Patient advocate: Get out and stay out (of the hospital)
Getting out of the hospital is good. Having to return a week or a month later? Not so much.
With all of the attention hospitals and the Centers for Medicare and Medicaid Services (CMS) give to reducing rehospitalization rates, it’s still a major challenge in health care. Discharge protocols, prevention strategies and penalties levied by CMS only go so far. Patients and their families have a big role to play.
And some need more help than they’re perhaps willing to admit.
Hospital readmissions are often the result of a complex web of factors involved in transitioning from hospital to home, meaning that pinning down numbers and exact causes is difficult. Researchers have identified the major reasons, generally broken down into medical or clinical factors and the “transition” gap.”
Certain chronic conditions, such as heart failure and COPD, are most often involved in readmission within 30 days. Older, frail patients, those with multiple and complex conditions, those who experience surgical complications or who have diseases that gradually worsen are some of the most frequent readmissions.
What I’ve seen as a private patient advocate, however, has more to do with the gaps between hospital care and home care. This is where careful planning and communication, along with support from loved ones or an advocate, can make all the difference in keeping you from being a “frequent flyer.”
One of the most common reasons for hospital readmission is mismanagement of medications. Getting discharged sometimes means being presented with a more complicated medication regimen. You’re told to stop taking some things, start these others, and take this one twice a day. If someone isn’t there to ask what the meds do and confirm how they’re supposed to be taken, medications can literally fall through the cracks
Other issues with medications are affordability, side effects, a patient’s vision or cognitive decline, and polypharmacy, the problem of multiple medications prescribed by different providers that shouldn’t be taken together.
Another major gap is in follow-up care. During a discharge planning meeting, patients are often instructed to follow up with their primary care provider within seven to 10 days. Enforcing this, however, is hit-and-miss. Some patients may not have a primary. Some may not have a ride to the doctor’s office.
Ideally, the primary care practice will reach out after a hospitalization for follow-up, but if there’s poor coordination between the hospital and the provider, this may not happen, especially if they happen to be in different health systems.
Then there’s the discharge process itself. Some hospitals do a great job with this, assigning certain nurses to spend as much time as needed to help patients and families understand what needs to be done. But sometimes, it’s a very rushed, five-minute conversation leaving a lot of questions on the table.
If discharge instructions are too complex or not provided in a patient-friendly way, it becomes more difficult to recognize “red flag” symptoms before they become serious enough to require another hospital stay.
In my experience, some patients – eager to get home – are less than honest about the support system they have in place. They may tell the discharge nurse that, of course, they can handle their personal needs (hygiene, meals, etc.), but if that’s not the case, that patient may be facing a quick round-trip to the hospital. If you don’t have support at home, the hospital’s social worker or a patient advocate can help get it arranged.
The transition gap is sometimes wider because of what researchers call “social determinants of health”: Does the patient live alone? Are they uninsured? Do they need an interpreter because English isn’t their first language? Do they have transportation to follow-up appointments? Can they afford groceries needed for a healthier diet? All of these are critical issues, and they don’t necessarily make it into the patient’s medical record.
The hospitals don’t want to see you back, so they are increasingly turning to our old friend A.I. to develop predictive tools that help them understand which patients are at the highest risk of returning before they even leave the hospital. One such measure is the LACE Index, which looks at length of stay, acuity of admission, comorbidities and emergency department visits.
The effectiveness of these tools is not yet where it needs to be, unfortunately. So it’s up to us humans – patients, families, medical professionals and advocates alike – to recognize post-hospital speedbumps and do all we can to avoid them.
• Teri (Dreher) Frykenberg, R.N., a registered nurse and board-certified patient advocate, is the founder of www.NurseAdvocateEntrepreneur.com, which trains medical professionals to become successful private patient advocates. She is the author of “How to Be a Healthcare Advocate for Yourself & Your Loved Ones” and her new book, “Advocating Well: Strategies for Finding Strength and Understanding in Health Care,” available at Amazon.com. Contact her at Teri@NurseAdvocateEntrepreneur.com to set up a free phone consultation.