In the April 2012 issue of the New England Journal of Medicine there was a Perspective’s article that is being circulated and discussed: Thirty-Day Readmissions – Truth and Consequence (you can download and read the article by clicking on it in my Dropbox™ account to the right). In the article the authors argue, “that policymakers’ emphasis on 30-day readmissions is misguided.”
They present three reasons:
1. many of the variables inherent in driving readmissions are beyond the hospitals’ control (e.g., “patient-and community-level factors”), and they note that, “it is unclear whether readmissions always reflect poor quality”;
2. improved discharge planning and care coordination could be more effectively achieved by focusing on other metrics, rather than readmissions; and
3. resources committed to reducing readmissions may be better allocated to focus areas able to demonstrate a perceived higher ROI (e.g., patient safety and quality).
I think this misses the point as to why there is a focus on hospital readmissions. In particular, noting that readmissions may not reflect poor quality seems like a fallacious assertion because I don’t think the argument is being made (at least by those who understand the issues and concerns) that readmissions necessarily do reflect poor quality. At issue is whether the readmission could have been avoided with more effective care planning and transitioning – and thus equal or better care provided in a lower cost setting. From listening to nursing staff at PA/LTC facilities, the evidence of opportunities for care transitioning improvement is overwhelming, albeit anecdotal from my frame of reference.
Admittedly, it is very difficult to study the true economic impact of hospital readmissions by attributing their causes. Some patients should never have been discharged in the first place, and there are a host of reasons that drive premature hospital discharges. Some patients are discharged to inappropriate settings – often because the patient and/or patient’s family intervenes over the recommendations of physicians and/or discharge planners. Some patients are convinced they can follow a required post-discharge regimen and fall way short within the first 24 hours. While some patients need just a little support (e.g., queuing, companionship, medication management), but they are in a situation where they have none. And finally, some patients – particularly the elderly – are significantly impacted emotionally by care setting transitions, leading to adverse reactions that are very unpredictable.
But research has shown that education, coaching and timely intervention can be very effective in disease management. We know that getting patients to change risky behaviors and become better self-managers of care can improve outcomes across a range of chronic illnesses. We know that doctors have neither the training nor the time to engage in counseling on behavior change or to give self-management support.
So it is inevitable that PA/LTC organizations will need to play a growing and critical role in designing, planning and implementing post-discharge care transitioning programs for patients in need of chronic disease management. The sooner those organizations embrace the importance of this role and begin to build the requisite knowledgebase to be successful partners in integrated care delivery models, the better chance they will have of surviving in an era of Healthcare Reform.
A good place to begin for many of those organizations may be to become familiar with the work of Dr. Eric Coleman (University of CO Denver School of Medicine) and his colleagues on care transitions. Many of the PA/LTC organizations that I work with now talk of the, “Coleman Model” and/or the “Coleman way” as an emerging standard bearer. Here’s their web site:
Have a Wonderful Memorial Day – and let’s all be very thankful to the brave men and women that have given so much to ensure we still have the ability to share ideas like I do here, open and freely!
~ Sparky
Sparky's Policy Pub 
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