Most people leave the hospital with absolutely no desire to return. But many U.S. patients come back all too soon as their at-home recoveries unravel. So who’s responsible for these expensive, unwanted readmissions?
In the past, the onus was put on patients: They were "noncompliant" – not taking their medications, flouting discharge instructions, leading unhealthy lifestyles. And as long as patients ignored what was best for them, the thinking went, the in-and-out-of-the-hospital cycle would continue.
But massive costs to the health care system eventually forced a closer examination of excessive readmission. At least one root cause emerged: Hospitals haven't been doing a good enough job getting patients ready to go home – and stay there.
[Read: 12 Questions to Ask Before Discharge .]
Back to Square One
In heart failure – the No. 1 reason for early readmission – the heart pumps too weakly and circulation is poor. Once a patient develops heart failure, it can't be cured. Fluid buildup in the feet, legs, neck veins and belly is a recurring symptom, causing extreme fatigue in patients and making it hard for them to breathe. That's when they land back in the hospital.
Once their symptoms are treated and temporarily in check, patients feel better and it's time to go home. Now it's all up to them – to take their diuretics (water pills), heart and blood pressure medications; to weigh themselves daily to detect weight gain from fluid; and to call health providers before symptoms spin out of control.
Nationwide, about one-fourth of patients with heart failure are readmitted to the hospital within 30 days, says Eileen Brinker, transitional care manager at the University of California San Francisco Medical Center.
In 2008, as part of a grant-funded program from the Gordon and Betty Moore Foundation, Brinker and fellow registered nurse Maureen Carroll were tasked with reducing these costly readmissions by teaching patients to better manage their conditions.
“The biggest reason I see for patients coming back and being readmitted is that they wait,” Brinker says. “They don’t call when there’s a change in their condition. And I understand. People don’t want to hear that they’re sicker, and they don’t want to come back to the hospital or emergency room that they just left.”
But if patients don’t speak up until they’ve gained 10 to 20 pounds of excess fluid, oral medicines won’t work anymore and outpatient care is no longer an option, she says.
"When we started, we found patients weren’t getting a lot of education," Brinker recalls. “But really, having a heart failure diagnosis is very serious – and chronic – and we saw 25 percent of our patients would be dead within a year of being hospitalized."
Something had to change.
[Read: The Facts on Heart Disease .]
When Discharge Instructions Don’t Cut It
It can be an abrupt change from hospital to home, says physician Kristin Rising, director of acute care transitions with the department of emergency medicine at Thomas Jefferson University Hospital in Pennsylvania.
"In the hospital, we just do everything for the patient. We feed them, we administer their meds at the right time, we call all their consults, we coordinate all of the services," Rising says. "Then one morning … we walk in say, ‘Good news, Mr. Jones, you’re going home.’ And then, all of a sudden, it transfers from we’re doing everything to they’re doing everything."
Patient advocate Trisha Torrey, author of "You Bet Your Life: The 10 Mistakes Every Patient Makes," says many patients don’t really understand their discharge instructions, what’s changed with their health and daily routine, and what they can or can’t do. They aren’t aware of the importance of a follow-up visit with their primary care provider soon after discharge.
Medication confusion is also common as patients try to fit new prescriptions into familiar drug regimens. Those who can’t leave the house, or who don’t have transportation, may have trouble getting refills. They may not understand how to use new equipment or be able to afford that walker to help them get around after surgery.
Eric Coleman, a geriatrician and director of the Medicare-funded Care Transitions Program, says that too often in the past, "the clinician would go in the room and give [patients] the same one-size-fits-none discharge instructions and then sure enough, it didn’t work that time either.”
When it comes to comprehending a new diagnosis or treatment, he says, "None of us really learns by someone handing us a brochure and saying, ‘Go home and read this.’”
[Read: What Your Doctors Wish You Knew .]
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