Interviewing patients regarding readmissions
After involved clinicians and independent physician reviewers performed extensive case reviews of more than 700 readmitted patients,6 Ashley Busuttil, MD, FHM, associate section chief, Hospital Medicine, University of California, Los Angeles Department of Medicine; and executive medical director, Medicine Services, UCLA Department of Medicine, and Erin Dowling, MD, assistant clinical professor, General Internal Medicine, Hospitalist Services, UCLA Medical Center, Santa Monica, Calif., and their colleagues were unable to identify which readmissions could have easily been prevented, and found that readmission causality varied extensively.
Given this, the researchers set out to identify a more nuanced understanding of why patients return to the hospital. They decided to do this by talking to patients directly, and specifically studied patient readiness from the patient perspective.
Through interviews with patients, the researchers determined that patients were more likely to think that their readmission was preventable if they felt unready for discharge during their initial hospitalization. This was despite the fact that patients met what clinicians would consider “ready” by objective, provider-centric criteria: they were medically stable, they had in-home support services, they had follow-up arranged, and so forth. As such, they wanted to put effort into educating and preparing patients for what home will look and feel like posthospitalization to address their feelings of unreadiness.
To that end, the researchers created an enhanced transition initiative that included showing an educational video near the time of admission and a patient-centered discharge checklist to help patients identify questions they might have after discharge. The discharge checklist asks patients to put themselves in the position of being at home and working through scenarios they may face so they will know how to deal with them. For example, if you have pain, who should you call? What should you do if you run out of medication?
Dr. Dowling believes that the hospitalist will, over time, become essential to assessing patient readiness. “As we learn more about how patients approach discharge, hospitalists’ understanding of patient needs beyond straightforward medical care will be crucial to having smoother transitions of care,” she said.
The researchers also explored pain control. As a health system, UCLA Medical Center has formed a multidisciplinary task force to optimize its approach to pain control. “If we can address comfort – for both patients at high risk of readmission and those that aren’t – we hope we can improve symptom control overall,” Dr. Busuttil said. “It’s not uncommon for patients to feel inadequate symptom control at discharge. While this is likely only one component of all the readmission pieces, a patient who feels that their symptoms are not controlled is likely to feel less ready for discharge. Increasing patient readiness, perhaps by increasing symptom control and improving communication regarding symptom management expectations, is a task that the hospitalist is well positioned to address.”
In addition, a focus group that included patient representatives was conducted to identify potential discharge paperwork enhancements. Patients were asked to identify opportunities for improvement in the health system’s discharge After Visit Summary (AVS). “We were surprised to learn that even though patients knew that they had follow-up appointments, they were unable to locate the follow-up appointment section on the AVS,” Dr. Busuttil said. “We also learned that the medication section was confusing. Efforts for an AVS revision are underway.”
The researchers also wanted to find out why patients may not use available outpatient resources, and assessed them for decisional conflict – a measure of certainty with decision making – when selecting from multiple options for accessing medical care if they were home postdischarge and began to feel ill again. “Patients with decisional conflict were more likely to state that they would go the emergency room rather than call their primary medical physician or visit an urgent care center,” Dr. Busuttil said.
The health system continues to screen patients for decisional conflict. “When positive, we provide bedside education on when to seek medical care through primary care, urgent care, or the emergency department,” Dr. Busuttil said. “We also provide patients with information on how to access each of these resources.”
While a prior discharge plan may have seemed ideal on paper, time and time again it’s not logistically possible for certain patients. “By having this knowledge gleaned from patient interviews, hospitalists are able to provide feedback to health systems regarding different options of outpatient care that may work for the different patient populations they serve,” Dr. Dowling said.
To understand why one particular patient population is being readmitted requires taking the time to understand that population, Dr. Dowling noted. “While many validated risk stratification tools are available, they may only serve as general guides,” she said. “To impact the population you serve, you must first understand the readmission process as it looks to them.”