Brief Description of the situation:
Mrs. C was readmitted back into the hospital six days after her recent discharge. She left the hospital in stable condition, resolved symptoms, having all of her prescriptions and instructions in hand. It was documented that she verbalized understanding of her discharge instructions including her follow up appointments and medications. So why did she come back? She came back because she still had a cough and shortness of breath. Mrs. C is 78 years of age, and was readmitted with the diagnosis of pneumonia. This was her third trip to the hospital within the last year. She also suffers from asthma, hypertension (HTN), and diabetes. Patient recently lost her husband of 47 years, her daughter lives nearby, works full time and has four children. “She visits as much as she can,” Mrs. C whispered about her daughter with tears in her eyes, “as the matter of fact, she will pick me up today,” she continued proudly.
Part of transitional care is to assess people for risk factors for readmission. Mrs. C’s responses to the Patient Health Questioner– 9 (PHQ-9) suggest moderate depression. Depression is not routinely assessed in a hospital, unless a patient has delirium or suicidal ideations. Mrs. C lives alone and has minimal social support which was not acknowledged during her hospitalization. Case management’s assessment indicated the patient was independent prior to discharge and there were no needs identified for the case manager. How is it that someone who is depressed, lives alone, has little support and has had multiple readmissions consider having “no needs?” No one addressed Mrs. C’s non-compliance and dietary indiscretion. Upon admission, her hemoglobin A1C was high at 8.3%. No one asked her if she was taking her antibiotics or using her new inhaler. When asked about how many times she missed her medications in the past week, she admitted to not taking any medications somedays, because she just “did not feel like doing anything.
The dilemma:
Millions of people are readmitted into the hospital within thirty days after hospitalization with the same or similar problems. Health care providers focus on the medical issues without inquiring why the patient was readmitted. If hospital staff only focus on the diagnosis of the readmission, and ignore the reasons that might have caused the readmission, the vicious cycle of readmissions will not be fixed.
For decades, reimbursement system was rewarding hospitals and healthcare providers for every encounter. Now, with the new payment system, hospitals are forced to look into the readmission problem much deeper. According to the statistic, Mrs. C is one of millions of people who have one in five chances of being readmitted back into the hospital within thirty days following discharge. If she gets readmitted, her care will contribute to the escalating cost of healthcare system.
Solution:
Every patient who is admitted to the hospital needs to be assessed based on the psycho-social factors of possible readmission such as: living situation, caregiver availability, depression, motivation, and primary care provider involvement. For people who do not have adequate support at home, we need to provide additional resources. Our solution is the involvement of Community Health Worker (CHW) post hospital discharge to successfully address ongoing psychosocial needs that contribute to readmission.
In our experience, we have found that depression plays a big role in the hospital readmission; it goes undiagnosed, untreated or undertreated and simply misunderstood. Hundreds of patients do not take their prescribed medications because they “just did not feel like doing anything,” just like Mrs. C. Our professional opinion – if Mrs. C’s primary care provider would have addressed her depression, then her blood glucose levels would be controlled and pneumonia could have been resolved as well.
Mrs. C is the example of many patients we have worked with over the years. We assess patients who are identified as being at high-risk for readmission, create transitional care plans, communicate with primary care providers and the hospital team to aid in the process of transitioning patients safely back home. We were pleased to know that post-discharge, our registered nurse will visit Mrs. C in her home. After discharge teaching and medication reconciliations, nurse will “hand her off” to the CHW who will follow Mrs. C for thirty days assisting her with follow up appointments, transportation, medication adherence, motivations and education. Based on the chart review and in-person assessment of Mrs. C, we were able to design her care plan focusing on education, red flags, medications, follow ups and mitigation of psycho-social barriers which puts her in risk of being readmitted to the hospital. When nurses and other healthcare providers fail to do the type of case management that is needed, we fail our patients and contribute to the high readmission rate. By providing much needed service of transitional care our experts continue to bridge the gap by addressing the underlining psycho-social cause of their readmission.