Thinking Seriously About Readmissions—and Care Transitions

But this whole problem of, we’ve got patients in for shorter stays—this has been happening for decades now—and we’ve got increasingly older and more fragile patients, with a bigger disease burden, so the discharge has become a riskier proposition. So instead of having a couple of nurses who work with the medical teams on a CHF program, I think they’re going to be organizing the transitional care as its own process. Because let’s say you’re doing a phone call to CHF patients on the day after discharge. Well, there are going to be many other patients who need phone calls. And you’re going to need to do that efficiently and in an organized way.

So yes, the nurse who knows what to say to a CHF patient, will need models for a pneumonia patient, or a really fragile diabetic, or a COPD [chronic obstructive pulmonary disease] patient. So you’re going to want to efficiently use the hospital resources available. And you’re going to want to think for each patient about what is at risk, what’s involved, and who is receiving the patient, and when the provider will connect with that patient.

So it makes sense for the hospital to connect as early as possible, and create the handoff. It may be this external program that actually executes the handoff the day after discharge. Or it may be a home visit. And the nurse practitioner from the PACE program is going to be visiting the home on day two. So I’m arguing that over time, you’re going to be connecting patients more formally with whatever that external care management party is; for some patients, it might be the patient’s primary care physician. And you’re going to want to work out elements like the med list, so you’re operating with useful information. But I think it’s a useful construct to operate with these formalized care plans.

But if you think about it, Medicare is reinforcing these silos, because the three conditions in the measures that Medicare is using are around heart failure, pneumonia, and cardiac issues (AMI—acute myocardial infarction—etc.). Now, in the accountable care organization program, they’re looking at all measures. In any case, it will be about taking this and making it into a much broader, non-siloed program, that comes up with a good transition plan for each patient.

I’ve reported on the Hospital at Home program that’s now live at Presbyterian Health Services in Albuquerque, which is transitioning patients very successfully from home care into a hospital-care-in-the-home setting, and back. What are your thoughts on programs like that one? Such programs like that could fit into this schematic, right?

Absolutely. And there are programs I referenced, not by name, but by concept, in the paper, that talk about front-loading post-discharge visits, including, if the patient can be gotten there, to the primary care physician on day one. In another instance, one program sends a team of a nurse practitioner, a social worker, and a pharmacist, and they go to the home. But this idea of providing pretty intensive care and support in those first few days—the Hospital at Home folks at Presbyterian call it an admission—that supports my thesis that we’ve got these categories—acute care, emergency care, and primary care, but that we have to start delivering transitional care. And the Presbyterian example is one set of interventions made available to the patient at home. And I think what you observed in Albuquerque is a model for what I’m writing about in this paper.

In fact, people have been working on readmissions and doing research on all this, for decades. So one of the things I tried to do in this white paper was to organize what’s known today. And that’s what I’m trying to do in the sections “What Research Tells Us” and “What Works in Readmissions.” And there are a lot of qualifiers to reach what we know. But what I decided after reading all the studies and program descriptions, was that several things stood out for me. One thing is that it’s pretty clear that doing a good job with the discharge plan helps, but high-risk patients, at least, need post-discharge care and support. And under, “What Research Tells Us,” I looked at programs that have achieved exemplary results, and have looked at what results they achieved, and the two tables, on and starting on page 6, and what I realized was, whether there’s been a formal research study saying a particular element works for particular patients, or whether it means looking at exemplary programs, as the Commonwealth Fund, the California Health Care Foundation, or IHI [Institute for Healthcare Improvement], through the Star Program, have found, when it came to comprehensive discharge planning, is that every one of these “validated” programs included one or more interventions under each of the three categories I list in the figure on page 6 of the report titled “Promising Components and Interventions—Comprehensive Discharge Planning.”

The reality is that we know who the patients are who are at highest risk; but we don’t know yet what the “killer risk” is yet, because most patients have a bucketful of risks. And so there’s no magic bullet saying, if we do X for patients living at home alone, they’ll do fine, right? And also, there’s quite a bit of research on the elements in the hospital stay that can contribute to avoidable readmissions.