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HEALTH CARE: Stopping the Revolving Hospital Door

Not a lot of aspects of U.S. health care still have the power to stun me, but when I first heard the statistics on U.S. hospital readmissions I was, well, stunned. I wrote about readmissions in today's Washington Post (in a collaboration with the new Kaiser Health News.) Readmissions is a pretty sprawling topic, but I think the reason it interested me so much is because it's a nexus of so much of what's wrong with our health care system. Errors of omission and commission. A system so complex and fragmented that we lose track of what the patient needs. Financial penalties (in some although not all cases) for hospitals that try to make things better.

For a Medicare patient who has been hospitalized, about one in five are rehospitalized in 30 days, one in three within 90 days. Within a year, two-thirds are either rehospitalized, or dead. For younger patients, the figures are better but not great. After all, don't we all have friends and family who have gotten out of the hospital and headed right back in again a week, two weeks, a month later?

Not every rehospitalization is unnecessary; people who have excellent care can still have setbacks. Diseases can and do progress. But a lot of these hospitalizations (some experts argue a majority of them) result from patients falling into one crack after another in our chronic care system.

Dozens if not hundreds of projects and initiatives are underway to reduce high readmissions rates. A few lessons have already emerged. For instance, Stephen Jencks, one of the experts I interviewed (he worked for Medicare for a long time and now consults for IHI) told me that one of the biggest factors is whether a patient sees his or her own physician outside the hospital quickly. (Finding out how many don't or can't get an appointment is another stunner). The quality of personal communication is also crucial. The Iowa "Teach Back" program I wrote about sounds so simple, but it actually takes careful effort over several days. The nurses make sure the patient understands what medicine he needs to take when he goes home from the hospital. Easier said than done. Patients who are groggy from their drugs, anxious because they are sick and in the hospital, in too much pain to concentrate or suffering from dementia or short-term memory deficits aren't going to understand complex directions. (Take the little orange pill four times a day on an empty stomach, take the big blue pill three times a day on a full stomach, take the pink pill as needed for pain, take the red pill before the pain starts, avoid grapefruit with the square white pill but have some yogurt to coat your stomach before the oblong white pill, take the little green one to help you sleep but don't take the big green one at night because it will keep you up...Add about a dozen more instructions for an elderly person with several chronic diseases, and call me in the morning). Teach Back is more complex than it sounds at first blush (and it can sound plenty daunting to nurses who are already overburdened by staffing shortages).

Relationships and self-care both seem to matter. The patients at Inova's Heartlink call in their health status, and they have to pay attention to their own bodies—their weight, their breathing, swelling in their limbs. (A relative can take this on if the patient is not well enough or not cognitively able to handle it). But the HeartLink nurse is keeping track. If someone doesn't call in, she notices and she'll check in. Some telephone-based disease management programs have not worked well. The Virginia program I wrote about is new, so their data is still quite preliminary and anecdotal. But it's also very encouraging. It's phone monitoring, but it's phone monitoring with a heart. The HeartLink nurse knows most of the patients in person, or she develops ongoing relationships over the phone. She isn't just a detached voice from out of town. Most of the HeartLink patients are treated by a small cardiology group that works closely with the high quality community hospital. Technically it isn't an "integrated" system, but the relationships—between doctor, nurse, patient and hospital—appear to work.

One last thought. As regular readers of this blog know, I've done a lot of writing on end of life and palliative care. Sometimes we send patients back to the hospital even though they might not really want to be there if their doctor had an honest conversation with them about the severity and likely course of their condition. At some point, even well-managed chronic diseases can become terminal diseases. Instead of going through the revolving door, back into ERs and ICUs, sometimes it is time, as nurse Honora Fowler noted, to have a conversation about palliative care or hospice. It can be hard. But the alternative can be harder.