Coordinated Approach May Help in Caring for Hospitals’ Neediest Patients
To my way of thinking, a person’s diagnosis or pathophysiology is not as strong a predictor of needing inpatient hospital care as it might have been 10 or 20 years ago. Rather than the clinical diagnosis (e.g. pneumonia), it seems to me that frailty or social complexity often are the principal determinants of which patients are admitted to a hospital for medical conditions.
Some of these patients are admitted frequently but appear to realize little or no benefit from hospitalization. These patients typically have little or no social support, and they often have either significant mental health disorders or substance abuse, or both. Much has been written about these patients, and I recommend an article by Dr. Atul Gawande in the Jan. 24, 2011, issue of The New Yorker titled “The Hot Spotters: Can We Lower Medical Costs by Giving the Neediest Patients Better Care?”
The Agency for Healthcare Research and Quality’s “Statistical Brief 354” on how health-care expenditures are allocated across the population reported that 1% of the population accounted for more than 22% of health-care spending in 2008. One in 5 of those were in that category again in 2009. Some of these patients would benefit from care plans.
The Role of Care Plans
It seems that there may be few effective inpatient interventions that will benefit these patients. After all, they have chronic issues that require ongoing relationships with outpatient providers, something that many of these patients lack. But for some (most?) of these patients, it seems clear that frequent hospitalizations don’t help and sometimes just perpetuate or worsen the patient’s dependence on the hospital at a high financial cost to society—and significant frustration and burnout on the part of hospital caregivers, including hospitalists.
For most hospitals, this problem is significant enough to require some sort of coordinated approach to the care of the dozens of types of patients in this category. Implementing whatever plan of care seems appropriate to the caregivers during each admission is frustrating, ensures lots of variation in care, and makes it easier for manipulative patients to abuse the hospital resources and personnel.
A better approach is to follow the same plan of care from one hospital visit to the next. You already knew that. But developing a care plan to follow during each ED visit and admission is time-consuming and often fraught with uncertainty about where boundaries should be set. So if you’re like me, you might just try to guide the patient to discharge this time and hope that whoever sees the patient on the next admission will take the initiative to develop the care plan. The result is that few such plans are developed.
Your Hospital Needs a Care Plan
Relying on individual doctors or nurses to take the initiative to develop care plans will almost always mean few plans are developed, they will vary in their effectiveness, and other providers may not be aware a plan exists. This was the case at the hospital where I practice until I heard Dr. Rick Hilger, MD, SFHM, a hospitalist at Regions Hospital in Minneapolis, present on this topic at HM12 in San Diego.
