Hospital Readmissions – Contributing to Overall Healthcare Costs
Healthcare has become something of a hard science, if the focus on data and numbers is any indication. It would seem that the research, the endless reporting and spreadsheets of healthcare administration, has served to at least shed light on the problems healthcare is currently facing as an industry – but the fix isn’t likely to be in black and white.
One such challenge, readmission rates, is easily demonstrated when you take a minute to look at the numbers; new reports show that readmissions are costing healthcare $26 billion dollars a year – and $17 billion of that comes from preventable readmissions. One in five elderly patients will be readmitted within 30 days of a hospital stay – and a lot of those readmissions can be attributed to poorly outlined discharge instructions, medication reconciliation / errors or a complete lack of follow-up. CMS, of course, is largely aware of the readmission problem and has already begun to financially penalize organizations that have high readmission rates. One of the major researchers of readmission causes, the Robert Wood Johnson Foundation, sought to get to the bottom of this issue by conducting a study they called The Revolving Door, which is a cheeky, perhaps, but apt title.
What set this study apart from previous ones was the human factor – the foundation interviewed patients, their families and the providers and hospitals to provide a comprehensive view of just what, precisely, goes wrong that leads to a readmission. By dissecting this event without making too many assumptions, they were able to pinpoint some common themes in readmissions – including patient demographic, patient experience and outcomes as well as organizational qualities that could be vulnerabilities.
Unsurprisingly, when one reviews the case studies it’s obvious that the majority of the patients have multiple, comorbid chronic conditions which they struggle to manage. This leads to initial hospitalizations where, ultimately, the problem is not addressed in a way that will sustain them upon discharge – so, they land back in the hospital (sometimes within days). One thing that the study points out that should encourage rather than discourage physicians is that patients need to be engaged in their care, too. A physician isn’t a mind reader – they can come to know a great deal about a patient’s condition but if the patient keeps mum about how they feel regarding it, the process of exploring opportunities will stagnate. Of course, many patients cite feeling “rushed” or “ignored” as a barrier to sharing their concerns – and, as we know from ER throughput problems, this can be a very common barrier and one that requires its own strategizing. The takeaway, though, should be that patient care needs to be a collaborative process – one that embraces interoperability, communication and at the very least a basic knowledge by all parties of “what the other hand is doing” so to speak. Or, in the case of the healthcare system, maybe we ought to say “tentacles”; maybe eons ago it was just between the doctor and the patient, but now there are plenty of other players and stakeholders who need their voices to be heard.
It’s not likely that the solution to the readmission issue will be a one-size fits all plan that can be rolled out the same way from one hospital to the next: we love “in-a-box” style fixes because they’re quick and easy, but they are rarely sustainable solutions, and that’s what healthcare needs. It’s not enough to patch up the readmission dilemma in order to meet government mandates or avoid penalties; we have to make real and lasting change to how we engage in and practice medicine, from the provider, patient and payer perspective, if we want to see these numbers decline.
Think about it like this: have you ever tried to shoot a basketball into a hoop? Back when I was a kid (one who was terrible at sports, I’m afraid) we were taught the most important part of taking a shot was the follow through: if you lowered your hands too quickly, ruining your form, you weren’t apt to make the basket. When it comes to discharging patients and losing them to follow-up, we’ve got to think not just about lining up the shot – but the follow-through. Easier said than done when you consider how much doctors are being asked to do – not just treat patients but organize staff, be an accountant and a transcriptionist and a number of other administrative tasks that may well be below their pay grade- but if we can shift the focus back to patient care and a sense of teamwork, I’d bet we’ll be making more shots than we miss when it comes to readmissions.
Hospital Readmissions Are Costing Us $26 Billion Annually
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Washington University in St. Louis reports that 20 percent of patients are readmitted within 30 days of discharge. Modern Medicine reports that 25 percent of patients are readmitted within two years.
Kaiser Health News reported that readmission rates are not budging. According to AHANews.com, readmission rates for 2012 dropped from an average of 19 percent from 2006-2011 to 18.4 percent — perhaps a budge. Budging or not, it appears that in spite of all of the emphasis and all of the efforts to decrease readmissions, the rate of readmissions remains relatively static.
If the current efforts are not working, what if we tried something else?
The first list below seems to lay the blame for readmissions squarely on the patients. The second list, my list, suggests there is plenty of blame to go around, and it could equally be parsed to include health systems.
I suggest that ownership of the blame is irrelevant, and that the solution is neither patient-centric nor health system-centric — it is both. I will also suggest that there is a solution that could easily decrease readmissions by double-digits. But please don’t throw metaphorical tomatoes at your monitor without understanding the entire argument.
The Top 5 reasons for patient readmissions, according to a Dartmouth study, Care About Your Care, are:
• Patients may not fully understand what’s wrong with them.
• Patients may be confused over which medications to take and when.
• Health systems don’t provide patients or doctors with important information or test results.
• Patients do not schedule a follow up appointment with their doctor.
• Family members lack proper knowledge to provide adequate care.
Written a little differently:
• The health system does not ensure that patients understood what’s wrong with them.
• The health system does not ensure that the patients understood which medications to take and when.
• The health system does not provide patients or doctors with important information or test results.
• The health system does not ensure that patients scheduled a follow-up appointment with their doctor.
• The health system does not ensure that family members had the proper knowledge to provide adequate care.
What observations can be made and what conclusions should be drawn from the above information?
According to the Top 5 list patients and their families lack the information that would keep them out of the health system. And who has the information that the patients and their families lack—the health systems.
So, what do we need to reduce readmissions? The patients need information from the health systems. And, here it comes, health systems need information from the discharged patients.
Let’s look at two patients, both with very similar issues who were discharged. The first patient goes home with their discharge orders and receives a call from the health system asking how they are doing. The second patient goes home and is watched daily, and their health is assessed daily. Which of the two patients is most likely not to be readmitted?
While the answer is obvious, we all know that if a patient is going to be watched and assessed the entire time they are away from the health system, they may as well remain in the health system. But what if there was another way to implement that approach?
Let’s begin with the notion that health systems need a way to ensure that patients and their families have all the information they need. However, what if patients could ensure health systems have timely (hourly and daily) access to all the information they may need about their condition.
What information is needed by the health system to lay the foundation for a viable solution?
• The health system needs access to the right patient information to assess a turn in the patient’s condition.
• The health system needs to assess the patient’s information early enough to prevent the need for the patient to be readmitted or to go to ED.
• The health system needs to be able to use that information to know when to contact the patient and to know what to do to prevent the patient’s conditioning from worsening.
• The health system needs to provide care to the patient that prevents the patient from needing to be readmitted or prevents the patient from going to ED.
What is needed by both the health system and its patients?
• A timely and accurate way for patients to tell the health system what the health system needs to know
• A timely and accurate way for the health system to tell the patient what the patient needs to know
• A way for both parties to assess the information
• A way of knowing how and when to communicate that either party’s information requires action.
What do they need, when do they need it, and how do we make it happen? Instead of health systems wishing they had access to real-time information about their discharged patients, and patients wishing they had real-time access to more information about their status, why not make both sets of information available?
What if, prior to discharging a patient, the health system added the patient to the health system’s “Discharged Patient Portal?” The health system may even provide the patient with a smart-device, with a killer user-interface, to allow the patient to get all of the information the patient needs, and to provide the health system with all of the information the health system needs about the patient. Information that travels two-ways (interactive); from the health system to the patient and from the patient to the health system.
Our cars can do this. They can tell us, based on the data they collect, when we need to see a mechanic. Why can’t we create the same digital interaction between discharged patients and their health system?