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Improving Care Transitions

By Jaimie Lazare

Shorter hospital stays, poorly communicated discharge plans, and delayed follow-up care all contribute to unnecessary hospital readmissions. Carefully devised strategies and technologies can improve care transitions.

Christopher A. Langston, PhD, program director at The John A. Hartford Foundation in New York, says the rate of rehospitalization is 20% within 30 days of discharge for people who were hospitalized because of a specific medical condition. “Even more troubling, as an indicator of the weakness in the healthcare system, half of those people who were rehospitalized did not see a healthcare professional in the outpatient setting,” he says.

This has become an unfortunate and costly situation in which patient needs aren’t being met. And not only do hospitals potentially benefit financially from expediting patients’ discharge in efforts to reduce length of stay, but they also benefit when the patients are readmitted because in most cases, they receive an additional payment.

These two forces are far from independent as the drive to reduce length of stay may influence patients’ readiness for discharge, which in turn may contribute to patients’ need for subsequent readmission, says Eric A. Coleman, MD, MPH, a professor of medicine and head of the Division of Health Care Policy and Research at the University of Colorado Denver and director of the Care Transitions Program. 

Hastened hospital discharges and poorly communicated information further complicate the complex management of an older adult’s care, which inevitably leads to avoidable readmissions.  A provision of the Patient Protection and Affordable Care Act includes disincentives for unnecessary hospital readmissions. The act recognizes the need to realign financial incentives to encourage hospitals to better address health issues that prompt the need for readmission. Coleman says a counterbalancing financial incentive needs to be created for when patients are rehospitalized for health issues that could have been avoided.

By October 1, as a measure to reduce poor care transitions, the Affordable Care Act will implement financial penalties by reducing Medicare payments to hospitals with a high number of preventable readmissions.

Interventions in Care Transitions
“The problem is that healthcare is not patient centered, and transitions fail to be patient centered,” says Langston. “The discharging nurse or social worker typically races through the care plan and says, ‘Do you understand?’ People don’t understand, but they want to leave. If you ask the question the wrong way, people will say, ‘No, I don’t have any questions.’ And if you ask the question in an inviting way, you can get people to actually ask questions,” he says.

To address this problem, Coleman and his colleagues created the Care Transitions Intervention, a four-week program uniquely focused on enhancing transition-specific self-care skills for patients with complex care needs. By interacting with a transitions coach during a single home visit and three phone calls, patients have the opportunity to engage in hands-on problem solving of current transition-related challenges and to role-play upcoming healthcare encounters. In the process, patients develop confidence to better articulate their needs and take effective action.  

Coleman notes that patients may learn key phrases or language for situations such as securing a timely follow-up appointment or speaking with the primary care physician or pharmacist to reduce the number of medications they take. Rigorous trials have demonstrated that this approach not only reduces hospital readmissions during the four-week program, but more importantly, results in a sustained reduction in hospital readmission out as far as six months.

Langston says Coleman’s model reduces readmissions because it recognizes that the discharge experience can be stressful and difficult so it provides a care transition coach to follow patients at their homes within a day or two. It is a better situation for the family, for the patient, and the caregivers. In many cases, with Medicare beneficiaries it’s really the family that needs to be educated, and it’s important to work with them to help them develop a care plan because many Medicare beneficiaries are cognitively impaired, making it difficult for them to fully participate in their own care, he says.

“One of the things we’ve been encouraging people to do is actually just go to the bedside and ask the older adults, ‘In your own words, why do you think you ended up back here in the hospital again?’ This helps to give the patient a voice in their own care,” Coleman says. “Because when we really look at the causes for readmission, it’s not so much about patients not following instructions as much as it is the challenges that they have of managing their multiple comorbid conditions and recognizing that in many cases the reason for readmission had to do with something nonmedical.”

“A lot of what our work has been doing is trying to encourage the hospital team to be able to meet the patient where they are with respect to literacy, cognition, and to include their caregivers. Care Transitions Intervention recognizes the essential role patients play in their own care, and this is a model entirely devoted to trying to raise their ability to assert themselves, to understand the right way of expressing themselves,” Coleman says.

Technological Opportunities
Janhavi M. Kirtane, MBA, director of clinical transformation for the Beacon Community Program in the Office of the National Coordinator for Health Information Technology in Washington, DC, says the healthcare system is on the path to modernization with more meaningful use of electronic health records (EHRs). Though it’s a new situation that’s not without challenges, if patient information, care plans, and discharge instructions are stored in an EHR, it creates a huge opportunity to help improve the hospital discharge process and care transitions, she says.

“Outside of the hospital system, we are beginning to see community-based providers use technology to better share information about patients with other providers. For example, to improve transitions of care, home health nurses could use their laptops or iPads to view and update patient care plans during their home visits. Results could then be shared with referring physicians or hospitals,” Kirtane says. 

Another platform for technology implementation is remote patient monitoring. Patients can have systems installed in their homes that transmit information to nurses or other healthcare providers to let them know—in real time—critical health information and then provide patients with more rapid interventions.

“Remote patient monitoring is being used by hospitals to improve transitions immediately following discharge, a time during which patients are at high risk for readmissions, as well as on an ongoing basis for patients with chronic diseases like CHF [chronic heart failure]. The technology is still evolving—for instance, some systems have video capabilities—how it’s being used is also evolving, but we are seeing some promising early results,” Kirtane says.

“Interestingly, there are many mobile apps for things like medication adherence (Did I take my medication? Are there potential complications with my medications?) However, less than 10% of the elderly have smart phones. Perhaps someone who is elderly may have dementia or might just not be capable of handling a smartphone, so engaging the caregiver is where mobile technology could be more powerful,” Kirtane says.

“I don’t really think technology is the issue,” Langston says. “The issue is making information available to everybody who’s involved in the patient’s care. One of the best technologies is having a good conversation. One of the measures of good communication is what’s called teach back. What teach back does is ask the person receiving the information to put it back in his or her own words as a test of whether you’ve successfully communicated. Now that’s a really important technology.”

— Jaimie Lazare is a freelance writer based in Brooklyn, New York.