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Too few chronic patients referred to post-acute care
Research highlights troubling findings
Clinicians often fail to identify patients who need home care services or other post-acute care after they're discharged from the hospital, research shows.
These chronically-ill patients with comorbidities are the same patients who often end up back in the hospital soon after being discharged, notes Kathryn Bowles, PhD, RN, FAAN, an associate professor at NewCourtland Center for Health and Transitions at the University of Pennsylvania School of Nursing in Philadelphia. Bowles has published many studies involving home health and post-acute health issues.
After analyzing data from a clinical trial that enrolled high-risk adults, Bowles made the surprising discovery that more than half of those enrolled were not referred to post-acute services after being hospitalized, despite their high-risk for rehospitalization.
"I started to explore why that happened," Bowles says. "We compared those who received home care and those who didn't and found the two groups looked similar, but some patients were not recognized as needing the service by clinicians making referrals."
After interviewing clinicians about why some patients didn't receive the post-acute referral, Bowles learned that clinicians didn't always know which questions to ask patients and might not be conducting comprehensive assessments. And if the patient didn't request help, they might think it's not necessary.
"A patient might say to the doctor, 'I'll be okay don't worry about me,'" Bowles says.
Also, there are system obstacles, such as clinicians not having enough time or discharges occurring late on a Friday, she adds.
"There also is a lack of knowledge about home care's value to the patient," Bowles says.
Bowles and co-investigators further studied the issue by reviewing medical records from high-risk patients involved in three clinical trials at six different hospitals in Pennsylvania.
"We generated case studies out of those records so we could compare what happened to them in real life versus what experts said should have happened to them," Bowles explains. "We ended up with 355 case studies that had health characteristics, social, and financial situations, and we sent those to a panel of eight experts."
The panel included both clinicians and academic experts with two physicians, two nurses, two social workers, and two physical therapists.
"They reviewed these cases and told us what they would have done in terms of making a referral," Bowles says.
"Then we ran an analysis of the characteristics of patients associated with the decision to refer to post-acute care, and we compared it with what really happened," she says. "We found the experts referred 56% more patients than what happened in real life."
The study concluded that current hospital discharge referral processes are not adequately identifying at-risk patients.1
One reason why the experts made more referrals could have been that they were given more comprehensive medical information than what clinicians often see, Bowles notes.
"We put the information all in one place with a case summary, and they could see what patients' needs were, versus the scattered information found throughout a paper medical record," she adds.
Time constraints were a second factor.
"The experts also had time to consider the referral, versus the real life clinical situation of a hectic environment with multiple people making decisions and a lack of clarity over whose role it is to make these decisions," Bowles says.
In earlier research, Bowles and co-investigators found that discharge planners and nurses often cited the pressure to discharge patients quickly as a reason why some at-risk patients might not receive post-acute service referrals.2
Weekend discharges were particularly a problem because of short staffing, poor planning, and inadequate communication, the study found.2
And the third reason why there was a significant disparity between the experts' decisions and real-life referral decisions was that researchers asked the experts to make their decision based solely on patients' clinical needs and not on insurance and limitations imposed by Medicare, Bowles says.
The experts could look at what these patients' needs were and whether they could benefit from post-acute services without making certain the patient qualified as "homebound" under Medicare rules, she adds.
Of the patients the experts would have sent to home care services but who were not referred in the real-life cases, 23% were rehospitalized within 12 weeks, Bowles says.
"So, they did not get services and went on to have poor outcomes," she says. "They looked a whole lot like the people who do receive home care, so we're missing these people."
As a result of the research, Bowles and co-investigators have developed a prediction model that provides scores related to whether or not patients should be referred to post-acute services. The model is expected to be published soon in Nursing Research.
1. Bowles KH, Ratcliff SJ, Holmes JH, et al. Post-acute referral decisions made by multidisciplinary experts compared to hospital clinicians and the patients' 12-week outcomes. Medical Care. 2008;46(20):158-166.
2. Bowles KH, Foust JB, Naylor MD. Hospital discharge referral decision making: a multidisciplinary perspective. Applied Nursing Research. 2003;16(3):134-143.