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Guest Columnist Author: Jan Berger M.D., MHL Last Updated: Sep 7, 2017 - 10:11:01 PM



Hospital Readmissions: What Patients, Doctors, and Health Plans Should Know

By Jan Berger M.D., MHL
Aug 20, 2009 - 12:08:07 PM



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(HealthNewsDigest.com) - The costs of preventable hospital readmissions are significant, both in hard dollars – PricewaterhouseCoopers estimates these costs at $25 billion per year – and in patient health. Recent studies show that the problem is also pervasive, with the New England Journal of Medicine reporting that approximately 20% of patients being discharged from the hospital are readmitted within 30 days. And yet, this issue is perhaps one of the most straightforward problems to solve when patients, healthcare providers and health plans all do their part to help.

As such, the issue of preventable hospital readmissions is gaining interest in Washington and has now become an integral part of the reform discussion. There are 14 demonstration projects currently in place with CMS (the Centers for Medicaid and Medicare Services) regarding patient re-hospitalization, pointing to the need for better communication and coordination of care between patients and their healthcare providers within the healthcare system.

Reasons for hospital readmissions and the importance of communications are highlighted in two recent studies. A 2008 Mayo Clinic study cites “Health information received by patients at discharge is critical to the success of their outpatient care plan because it guides them when they are no longer under a physician’s supervision and so more likely to make an error.”

Furthermore, a recent Silverlink Communications study identifies patients’ requirements for transitional care once they leave the hospital. The data indicates that almost 30% of patients are lacking at least one critical care component during post-hospitalization. Of that group, patients need support in the following areas:

· 31% need prescriptions

· 19% need help around the house

· 15% have financial barriers to care

· 13% need same day follow-up with a care manager

· 11% had no follow-up with provider

· 11% need transportation

To reduce hospital readmissions, everyone has to do their part. Patients must be responsible for their own care and healthcare providers and health plans must provide effective support and communications.

What Patients Can Do

Hospital discharge can be a time of confusion for the patient and their caregiver and both are often overwhelmed physically and emotionally. There are simple actions that patients and their caregivers can take to keep from having a lapse in care and from being readmitted to the hospital.

Communicate. Ask questions or ask the doctors or nurses to repeat something if it is not clear.

Four ears are better than two. Have a family member or friend present when talking with the doctors and nurses.

Make sure to follow up. Make a follow-up doctor visit before leaving the hospital.

Medications. Don't leave the hospital without first calling in prescribed medications. Nurses at the hospital can call the prescription into the local pharmacy so they can be picked up on the way home.

Make a check list and understand the plan. Put this plan in writing and have the doctors and nurses check the list before leaving the hospital.

Get family and friends to help. Caregivers should help with driving the patient to follow-up doctor visits, making meals, picking up medications, etc.

Don't let your pride get in the way of your health. Care can be expensive, so inquire with the doctors or nurses if there is an issue paying for care.

Progress report. Call the doctor if there are issues or if there are questions.

Find a doctor you can trust. It is important that the doctor can be reached when needed, and all issues can be discussed in a comfortable manner.

Compare notes and share. It is important that all doctors involved in care talk to one another other. This includes doctors providing care in the hospital and outside of the hospital. Key information that needs to be shared includes prescribed medicines, vitamins, minerals and over the counter medicines. Have one doctor be the leader of care. This person can help gather all of the relevant information and make sure that the doctors are communicating with one another.

What Healthcare Providers and Health Plans Can Do

Patients aren’t the only ones responsible for reducing hospital readmissions. Healthcare providers and health plans are responsible for making sure there is coordination of care, communication, and follow up to a hospital visit.

While still at the hospital, healthcare providers should make sure they are communicating properly to patients about their diagnosis, medication, and side effects of medication. This can be done by creating a plan of care, writing it down and asking patients to repeat back what they have heard to make sure they are retaining the information.

Shortly after discharge, healthcare providers and health plans alike should put a best practice communications strategy into place. There are many technologies that allow for scalable outreach to recently discharged patients that can collect information, understand lapses in care and connect patients with a care manager should the patient’s condition be at risk for complications.

Reducing hospital readmissions rates is an important task. When everyone does their part, it can be accomplished.

With over 25 years of clinical expertise and extensive experience in lifestyle management, disease management and preventive health issues, Dr. Jan Berger is considered a national healthcare thought leader. She is currently the Chief Medical Officer at Silverlink Communications. Previously, Jan was the Senior Vice President and Chief Clinical Officer for CVS Caremark. Jan is actively involved in national population health initiatives, participating in numerous committees for NCQA, NQF, DMAA and the Center for Health Value Innovation. Additionally, she is the Editor in Chief of American Journal of Pharmacy Benefit and has published over 100 articles.

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