are often discharged from the hospital without the skills or resources to care for themselves at home. They might misunderstand medication or diet instructions or might not have a primary care provider to follow-up with after discharge.

Programs that have patients demonstrate their ability to carry out instructions prior to discharge can help identify patient deficits while the patient is still in the hospital.

The Teach Back Program is one such initiative discussed at this year's SHM meeting.

Patient education programs are a vital part of this process, Dr. Williams said. "Eric brought this up — at a hospital in northern Mississippi, they set up a simulation lab for patients, [and] heart failure is a perfect example.

Instead of just talking at patients as if it was a didactic lecture, you have patients go through a simulation of what they're going to need to do when they go home. [You have them] learn how to weigh themselves. You have the patient call up and schedule the appointment with the outpatient provider. You have patients learn about their diet and managing salt intake and so forth. You have patients learn how to manage their pills so that they take them with high compliance. You have the patient ensure that their prescriptions go to the pharmacy.... It's training the patients to be better at taking care of themselves.

"I'm actually not familiar with the program in Mississippi, but it sounds fascinating and it makes a lot of sense. A lot of people are doing this. I think the best examples are around teaching patients how to use metered-dose inhalers and having them demonstrate that they actually know how to do it," said Dr. Williams.

How Hospitalists Can Make a Difference

Dr. Williams explained steps that hospitalists can take to reduce readmissions. "They need to become involved in a quality-improvement project at their institution, to either restructure the entire discharge process, or identify "quick fixes" as part of this.

The key elements for hospitalists are to learn and develop an appreciation of how important the "teach back" approach is to patient education, to ensure that all their patients have follow-up soon after hospital discharge, and to engage the patients in scheduling that, Dr. Williams said.

We have examples of some sites that mandated that every patient discharged from the hospital have an appointment scheduled, but they didn't engage the patients in this outpatient scheduling, so follow-up rates were terrible. The outpatient community providers were furious, because their outpatient schedules were being blocked by patients who never showed up. I would emphasize over and over again: Engage the patients in developing your solutions."

Discharge Clinics Meet an Urgent Need

Discharge clinics are another way that hospitalists and other healthcare providers are trying to compensate for a lack of primary care providers in the community. These programs have many strengths, but there is a risk that patients may overuse them for things better suited for primary care providers. Some believe this strategy is merely a bandage for a system that needs a bigger fix.

Lauren Doctoroff, MD, FHM, a hospitalist at Beth Israel Deaconess Medical Center and founding medical director of the Healthcare Associates Post Discharge Clinic in Boston, Massachusetts, commented on the session and the role of discharge clinics in an interview with Medscape Medical News.

"I think that there's a lot of debate about the roles that discharge clinics play, whether staffed by hospitalists or staffed by primary care doctors. There's a great variety in discharge clinics; to a large extent...the development of discharge clinics is usually an accommodation to whatever particular problem you're dealing with in your local situation. Whether it's a place where primary care access is poor because there are no primary care doctors or whether it is, as in our case, where the primary care access is difficult because there are a lot of part-time providers, either in an academic practice or in a faculty practice... When you're dealing with that, in the absence of other easy solutions for opening primary care access, and seeing that patients should be seen after discharge — whether or not it decreases their readmission rate — then having hospitalists fill that role, at least right now, seems like a possible solution to the problem," Dr. Doctoroff said.

Hospitals, Hospitalists Share Financial Burden

"One of the themes that you heard is that hospitalists and hospitals cannot function as an island," Dr. Doctoroff noted. "We functioned that way for a long time. Whether it is our connections with primary care doctors, or our connections with the elder service agencies or visiting nurses or extended care facilities, the more that hospitals and hospitalists are responsible for what happens to a patient after discharge, the hospitals and hospitalists are the ones who are going to feel the financial burden.

"It behooves us to figure out who can help us solve this problem, not just for us, but for the patients, too. It's hard to imagine patients who want to spend more time in the hospital, although there's probably a role for hospitalization in those patients, and also a role for rehospitalization," said Dr. Doctoroff.

Dr. Coleman, Dr. Williams, and Dr. Doctoroff have disclosed no relevant financial relationships.

Hospital Medicine 2012: Society of Hospital Medicine (SHM) Annual Meeting. Presented April 2, 2012.


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