Elizabeth Leis Newman

In life, as Donald Rumsfeld once said, there are known knowns, known unknowns and unknown unknowns.

This may sound like gobbledygook, but it’s actually relevant to business and long-term care. Specifically, providers have to first figure out what they know when it comes to hospital readmissions: There are too many, with the 30-day readmission rate for Medicare beneficiaries being as high as 30%. Collectively, there are elements to readmissions that we don’t even know that we don’t know yet, and there’s only so much time we can spend worrying about that.

But one of the “known unknown” areas of readmissions has been related to the role of the patient. Specifically, how much of going back to the hospital has to do with the individual’s personality or life story, rather than their illness? Are we treating the entire Medicare or Medicaid population under a mindset of being “old” or “poor” without evaluating each person’s understanding of their situation?

A new study, published in Journal of General Internal Medicine this month, sheds some light, finding that depression, low health literacy, advanced age, complex medication regimens and taking certain high risk medications all put someone at risk for being readmitted. It’s also higher if you are a man. In other words, if you have a male senior who is on a bunch of medications that he doesn’t understand, and he’s down about his deteriorating health, well, that’s a person you need to devote some attention to.

Answers on how to identify these patients lies with the Patient Activation Measure®, created at University of Oregon and licensed through Insignia Health. Researchers at Boston Medical Center used four levels in the PAM model for their study, and evaluated close to 700 patients.

The study isn’t perfect for your purposes, in that participants were not admitted from a skilled nursing facility, were in Massachusetts, and were, on average, around age 48. But the idea of “patient activation” still has implications for those in and out of hospitals, such as long-term care residents. It is a “modifiable risk factor for readmission,” the authors write.

By using the PAM measure, hospitals can identify which patients have low levels of activation during their stay. Those patients receive more time and resources in preparing for the post-hospital period. Discharge planners who know which people have low PAM scores can develop “tailored and cost-effective tiered intervention plans based on the individual’s activation level to prepare patients for a safe and effective discharge that reduces the risk for readmission or ED visits.” Hospitals in 25 states are now using PAM.

What is another known known is that long-term care has to be more invested in what happens to residents in the hospital who are headed their way. While many hospitals have found success with patient navigators, and long-term care facilities would be wise to invest in care transitions training, PAM allows providers to figure out who most needs help in staying healthy. In an era of belt-tightening, it’s wise to figure out, objectively, which patients need the most help. You can call it rationing, but I think of it as cost efficiency.

Elizabeth Newman is Senior Editor at McKnight’s. Follow her @TigerELN.