An Individualized Plan to Reduce Readmission

Failure To Communicate: Why Seniors Are Readmitted To The Hospital So Often

This article  in Forbes highlights the importance of continued care after the patient leaves the hospital as a key to reducing readmission. It provides some important qualitative data about readmission issues from the patients' perspective. Here's my take on this, based on my nursing experiences providing care in hospital, clinic and home settings, as well as being on the patient and family side of the issue with several family members.  Continuity of care is important, but some keys will be important to ensure that it is effective.

Care after discharge should  should happen IN THE HOME with the caregiver(s) and others who are involved in the patient's life. In the home, ON THE PATIENT's OWN TURF,  the patient is comfortable and in control- key elements that are missing in the hospital or clinic. In the home the provider can most effectively develop a good understanding of the patient's resources and environment, how s/he lives, their responsibilities, and what is most important to that person. These are all keys to working with the patient to develop a self-management and follow-up plan. The plan needs to be realistic yet as simple as possible, targeting the few self management interventions that the person should focus on doing consistently, and that will be most important to reducing readmission for that particular person- their low-hanging fruit. The motivation for following this plan should focus on the things that determine that person's quality of life- showing how this plan will help them live as they want to- that will make it meaningful and will help motivate them.

Research has shown that reduction of readmission rates for older adults with heart failure CAN be achieved through comprehensive discharge planning followed by post-discharge care. This should include a home visit by a nurse and/or clinical pharmacist for anyone at risk of readmission during the first few days after discharge. This visit should include a comprehensive assessment, documenting key information about resources, environment, support systems, barriers, etc in the EMR where it is AVAILABLE TO ALL PROVIDERS. This visit should include the development of an individualized plan for self management that focuses on a FEW KEY SELF MANAGEMENT strategies that particular person needs to do to keep them out of the hospital- the low-hanging fruit. Finally, the person should be given ONE NUMBER they can call for any questions or concerns.

It's impossible to develop this kind of individualized, realistic self-management plan in the hospital during a crisis without the benefit of the person's support systems and without seeing how the person lives. That's one of the many reasons that discharge plan developed in the hospital alone and that do not provide continued care after the hospital are not going to be effective. And while clinic visits can be helpful, they  remove the patient from the context of his/her life without accurately reflecting their barriers and resources to self-management. Often, the clinic follow-up visits are scheduled 1-2 weeks after discharge- after the vulnerable period of transition from hospital to home is over, and they have already been readmitted. Therefore, a home visit during the 1-3 days after discharge will be most effective.

Another key to reducing readmission is communication. All who care for the patient where ever they go should have access to the plan through a computerized system that communicates across settings and organizations anywhere the patient goes. The person who needs the plan most is the patient, but and all of  those who are important in their lives need it too. It also needs to be documented where all of their providers can access it at a moment's notice, such as when the person calls in the middle of the night with a concern, or they present to the ED in crisis. And it should evolve with the person's changing needs, preferences and resources.

Keys to an effective plan for reducing discharge from the perspective of the patient and family? Simplicity. Effectiveness. Individualization. Continuity.  So how can we ensure that this consistently happens in EVERY HOSPITAL for EVERY PATIENT at risk of readmission?

Medicaid Snafu: A Letter To Governor Scott Walker

Governor Walker,

I'm writing to voice my concern about the changes that have been happening in the healthcare system here  in Wisconsin over the past year, since your healthcare policies have been put in place. My brother has relied on Medicaid coverage for his healthcare needs. He is a cancer survivor, who 16 years later still struggles on a daily basis with his health due to the detrimental effects of the chemo and radiation treatments he needed to save his life.

His heart is totally dependent on a pacemaker and several medications to keep his heart beating and to prevent him from winding up in the hospital due to worsening cardiomyopathy, or to prevent him from dying prematurely. However, his Medicaid coverage was suddenly given to Physician's Plus  insurance last fall. This meant that he had to find a new cardiologist and pacemaker specialist at Meriter since he was no longer allowed to see the doctors who knew him very well at UW Health. After many hours trying to find new doctors for him, the coverage specialists finally concluded that Meriter could not provide the care he required and granted him a special dispensation to return to UW for his cardiac care.

At the same time, my brother requires oxygen at night and has significant breathing problems due to extensive scarring in his lungs. His pulmonologist at UW Health has been keeping him stable and prescribing his oxygen, but again this had to change. His Primary Care Provider who prescribes his other medications had to change also, again, as he was seen at a UW Health clinic. Meanwhile the private company contracted to process his Medicaid enrollment payment lost it. Thus, he was suddenly told that he had no healthcare coverage. This type of healthcare experience is unacceptable.

As a nursing professor and advanced practice nurse myself, I know the challenges of staying healthy on good days for people with chronic conditions such as my brother's. Why does this kind of incompetence, uncertainty and red tape need to compound these challenges? Most who are not fully invested in staying healthy like my brother is would give up.

I am also concerned about the cost to taxpayers and healthcare consumers that is being incurred by the time that the employees at companies and agencies such as Physician's Plus, Meriter, UW Health and DHS are spending trying to handle the claims and changes to implement these policies you have set in place. Privatization, refusing federal aid and trying to do things your way are not working. We need a better healthcare solution that will not jeopardize the health of our citizens.

Beth Fahlberg PhD, RN

Hospice is Being Used More, But So is ICU

USA today article: Hospice & ICU use in Final Month

We're making progress in referring to hospice more often. However, we're also using ICU more during the final month of life. For some patients and families this is what they want, holding out hope for a longer life. But this makes me wonder whether some were in ICU because their wishes weren't determined and documented? Did they have an accurate understanding of their prognosis, and were they and their families prepared? 

I also wonder what that last month was like for these people in ICU and for their loved ones.  Were they comfortable? Did they experience pain, distress or worry from medically futile tests treatments? Were their psychosocial and spiritual needs adequately met? Did they have the information and support they needed to make complex decisions? 

The reality is that many people with HF die in the hospital. Many want CPR and other life-saving interventions, often because they have been saved by these in the past. They want the defibrillator on until the end. And this is fine- it's their choice. Regardless of these types of decisions, how can we promote the best end-of-life experience possible for every patient, no matter what their choices and no matter where they die?

Palliative care is not just a special medical team, or place or organization. Palliative care is a philosophy, a mind set, a choice we make about how we care for people. And it's a philosophy we can use wherever we practice. 

• We provide palliative when we provide information about what to expect and support with decision-making. 
• We provide palliative care when we promote comfort, quality of life and dignity for the individual.
• We provide palliative care when we keep the patient and family as the focus of our care.

While we are making progress in promoting hospice referral for our patients with advanced HF, we should also consider how we promote the best end-of-life experience possible in the hospital as well. Our patients and their families deserve no less. 

When Does End of Life Begin: Implications for Hospice Medicare Policy

News Video: When Does End of Life Begin: Hospice Under Scrutiny

Finally! 
The government is examining whether the 6 month prognosis for hospice eligibility is appropriate, or whether it should be extended. The hospice medicare reimbursement and eligibility structure is antiquated and inappropriate for modern chronic illness care. It's high time that this policy is examined and updated 

Despite the many attempts to develop prognostic tools that work in HF, we still cannot accurately predict when people with chronic illness will die. We've known this since the late 1990s when the SUPPORT study was published. At the same time, people with heart failure and other end-stage chronic illnesses derive tremendous benefit from the hospice model of care with outcomes including reduced hospitalizations and improved QOL, To me, these are not just statistics- I've seen this in my dad and mother-in-law, both of whom died of end-stage heart failure, and who each received hospice services for the last 5-6 months of their lives. In each of them, hospice prevented several hospitalizations. At the same time, we had the ongoing support needed to closely follow them and provide the support we needed. And both died suddenly, with no indication that 24 hours later they would be gone.

Hospice-model care during the final year of life in chronic illness can save the government money by reducing the costs of expensive hospitalizations and interventions in the last year that are often futile and fraught with complications, as these individuals are very frail with multiple comorbidities. The costs of hospital-based care for these individuals are not just financial. For the patients and their families, these costs include pain, fear and anxiety, loss of control, physical and mental exhaustion and frustration- at a time when they are already stretched to their limits. Is it any wonder that patients and families who have been through multiple hospitalizations and near-death experiences would delay seeking care when they know it's going to be like this again? During my Dad's last year, when he had to go into the ER, he would cry out with frustration and despair, and I would just cringe inside- knowing what I needed to do, but wishing that there was some other option.

We need to weigh in on these policy processes, advocating for a more appropriate hospice benefit, that fits the trajectory of end-stage chronic illness, and that will promote quality at the end of life for all Americans.