Clarity on how providers fit into the rehospitalization picture
James M. Berklan, McKnight's Editor
Mentions of nursing homes and post-acute care facilities are conspicuously hard to find in study reports released Wednesday in a Journal of the American Medical Association article. But they powerfully fill the nooks and crannies of the findings like ghosts in the mist.
How could they not?
In brief, the study found that heart failure, heart attack and pneumonia patients are fairly frequently readmitted to the hospital within 30 days — but usually for diagnoses different than their original admission.
In a series of wonderful charts and explanations, researchers detail which diagnoses are most prevalent, and when they're most likely to drive someone back into the hospital. One of the implications is that many, if not most, of these former hospital patients need better follow-up from home if they don't want to end up back in the hospital.
But the results also confirm that long-term care providers' mission is incredibly important. That goes for the first 15 days after hospitalization, and also the second 15 days, which in many cases is equally as important, according to researchers.
The finding that jumped out the most forcefully to me was that a multidisciplinary team is critically needed to cover recently hospitalized patients. That's not necessarily a shocking revelation. But it is something worth repeating, and acting upon. It's not just enough to prevent a same-condition relapse. You have to be able to heal the whole person and stave off readmissions for other, affiliated reasons.
That's a tall order. But providers will ignore this finding at risk of their own economic peril.
Many long-term care residents emerged from the hospital only to be more vulnerable to a variety of other breakdowns. Whether it has to do with medication adherence, delirium, sleep deprivation, weight loss, nutritional issues or other factors, these patients represent plentiful challenges for long-term care providers.
“Challenges,” of course, being code language for “opportunities.” As the government regulators tighten the screws on hospitals with higher readmission rates, hospitals are going to continue to scour their environs for motivated, high-quality long-term care providers. The researchers note that early efforts to better coordinate inpatient and outpatient care have paid dividends. But they're not widespread enough yet.
Can you help reduce readmissions in the categories now being scrutinized — heart failure, heart attach and pneumonia? Just as importantly, can you prevent other negative conditions from sending these same compromised individuals back to the hospital?
It's time to take a hard look.