1. Focused targeting
When we talk about readmissions, the first step is to identify those patients who are at the highest risk of coming straight back into the hospital. It's a mix of socioeconomic status, demographics, social support, education, and most importantly baseline co-morbidities and functional status. If your readmission program targets “everyone”, it will expend too much energy on the vast majority of people who don't get readmitted. Employing Pareto's principle (see my previous article); remember that 80% or more readmissions will come from 20% or less of the same patients.
2. Discharge process
Discharging a patient in the typical rushed environment of a hospital is too often haphazard and disjointed. This is the one chance to make sure that all the paperwork and instructions are as thorough and comprehensive as possible. Exhaustively educate the patient and family. It should be the physician that leads this process. Much is made of a discharge taking at least 30 minutes—but perhaps even an hour would be a better time.
The problem with this? It's not as simple as it sounds. In the real word of economic pressures for both doctors and hospitals, spending an hour with every patient you discharge isn't really possible (that's not just a problem for U.S. medicine, because socialized countries in fact usually see more patients in even less time).
3. Intense primary care
Studies may show differing results, but I can tell you with certainty that patients with strong primary care follow-up and outpatient monitoring are definitely less likely to be readmitted. Make sure those high-risk patients have close follow-up ideally within a day or two of exiting the hospital.
The drive to reduce readmissions is a noble one. But we have to be realistic too. With an ageing population, this issue is going to remain at the forefront. The nature of illness is that it's a fragile time for our patients, and particularly for those with chronic underlying illnesses such as COPD or congestive heart failure. It doesn't take much to push things over the edge and for people to be sick enough to require a hospital bed. Battling nature can be hard. The question is: how can we best minimize the likelihood of the next setback and continue to keep more and more people out of hospital and in the comforts of their own home?
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.
