For many older people, hospitals have revolving doors.
About one in every five seniors who spends time getting care in a hospital is readmitted within 30 days of being discharged. A hospital readmission often signals a gap in the quality of medical care. In addition, it’s a disruptive and unsettling experience — and an expensive one, too, costing an estimated $17.4 billion every year, according to a study published in the New England Journal of Medicine.
This indicator of substandard care, combined with the reality that hospitals, beholden to payment schemes, are routinely pressured to discharge patients as soon as possible, prompted some recent government action. Included in the Affordable Care Act — which now faces an uncertain future — was the Hospital Readmission Reduction Program. Phased in beginning in 2012, it exacts a penalty on hospitals with higher-than-expected readmissions for specific conditions, including heart attacks, pneumonia, and congestive heart failure — with more conditions measured and monitored each year.
Money talks. The year the program went into effect also marked the first measurable decrease in hospital readmissions, and the decreases are trending to continue. From 2010 to 2015, readmission rates fell by 8 percent nationally.
An added boon: Since Medicare posts the results of the hospitals that are dinged most heavily online, savvy consumers with the time and inclination to comparison shop for hospitals can get a look at this marker of poor quality care before being admitted in the first place.
Despite these improvements, the need to reduce readmission rates — and to do so opaquely — remains a high priority for those concerned about quality medical care for the elderly.
Why the High Rates?
Some hospital readmissions can’t be avoided — and are actually a sign of conscientious rather than haphazard medical care. And some are truly life-saving. The focus of concern is on “avoidable” readmissions. A few common factors are often to blame.
Inadequate discharge plans. Before leaving the hospital, patients are supposed to have in hand a “discharge plan” — a clear blueprint for follow-up care and treatment once they return home. In reality, however, the discharge process is often a hurried flurry, or a game of hurry-up-and-wait as bureaucratic paperwork gets completed. Most patients say they get wheeled out of the doors without a real understanding of care or medications needed once they leave a hospital. Many receive very general one-size-fits-all explanations, or no clear written instructions at all, much less personal explanations from medical staff. Essential matters such as how to clean an incision, exercise and diet restrictions, and potential side effects of medications are left unaddressed.
Lack of coordinated medical care. Today’s health care system, packed with specialists and fraught with insurance complications, is frequently fragmented. And that problem is most profound for people after hospital stays. Many patients receive care from a staff hospitalist — a doctor responsible for care only while a person is in the hospital — or perhaps a surgeon or other medical specialist who has not treated them before.
And several studies have uncovered that more than half of the older patients discharged do not see a primary care physician or specialist within two weeks of being discharged from the hospital — another indicator that the care is not coordinated.
As a result, after discharge, many patients are understandably confused about the proper provider to contact if they have questions about their care at home, need help coordinating medications, or suffer some health-related setback.
Inadequate support at home. Many of those who return home after a hospital stay are too weak, frail, or confused to care for themselves properly — and some may not have the connections or resources to secure the help they need. Recent interviews with former hospital patients revealed that single or divorced men were hardest hit by this problem.
Patient issues. Problems after discharge aren’t always the faults of the medical providers or establishments. The common refrain that they “don’t like hospitals” causes some patients to push to be discharged even though they know they are still not well and need medical supervision.
Some people may forget to take medications in a new regime, or be unclear about how and when to take them safely.
Plain old human stubbornness is often an issue, too. Patients diagnosed with diabetes, for example, might simply refuse to change their eating and exercise habits and those diagnosed with COPD might continue smoking once released back home and out of the watchful eyes of hospital personnel.
And some patients, angling for early release, may fib to medical personnel about their understanding of a care regime or be uncomfortable admitting they lack the finances to pay for medications or home care. They may be too sick or weak to go to scheduled follow-up appointments.
Steps From Hospital to Home
Taking a few practical steps can help ease the transition from hospital to home.
Become informed. Before leaving the hospital, ask specific questions — and insist on specific answers. Hospitals can be intimidating places, and even a brief stay in one can be disorienting. It’s always wise to have a family member or friend present during the entire discharge process to help bolster your courage or keep track of information provided.
Doctor or discharge planners will commonly say offhandedly that a patient will require “24-hour care” for some period after being discharged. Press for details on the actual care required and what the risks may be for being alone during the days and nights. Help may range from the untrained monitoring that a family member or friend can provide for a while, to a few hours of home care — personal care or companionship services, to full-time home health care provided by those with medical training — such as physical therapists or registered nurses.
Prepare the home. Make sure prescriptions for all medications have been filled, either through the hospital pharmacy, or better yet, through the patient’s usual provider, where the pharmacist is more likely to be aware of allergies and personal proclivities. Also arrange in advance for any medical equipment that might be required, such as a walker or toilet set riser — and have it delivered. And make any temporary or permanent safety improvements that may be required to accommodate changed physical conditions, such as removing throw rugs or adding grab bars or stair ramps. And finally, don’t overlook the two things most often ignored for homecomers’ health and safety: clean linens and fresh, healthy food.
For additional guidance, see the online booklet Returning Home: A Guide to Your Senior Loved One’s Safe Transition Home.