Take time to base the discharge plan on patients’ individual challenges
There are many reasons why patients come back
It’s a mistake to assume that every readmission could be prevented by better medical management, says Amy Boutwell, MD, MPP, president of Lexington, MA-based Collaborative Healthcare Strategies, and one of the original co-developers of The Institute for Healthcare Improvement’s STAAR (State Action on Avoidable Rehospitalizations) initiative.
In fact, about half of all readmissions are attributed to social issues, says Bridget Gulotta, RN, senior consultant for The Camden Group. “Patients may have financial issues, behavioral health problems, housing deficits, lack of transportation or a combination of things that can impact their ability to follow their discharge plan. Often, readmission prevention initiatives don’t take social issues into consideration,” she adds.
When patients are readmitted, talk to them and their family members and identify the issues that led to a readmission for each individual, she advises.
“Case managers have to look at each patient as a whole person and identify the individual needs of each patient rather than taking a disease-specific approach,” Boutwell says.
For instance, many hospitals focus on heart failure management because a significant number of patients who were readmitted have heart failure. But people with heart failure often have multiple comorbidities, such as diabetes, cancer, kidney failure, or coronary artery disease, Boutwell points out.
“If case managers are not assessing the whole person and developing a plan that takes into account all of the individual’s issues, they’re not going to prevent a readmission,” she says.
Many case managers are not spending a lot of time on discharge planning because they have large caseloads and don’t have the time, says Toni Cesta, RN, PhD, FAAN, partner and consultant for Case Management Concepts.
But certain groups of patients have a higher risk than others and need a comprehensive discharge plan, Cesta points out. For instance, some Medicaid patients have financial issues, or lack basic needs like housing and utilities. Other at-risk patients have behavioral health issues, chemical or alcohol dependency.
Case managers should perform a comprehensive risk assessment of patients early in the stay and determine any issues that might put them at risk for readmission and take steps to lower the risk, Cesta says.
Geriatric patients have their own set of issues, many of which revolve around medication, Cesta says. Many geriatric patients don’t understand how and when to take their medication and are confused when their prescriptions change following hospitalization, she says. In one case, a home health nurse told Cesta she spent two hours on medication reconciliation for one elderly patient because she had to go through years and years of old medications.
Cesta recommends that geriatric patients have at least one home health visit for medication reconciliation. Medicare will pay for one home health visit and it could prevent a lot of problems in the future, Cesta says.
Lack of health literacy can have a big effect on how patients manage after discharge and whether they come back to the hospital, Cesta says.
“You can educate patients until the cows come home, but if you’re not educating them in a modality they understand or repeating the instructions enough they are likely to visit the emergency department and/or be readmitted,” she says.
Patients typically are discharged with stacks of papers and don’t look at them for days, Cesta points out. “But the case manager often feels that people leave completely cognizant about what they are supposed to do,” she adds.
Health literacy experts advise hospitals to create materials at a third-grade reading level, Cesta says. “But even if you use simple words, it doesn’t guarantee the person understands. Health literacy is a huge problem that has not be addressed and it a big piece of the missing link in the transition of patients,” she adds. (For information on how one organization tackles healthcare literacy, see story in this issue.)
Patients for whom English is a second language are another challenge, she adds. They might not understand even the simplest instructions. Use pictures and diagrams and call in an interpreter when needed, she says.
Some patients are being readmitted because they don’t understand their disease processes and medication regimen, adds Brian Pisarsky, RN, MHA, ACM, associate director at Berkeley Research Group, with headquarters in Emeryville, CA.
“Education on the patient’s disease process and medication regimen may be lacking. When case managers, nurses, or hospital educators are trying to jam education into today’s short lengths of stay, it usually means just words on a piece of paper or gets lost in translation,” he says.
Pisarsky recommends that case managers take a proactive approach in identifying an advocate for the patient, usually a family member or the primary caregiver. “Work with the advocate to help the patient understand the disease, medication regimen, and the necessary changes to obtain optimal health and prevent readmissions,” he suggests.
In many cases, education should include information about palliative and hospice care and end-of-life issues when it’s appropriate, Pisarsky says.
“Patients are being readmitted because they don’t understand the disease and the prognosis. Hospitals aren’t good at telling patients and families that the prognosis is grim. Their mission is to make people well, but when patients are facing a life-changing diagnosis or end of life, we are doing them a disservice if we don’t educate them about palliative and hospice care,” he says.
Organizations that have found a way to transition discharged patients who come into the emergency room back into the outpatient arena are seeing good results in reducing admissions and are avoiding penalties, reports Mindy Owen, RN, CRRN, CCM, principal owner of Phoenix Healthcare Associates in Coral Springs, FL, and senior consultant for the Center for Case Management.
“There’s got to be a collaboration between inpatient services and clinics or other outpatient services. The discharge or transition plan has to be a safe one but it also needs to provide what the patient and family need to sustain in the next level of care,” Owen says.
Cesta suggests making emergency department case managers responsible for scrutinizing patients who present to the emergency room within 30 days of discharge. “When patients discharged within 30 days come into the emergency department, the case managers should have the opportunity to review the case and provide the physician with an alternative to admission if it’s appropriate,” she says.
They should conduct a root cause analysis on why the patient came back and depending on the reason, work with the emergency department physicians to prevent a readmission, she says.
For instance, if the reason that patient is coming back is that he didn’t take his medications because he couldn’t afford them, the case manager or social worker can line the patient up with a medication assistance program.
It’s a mistake to assume that every readmission could be prevented by better medical management. In fact, about half of all readmissions are attributed to social issues.
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