Seniors continue to be readmitted to the hospital too frequently. But when it comes to explaining why, patients and providers are on Mars and Venus. The patients blame doctors and nurses. Doctors and nurses blame patients. And everybody blames the hospitals.
The problem, everyone seems to agree, is that hospital discharges are a mess. Patients don’t understand what they need to do after they go home: They don’t see their primary care doctor, they don’t take their medications properly, and they land back in the hospital. That revolving door jeopardizes their health and costs Medicare billions of dollars.
A new report by the Robert Wood Johnson Foundation looks at hospital readmissions from two perspectives. A new study by the Dartmouth Institute for Health Policy and Clinical Practice finds there has been little improvement in hospital readmissions, despite an intense new focus on the problem by Medicare. The study also finds a huge variation in readmissions from one part of the country to another, which suggests that, with the right motivation and tools, health systems can get a handle on this challenge. After all, if they can do it right in Minnesota, they ought to be able to do it in New York.
But perhaps even more interesting was the second part of the same study: a report by PerryUndem Research and Communication based on 28 interviews with patients and health providers in Washington, D.C., New York City, and Dallas. These, of course, are anecdotes, not data. But they are incredibly revealing and show a yawning chasm between the perceptions of health professional and patients. “What we have here,” as the captain said in the classic film Cool Hand Luke, “is failure to communicate.”
In these interviews, doctors and nurses saw patients who are, in the dreaded term, non-compliant. From the perspective of these health professionals, elders often are so anxious to leave the hospital that they are not honest about whether they can manage their discharge. They say they understand instructions when they really don’t. They say they have caregiver help even if they are alone. Then, once they get home, they fall back on the same bad habits that got them hospitalized in the first place. And when they get sick, they go to the ER instead of calling their primary care doctor.
But when the interviewers asked elders, their story was completely different. To them, hospitalization is overwhelming and terrifying. It is, in the words of one “an alien world.” They say doctors expect them to understand complicated instructions and make decisions while they are in pain or in the fog of medication. Instructions are written in jargon that may be second nature to doctors, but is incomprehensible to their patients.
To older patients, a new diagnosis of a chronic disease can be frightening. After the shock of hearing such news, they may need extra help understanding what to do. At the same time, while doctors assume patients who have been living with a disease for many years understand how to manage it, patients say they often do not (after all, if the disease was well-controlled, they probably wouldn’t be back in the hospital).
Men, especially, are often alone when they go home. They have no one to care for them or to call a doctor if their condition deteriorates. And what may be obvious to a health professional may not be to an elderly patient. In one case, a patient got an infection when he resused compresses on a surgical wound. No one told him he couldn’t.
Both doctors and patients agreed that hospitals are under tremendous financial pressure to discharge patients quickly—a step that often puts more burden on discharged seniors to care for themselves. They are right. Hospitals are being pushed by Medicare to both discharge quickly and prevent readmissions.
Walking that fine line won’t be easy. That’s why it is more important than ever that doctors and nurses learn to talk to patients and that hospitals vastly improve discharge programs that, too often, are the broken link in the health care chain.