Discharge? That's just the start

John Taylor: October 09, 20130 Comments

Conference speakers tend to have a compass with three needles -- poking fun,  jabbing fingers or revving up encouragement. Dr. Eric Coleman nailed two of them in a presentation about the importance of hospitals investing n high-quality transitional care.

Hospitals, like Community Medical Centers, that have skilled nursing facilities will soon be penalized under the Affordable Care Act for what he called care-sensitive, preventable readmissions.

Hospitals need to build capacity in terms of the various human expertises they have, he said, rather than investing largely in bricks and mortar. That means involving and educating patients and their key at-home caregivers – their families.

Coleman is a professor of medicine and head of healthcare policy and research at the University of Colorado Anschutz medical campus and essentially in charge of what they call in the business “care hand-offs.” He certainly knew some of the soft spots in his audience – more than 100 hospital executives at a recent annual summit of the Hospital Council of Northern and Central California.

Here’s some of what’s not working:

  • Fancy new names like “rapid response transitional care teams” – more commonly known as discharge planners.
  • Branding readmitted patients as “non-compliant.” When a patient gets that label, he said, patient engagement stops. Caregivers do “drive-by” visits and stop efforts at communication.
  • Too many follow-up calls, too many assessment plans, too many care coordinators --- duplication and harm done in the name of compliance, regulation or payment systems built into silos. “Care plans are informed guesses. What if (the family) could test drive them first?”
  • Ignoring offers by community-based organizations that might offer in-home help to patients.

Most at-home care is provided by families who get little support from the hospitals that have exported their loved ones home. They don’t fully understand what could go wrong, and when they call for assistance, they’re treated as an annoyance or as background noise.

Patients are told to check their weight – but what if they have bad eyesight or have abdomens so large they can’t see the scale? A trial run might explain lack of compliance there. Maybe one way to help with heart failure management is to remind patients that success might mean being able to go to church in shoes instead of flip-flops.

What’s needed, said Coleman, is a single set of patient education information – not the Everest-like stack of papers, including invoices, that accompany patients and their families as they trundle home.

“Fixing a problem creates a dependency and a promise that they could come back,” he said. Interaction at the right time reduces avoidable readmissions or transfers.

He said one website, from the United Hospital Fund, may be helpful --- www.nextstepincare.org

Everyone’s goal, he added, should be “keeping wellness from unraveling.”


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