As part of the changes that the Center of Medicare Services (CMS) have recently implemented, many hospitals will no longer be reimbursed for inpatient hospital stays if a patient is readmitted within thirty days of discharge. In looking at some of the data on rehospitalization rates we see a wide fluctuation nationwide. Some states have rates as low as 13 %, some are as high as 27%. There are wide variations within some states. What can we learn from the states that are doing well? What does best practice look like? There are a growing number of approaches but many experts agree that the design of our current health care system itself is flawed, at least in this country. We have a highly fragmented system which means that no one provider can remedy this problem. We need greater transparency between medical facilities as far as patient records to ease patient transitions and our current reimbursement system is based on the amount of care and not necessarily on the quality of services rendered.
So where can we start? In the home health arena there are some areas where we can at least begin to make headway:
• Timely follow up.
If an appointment with the primary care physician has not been made by the patient or family at the time of admission to home care services then the admitting RN can make that appointment for the patient or have them call that day. It could be made part of the admission process. Fifty percent of all 30 day hospital readmissions nationally occurred before the patient had their first post hospitalization appointment with the primary care physician (PCP). The ideal would be to have that appointment set up prior to hospital discharge but in the event that it does not happen the visiting nurse should be the safety net.
• Medication reconciliation.
Patients medications change frequently with hospitalizations. The primary care physician must be made aware of the patient's current medication regime. With the increased utilization of hospitalists, most PCPs are no longer treating the patient while in the hospital hence they are not aware of medication changes. Ten day summaries that come from the hospital to the PCPs office need to be more timely, ideally within days after discharge.
• Educating the patient.
The patient needs to recognize the signs and symptoms that necessitate a call to his PCP. The patient needs to be educated as to his disease process and understand the effect that it has on his daily living and the modifications needed to successfully live with his current limitations, whether they be temporary or permanent. Discovering what contributed to this present hospitalization and how to alter or recognize those circumstances is key to preventing an avoidable readmission.
In conclusion, the post acute care plan needs to be comprehensive in meeting all of the patient's needs and most importantly the patient and family need to be part of the health care team. Proper assessment of what the patient/family actually learned from a hospitalization and what they need to understand to prevent a recurrence is essential going forward.