Study shows gap in care for discharged patients
NEJM article shows follow-up care lacking
Knowing your readmission rate is critical and will become even more important as the health care industry waits for the Centers for Medicare & Medicaid Services' decision on how to alter reimbursement based on rehospitalization rates.
A recent study that has garnered much attention from media and health care personnel, "Rehospitalizations among patients in the Medicare fee-for-service program," found that one in five Medicare beneficiaries discharged is readmitted within 30 days. The study also looked at which DRGs had the most associated readmissions and which states had the worse rates.
But most surprising to lead author Stephen F. Jencks, MD, MPH, a consultant in health care safety and quality, was that: "In the case of 50.2% of the patients who were rehospitalized within 30 days after a medical discharge to the community, there was no bill for a visit to a physician's office between the time of discharge and rehospitalization."1
"I think it's a breakdown in the team; it's not easy for somebody on the floor to get an appointment with the patient's primary care physician. The problem is, if it's not easy for them, how hard do you think it's going to be for the patient? But that's sort of one side. The other side is that too many of them have responded to the fact that it's not easy by deciding not to do it. Because it's much easier to give the patient a phone number and let the patient be frustrated," Jencks says.
Know your readmission rates
First, you should go to your chief of medical records to get your 30-day rehospitalization rate, Jencks advises. "Now, that's an incomplete picture because something like 30% of rehospitalizations nationwide go to other hospitals, nursing homes."
Identify who in the hospital is going to care about readmission rates. In one hospital, he says, it may be the cath lab personnel who would rather be doing procedures than being in the emergency department at 2 a.m. Or it could be the chief of surgery who becomes appalled that the rate was what it was and he or she wasn't told. "It's knowing your hospital and knowing where you're going to find your allies," Jencks says.
"The other piece that may be useful is to know where your patients go. And how easily you can find this out is often uncertain," he says. You may ask your discharge planner what three nursing facilities she most often sends her patients to. But that information is disparate, often found only in individual patients' folders.
Creating relationships with skilled nursing facilities is crucial to following where patients go after discharge. Jencks suggests inviting staff from local skilled nursing facilities (SNFs) to meet with you and finding out from them if you are sending them all the information they need. After communicating with SNF staff they might say, "You know what? You're not really giving us what we need."
And the hospital person, Jencks says, may first retort, "We break our backs to get the narrative summaries to you in 24 hours." The SNF staff, further clarifying what they need when they get patients, could say, "Yeah, but those are physician narrative summaries and they don't tell us about the actual nursing care plan, which is what we need to do within five minutes of the person's arrival."
What else can you do?
• Schedule a follow-up for the patient before he or she leaves the hospital.
It may sound simple, but Jencks says a patient should leave the hospital with a scheduled follow-up appointment. He recommends handing the patient a paper noting the appointment already scheduled with his or her primary care physician (PCP). The patient should be told, "If you can't get there, and I understand you might have trouble with transportation or your daughter may be at work, you can call and change the appointment. But you see at the bottom here? It says if you do change the appointment, do not delay it."
• Provide patients with a number for questions or concerns.
Patients should leave the hospital with a number to call if they experience complications or pain and you should "teach them there are certain things that are worth calling about."
"One thing that a number of hospitals have started to do is to have somebody call the patient within 24 to 48 hours after discharge," he says.
• Educate using the teach-back method.
Jencks stresses educating patients and their family members about what they need to do to take care of themselves post-discharge. Using the teach-back method, patients are asked to repeat in their own words what they just learned or heard.
• Talk to the local primary care physicians.
Talking to the local PCPs and after-care facilities is an important piece of solving the puzzle. Jencks says PCPs often do not know their patient is in the hospital let alone that he or she has been discharged from the hospital.
Reference
- Jencks SF, Williams MV, Coleman EA "Rehospitalizations among patients in the Medicare fee-for-service program" NEJM 2009 Apr 2;360(14):1457-9.
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