Prediction of Hospital Readmission — it’s no secret

The cause of hospital readmissions is not a secret.   Patients are readmitted to the hospital because the patient, physician or both are too optimistic about the patient’s situation: too optimistic about the patient’s social problems,  too optimistic about the strength of primary care, or too optimistic about the possibility of surgical complications.

It feels better to be Optimistic than the alternative.  It feels better to the patient to be going home.  It feels better to the doctor to believe all is well.  But, the data about readmissions suggest the feelings are not always accurate.  Perhaps we should be optimistic there are ways to find and correct the reasons for readmission.  Providers need to focus on solving more problems before discharge, not just the problem of sending the patient out the door.  Providers need to follow a discharge check list, just like a pilot getting ready for takeoff – not just be optimistic the plane will do just fine.

Rehospitalization is often attributed to fragmentation of health care.  So, what constitutes a non-fragmented (smooth) transition from hospital to home?  The following is the basis of that preflight checklist:

• The hospitalization is long enough to make sure the patient is stable.
• Providers anticipate the day of discharge:
  • the likely date of discharge is discussed at least twice
    1. on the day of admission
    2. when the patient is feeling better, at least 48 hours before actual discharge
  • patient questions are answered
  • minimize medication complexity
    • absolute minimum number of meds
    • simplify dose schedule (don’t mix intervals)
    • educate about new medications
  • explain and write down
    • the reason the patient was hospitalized
    • the final diagnoses
    • the name of surgery performed
    • the complete list of medications including
      • home meds discontinued
      • home meds continued at same or different doses
      • new meds (make sure they are generic or on the insurance formulary)
      • why each medication is needed
  • financial problems addressed (can medications be purchased?)
  • home social situation reviewed
  • obtain home monitoring equipment (glucose meters, scales, blood pressure checkers)
  • send needed prescriptions to the patient’s pharmacy electronically
• family engaged, discharge plans discussed with family
• visiting nurses called if needed
• primary care providers called and discharge summary faxed same day
• discharge instructions reviewed verbally and in writing with patient
• follow up appointments made
  • specialty care as needed
  • primary care within one week
• transportation arranged
• phone follow-up next day by discharging provider

What indicates high risk for rehospitalization?

• Intensive care stay
• Living alone
• Previous readmissions
• Lack of insurance
• Poverty
• No primary care provider
• Smoking or other substance abuse
• Congestive heart failure
• COPD or asthma
• Insulin dependent diabetes
• Surgical wound drainage
• Illiteracy
• Weakness or falling
• Over 15 lb wt loss
• No phone at home
• No transportation (except ambulance)

Rehospitalization may be foreshadowed during a hospitalization.   Health care providers sometimes fail to notice wound drainage, night time confusion, low grade fever, shortness of breath, leg swelling, anxiety,  or comments about the cost of medications.  The errors of omission can be reduced by minimizing provider changes and hand-offs — so patients do not “fall through the cracks”.  Providers should take a second look  at labs, vital signs and nursing notes before giving the green light for discharge.

Sarah Needleman of the Wall Street Journal was the author of “Rx to Avoid Health-Law Fines” which appeared August 8, 2013.   She reported on new companies that help hospitals reduce hospital readmissions by printing sensible discharge instructions and also by predicting the chance of readmission to help focus resources on high risk patients.

Discharge software is expensive and probably not more effective than a good checklist of risks.  Most importantly, hospitals must have action plans for each high readmission risk factor  (like no transportation or no phone).

The Robert Wood Johnson Foundation published  “The Revolving Door: A Report on U.S. Hospital Readmissions” in February 2013.  The report puts a strong focus on fragmentation of care, being a root cause of  rehospitalization.  The fragmentation can be significantly reduced by strong primary care, doing close follow-up after discharge,  engaging additional social services if needed, extensively  using the phone to communicate with patients who have chronic illness.

A good idea:  phone follow up.  Many primary care providers complain that post hospital phone calls are an unreimbursed expenses (so they don’t make the calls) — hospitals should consider paying a fee to primary care for phone calls during the month after discharge.

Another good idea:  the hospitalist outpatient check.  Some hospitalist groups actually have a discharge follow-up clinic for patients who had a long hospitalization or who have rehospitalization risks.   The visit is usually a couple of days after discharge and is focused on solving problems before they become big problems and also to make the transition to a new or existing primary care provider.