Hospital readmissions are bad for patients—especially seniors who may already be weakened by multiple chronic disease. They cost tens of billions of dollars. They are not even good for hospitals (at least not top-quality facilities that regularly fill their beds).
About one in five Medicare patients are readmitted within 30 days, and one-third within 90 days, according to a New England Journal of Medicine study. Medicare alone spends $17 billion on these roundtrips annually, and private insurers spend uncounted more dollars. Patients most at risk suffer from pneumonia or other infections, congestive heart failure, or pulmonary disease.
There is a growing movement to try to reduce readmissions, and the 2010 Affordable Care Act includes big penalties for hospitals that don’t get with the program. But figuring out how to keep patients with complex medical problems out of the hospital is not easy.
I was struck by just how hard when I saw a new consumer guide from the Agency for Healthcare Research and Quality, a highly regarded government agency. The booklet, called “Taking Care of Myself: A Guide When Leaving the Hospital” is a checklist of what to know and what to do so you can care for yourself after discharge.
It is 16 pages long.
I’m not criticizing the AHRQ or the careful research by Brian Jack at Project Reengineered Discharge (RED) upon which the booklet was based. Indeed, the guide seems incredibly valuable and I’d recommend that health systems make it available to everyone they discharge.
But how is anyone, especially a frail senior, going to keep track of 16 pages of information? What medications do I take? What do I take them for? When do I take them? Who are my doctors? When is my next appointment? What questions should I ask? This is overwhelming for an 80-year-old widow, especially if she is suffering from some dementia.
Increasingly, hospitals are coming to recognize that many patients can’t manage their post-acute care without help. And I don’t just mean the assistance of a nurse or nurse’s aide with managing medical devices, changing bandages, or even help bathing or toileting. I also mean help organizing their care.
No longer will a facility’s responsibility for patients end when they role out the front door at discharge. Keeping them from returning to the ER will require hospitals (and skilled nursing and rehab facilities) to take on some important new roles. They include:
- Working with patients on their discharge plan at admission. Don’t wait until an hour before discharge.
- Learning about the patient’s home situation. Is she physically and cognitively able to care for herself? Does she have a family member who can help her? Does she have neighbors, friends, or members of her church or synagogue who can help?
- Determining whether palliative care or hospice is appropriate.
- Determining whether a care manager is appropriate
- Identifying those patients most at risk of readmission and assigning them a nurse or social worker who can work closely with them once they have returned home. We have now seen the results of several transitional care demonstrations. Done right, they work.
All of these initiatives cost up-front dollars that are rarely reimbursed by Medicare or private insurance. Eventually, the new health law should provide mechanisms to pay for them. For now, hospitals and nursing facilities will have to eat the cost. But it is the right thing to do, and I’m convinced it will pay off, in terms of both patient care and controlling costs.