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“So, what brought you back to the hospital?”

Seeking the patient's perspective to tamp down readmissions

October 2016
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Published in the October 2016 issue of Today’s Hospitalist

THE MEDICAL CRISIS is over, the patient is stable and it’s time for discharge.

But not so fast. New research shows that many patients feel they are being discharged too soon, a perception that may contribute to a readmission in the following days or weeks. Interviews with readmitted patients make it clear that a clinician’s objective assessment of medical facts is just one factor in a discharge decision, says Nasim Afsar-manesh, MD, chief quality officer for the department of medicine at UCLA Health in Los Angeles.

“The main point we have learned is to have humility around the discharge process.”analysis-readmission-asfar

~ Nasim Afsar-manesh, MD, UCLA Health

“There is subjectivity to the discharge process, and that can have just as much weight as the objective things that we look at,” says Dr. Afsar, who was the senior author of a recent study in which readmitted patients were asked why they thought they had bounced back. “Unfortunately, the objective metrics for assessing a patient are not perfect.”

More important than ever
For American hospitals, inpatient readmissions are an increasingly expensive proposition. Since 2012, the Centers for Medicare and Medicaid Services has been reducing payments to hospitals whose 30-day readmission rates for certain conditions exceed the national average, and those penalties are getting steeper.

Nearly seven years ago, the UCLA Health hospitalists conducted a chart review of about 600 readmitted patients to uncover the root causes of 30-day readmissions. Dr. Afsar and her colleagues expected to identify specific interventions—the need for a follow-up appointment, for example, or for medication reconciliation—that could have prevented many of those. No such luck.

“We basically came up with no good answers for how to alleviate the problem of readmissions in our patient population,” she says.

Stumped, Dr. Afsar headed to the units in search of patients who had returned to the hospital after a recent discharge.

“What I found was absolutely eye-opening,” she says. “The patient’s chart would list one reason for why the patient came back in, but when I dived deeper with the patient, the root cause of the readmission was something completely different.”

Some patients had social issues that prevented a successful recovery. Some felt their symptoms had not been adequately addressed before discharge, while others believed they could get better care in the hospital than at home.

Based on those informal conversations, Dr. Afsar and her colleagues went on to formally interview nearly 100 patients. Their goal was to learn, from the patients’ perspective, why they were readmitted and whether the readmission could have been prevented.

A sizeable number of patients who believed their readmission was preventable told the interviewers that they felt they had been discharged too soon. To understand why, the research team during a seven-month period in 2014 conducted interviews with 230 patients who had been readmitted to Ronald Reagan UCLA Medical Center or an affiliated community hospital.

The goal of that second study, with results published in the June issue of the Journal of Hospital Medicine, was to find out patients’ beliefs and attitudes about their readmissions and identify opportunities for reducing readmission rates.

What patients say
More than one-quarter of readmitted patients told interviewers that they felt they had not been ready for discharge from the initial inpatient admission. Among patients who did not feel ready:

  • 68% said their symptoms were not resolved enough to leave the hospital;
  • 43% felt their pain was not under control at time of discharge; and
  • 54% had concerns about being able to take care of themselves at home or not being strong enough to go home.

By contrast, readmitted patients who said they did feel ready for discharge after their initial admission had strikingly different views. More than 90%, for instance, said their symptoms were resolved enough to leave the hospital and that their pain was under control at discharge. And just 25% said they were concerned about being able to care for themselves at home.

Relief to be back
Further, patient interviews revealed that standard discharge practices often did not work as planned. For example: More than one-third of readmitted patients did not remember receiving or reviewing discharge paperwork. Among patients who did recall the paperwork, nearly 25% had difficulty finding contact phone numbers and warning symptoms that indicated when to seek medical attention.

Patients who remembered getting a contact number from the discharge team generally did not use it. Indeed, just 56% of readmitted patients contacted a physician before going to the emergency department (ED) and returning to an inpatient bed. And while 90% of patients knew how to access same-day care other than the ED, they still opted to go to the ED instead.

And perhaps most significant: Many readmitted patients admitted that they simply prefer to be in the hospital. Researchers asked patients to rate on a scale of 1 to 10 the extent of burden of returning to the hospital, as well as the extent of relief they felt upon being readmitted, using the same scale.

On average, patients rated their sense of relief 1.8 points higher than their sense of burden at being readmitted, while the vast majority (79%) rated their relief as being equal to or greater than the burden.

New discharge approaches
Dr. Afsar admits that she and her colleagues weren’t happy to learn that 28% of readmitted patients did not feel ready for discharge. But “this information was very helpful,” she says. “These are all concerns that we could develop programs around.”

For example, hospitalists now send medication orders to the hospital pharmacy, which delivers those medicines to the patient’s bedside before discharge. For patients with complex medication regimens, pharmacists now provide extra education before discharge.

Plus, “we have intensified home health resources for patients who we think will need more support,” says Dr. Afsar. “Now, someone will come in and make sure that patients are clinically doing well with their multiple comorbidities.”

For high-risk patients, staff make follow-up appointments while those patients are still in the hospital, giving patients those appointment details as part of the discharge process.

All clinicians involved in discharges have been trained to take time with patients to make sure they understand their discharge instructions. And two separate improvement initiatives that have since been launched have focused on discharge paperwork, making sure, for instance, that contact information is more prominent.

Dr. Afsar and her colleagues are continuing their research, and they next want to identify the subset of patients likely to go to the ED after discharge.

For now, she says, “The main point we have learned is to have humility around the discharge process. It is a very complicated process, and there are many other factors that have nothing to do with the patient no longer having a fever or the fact that their white count has gone down.”

Lola Butcher is a freelance health care writer based in Springfield, Mo.