Hospitals never seem to have enough resources, but you might be overlooking people who could be effective in improving post-discharge care and reducing readmissions: the friends and family of the patient.
Including family and friends means more than just letting them sit in on discharge instructions, says Juleen Rodakowski, OTD, OTR/L, assistant professor in the Department of Occupational Therapy in the University of Pittsburgh’s School of Health and Rehabilitation Sciences. She is the lead author of a recent report on using informal caregivers to reduce readmissions, the first to quantify the post-discharge impact of caregiver integration into discharge planning on healthcare costs and resource utilization. (An abstract of the study is available online at: http://bit.ly/2rFEeI1.)
Her research found that integrating informal caregivers into the discharge process can cut readmissions by 25%, a finding that she says validates the Caregiver Advise, Record, and Enable (CARE) Act, which has been adopted by more than 30 states and the District of Columbia, as well as proposed Medicare regulations that require caregiver identification and training before patients leave a healthcare facility. (See the story in this story for more on the CARE Act.)
“We’ve always had the notion of family and friends helping patients after discharge, but they are taking on more and more care responsibilities for patients. With the advent of new technologies and clinical developments that make home care more beneficial for patients, these caregivers are being asked to do more,” Rodakowski says. “They might be called on for medication management, including some that are fairly complex, along with wound care and using medical equipment in the home. We’re finding that caregivers are capable of all this as long as we give them the necessary support, and they’re willing, especially when they understand how much this can influence keeping their loved ones from going back to the hospital.”
No Single Type of Caregiver
The person taking on the role of informal caregiver will vary greatly from patient to patient, Rodakowski notes. But whoever steps into that role, the hospital must provide training for that caregiver, she says.
Much of the strategy with informal caregivers seems obvious, teaching a friend or family member the information that a groggy and possibly distressed patient isn’t going to absorb well, but the CARE Act helps solidify the surrounding work processes, says Connie Feiler, RN, MSN, senior manager of patient education at the University of Pittsburgh Medical Center (UPMC). UPMC adopted the CARE Act requirements April 1 and the law took effect in Pennsylvania on April 30.
“Now, on admission, we’re asking every patient if they would like to designate a home caregiver, someone they would like to be involved with the discharge process and afterward at home,” Feiler says. “Most people would readily agree that that makes sense, but the CARE Act provides a structure to make that happen consistently and effectively.”
Informal caregivers can provide support for medical tasks and activities critical to the daily life and health of someone who had a recent hospital or nursing home stay, explains senior author A. Everette James, JD, MBA, director of the University of Pittsburgh’s Health Policy Institute and its Stern Center for Evidence-Based Policy.
“While integrating informal caregivers into the patient discharge process may require additional efforts to identify and educate a patient’s family member, it is likely to pay dividends through improved patient outcomes and helping providers avoid economic penalties for patient readmissions,” he says.
James notes that a recent Congressional Budget Office analysis found that caregivers provide 80% of all community-based long-term services and support for older adults. He, Rodakowski, and their colleagues systematically reviewed 10,715 scientific publications related to patient discharge planning and older adults, focusing the meta-analysis on the 15 publications describing randomized, controlled trials that included enough relevant information and data to draw insights into the influence of discharge planning on hospital readmissions.
The studies included 4,361 patients with an average age of 70 years. Two-thirds of the caregivers were female, and 61% were a spouse or partner, while 35% were adult children, Rodakowski says.
The research indicated that integrating caregivers into discharge planning resulted in a 25% reduction in risk of the elderly patient being readmitted to the hospital within 90 days, and a 24% reduction in risk of being readmitted within 180 days, when compared with control groups where no such integration occurred.
Different Ways to Implement
The healthcare organizations that integrated informal caregivers did so in various ways, but they had common themes and patterns, Rodakowski says. Common strategies included connecting patients and caregivers to community resources, providing written care plans and medication reconciliation, and using learning validation methods such as teach-back, where the caregiver demonstrates his or her training to an instructor, typically a nurse.
Feiler notes that, like with patients, the education for their informal caregivers must be tailored to what works best for the individual.
“Hospitals typically give loads of printed materials because it is helpful to have something to refer to when you go home, but we know that, often, patients also like a demonstration of things like drawing and injecting insulin. Others like videos they can watch at home,” she says. “We include the caregiver in that whenever possible, and we build in the education early enough in the workflow so that we have time, rather than trying to do it all five minutes before discharge.”
There was no clear indication that any particular type of healthcare professional was better at educating the informal caregivers, Rodakowski says, and the study included a variety of healthcare settings.
“What this shows is that no matter the setting and the details of who, what, and when the education was provided, the integration of informal caregivers was effective in reducing readmissions,” Rodakowski says. “It was a variety of discharge planning interventions, so the study results supported the overall concept of informal caregivers rather than specific ways to implement that strategy.”
Possible with Most Patients
Integrating informal caregivers is possible in most cases, Feiler says. Most patients have someone who can step into the role, usually a family member, but Feiler notes that a significant number will have a neighbor or other friend who can help. If the patient has no one to designate as a caregiver, UPMC can provide assistance through case managers and home care services.
Patients also are free to decline having a home caregiver, and the person originally selected may change during the hospital stay or after, Feiler notes.
“The wife might say her husband will do it, just automatically, but then during the hospital stay the husband might realize he doesn’t want to give injections or be responsible for other aspects of the care after discharge,” she says. “They usually can find someone else who is a better fit.”
UPMC built the strategy into its electronic medical record with alerts during the hospital stay to remind clinicians to ask about designating a caregiver, and another prior to discharge to remind clinicians to include the caregiver in discharge and schedule a time for education.
Informal caregivers are not a substitute for home care services, explains Linda Waddell, RN, MSN, CJCP, CPPS, senior manager of quality and crisis intervention at UPMC. Not all patients require home care services, but those that do still can benefit from an informal caregiver, she says. Likewise, having an informal caregiver does not rule out the professional home caregiver.
“If the patient also needs a home care nurse, the informal caregiver is still there to support the patient and continue to learn how to assist the patient at home,” Waddell says. “There may be additional services that should be provided by a home care nurse, but that nurse is not going to be there with the same frequency that an informal caregiver might be. That designated caregiver is still going to be an important part of the patient’s recovery process.”
- Juleen Rodakowski, OTD, MS, OTR/L, Assistant Professor, University of Pittsburgh School of Health and Rehabilitation Sciences. Telephone: (412) 383-6615. Email: firstname.lastname@example.org.
- Connie Feiler, RN, MSN, Senior Manager of Patient Education, University of Pittsburgh Medical Center. Telephone: (412) 647-9776. Email:email@example.com.
- Linda Waddell, RN, MSN, CJCP, CPPS, Senior Manager of Quality and Crisis Intervention, University of Pittsburgh Medical Center. Telephone: (412) 802-8067. Email: firstname.lastname@example.org.