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Doc, I am Back Again

Just recently, I admitted a patient into the hospital for a flare of congestive heart failure. As I reviewed his history with our new electronic medical record system, I was astonished to find that he had 10 re-hospitalizations in this past year with one just two weeks prior.

‘What happened?’ I ask him.

‘I don’t know. This always happens. When I feel the fluid starting to build up, I know I have to come in.’

When I probed further, he said that he did not have a chance to fill his prescriptions to treat his heart failure when he last left the hospital. But probing even further, he did not have a chance to apply for his Grady card, a pseudo-insurance device issued by Grady Memorial Hospital (GMH), which would have helped reduce the cost of his medications.

‘Why didn’t you get a Grady card?’ I asked.

Well, a few things were required for him to get a Grady card: he needed a form of identification (which he had), a source of income (which he did not have, although he was in the process of applying for disability), and a proof of residency (which he did not have as he was floating between different shelters).

 ‘I knew it wasn’t going to be easy, so I didn’t get it.’

He was right. It didn’t sound easy.

To put things into a little more perspective, one of five Medicare hospital patients return to the hospital within 30 days at a cost to Medicare of $12 billion to $15 billion a year.¹ In 2004, the cost to Medicare of unplanned re-hospitalizations was $17.4 billion of the $102.6 billion in hospital payments (17%). And what more, a 2007 congressional report by the Medicare Payment Advisory Commission stated that 75% of readmissions can be avoided with better care!²

Granted my patient does not have Medicare, his poor socioeconomic status and medical illness already places him at a high risk for re-hospitalization rates. Hospital readmissions pose both a significant emotional and psychological (not to mention physical) burden upon our patients and a financial burden upon both our patients and our health care system. Therefore, reducing preventable readmissions is a pertinent part of the solution to reducing system-wide inefficiencies, improving quality of care, and decreasing costs associated with care.

Reasons for readmissions are multiple and include: poor health literacy, multiple co-morbidities, medication or medical errors, lack of primary care follow-up, and dysfunctional social environments.

Several interventions have been shown to effectively reduce the rate of preventable re-admissions such as appropriate hospital discharge planning, improved patient education, and close primary care follow-up, but we need to continue to implement these interventions nationwide, and more importantly, work with our governments, health care organizations, other health care professionals to address the socio-economic factors that preclude many of our patients from accessing health care, subsequently leading to them using the emergency room when their illness gets to a more serious stage.

Now under our new health care law, the Centers for Medicare and Medicaid Services will use a 30-day cutoff to start penalizing hospitals with higher than expected rates of re-admissions. Hopefully this will create the incentive to implement programs that will improve care coordination upon discharge and in follow-up and provide better quality of care for our patients.

Several innovative programs are already at the forefront in designing programs to improve care coordination at discharge: the Society of Hospital Medicine’s Better Outcomes for Older Adults Through Safe Transitions (BOOST) project; Boston University Medical Center’s Reengineered Hospital Discharge (RED) project; and the Institute for Healthcare Improvement’s State Action on Avoidable Rehospitalizations initiative.

We need to desperately join our colleagues in this effort!

Check out Heritage Health Prize awarding a prize worth $3 million dollars to a team that is able to develop a breakthrough algorithm to predict and prevent avoidable re-hospitalizations.

Perhaps this may be our chance to fight for our patient’s right for quality care and to take a stab at tackling our ailing health care system.

¹Jencks SF, Williams MV, Coleman EA. Rehospitalizations among Patients in the Medicare Fee-for-Service Program. New England Journal of Medicine. 2009; 360(14): 1418-1428.

²MEDPAC, Report to the Congress:  Promoting Greater Efficiency in Medicare, June 2007.