At too many hospitals, a revolving door
07/26/2013 - The New York Times. By Judith Graham.
WASHINGTON, DC - Jessie Gruman can’t remember the number of times she’s been hospitalized for cancer. The list of the conditions she’s had over almost 40 years is daunting: from Hodgkin’s lymphoma to cancers of the cervix and lung.
But Ms. Gruman, 59, can’t forget her experience three years ago, when it was time to leave the hospital after having her stomach removed, a consequence of gastric cancer.
Ms. Gruman was alone; her husband was on his way to this hospital but hadn’t yet arrived. This is all she remembers a nurse saying before she was shown the door.
"Here is a prescription for pain medication. Don’t drive if you take it. Call your surgeon if you have a temperature or are worried about anything. Go see your doctor in two weeks. Do you want a flu shot? I can give you one before you leave. If you need a wheel chair to take you to the door, I’ll call for one. If not, you can go home. Take care of yourself. You are going to do great!"
What wasn’t communicated to Ms. Gruman: Here’s a number to call if you have any questions. Here’s the medical expert who’s in charge of your follow-up care and how to reach him or her. Here’s the plan for your care over the next month, and here’s the plan for the next six months.
Or this: You’re going to experience a lot of challenges when you get home. Here are the three or four concerns that should be your priorities. Here’s what your caregiver needs to know to help you most effectively. Here are resources in the community that might be of assistance.
Given the inadequacies in care for discharged patients — a well-documented and common problem — is it any wonder that so many bounce back to hospitals after they’re sent home?
Medicare, the government’s health care program for seniors, has trained its sights on the issue and is focused on trying to reduce the number of seniors readmitted to hospitals shortly after being sent home. Nearly one in five older adults discharged from a hospital returns within 30 days, at an annual cost of $17.4 billion, according to a recent study in The New England Journal of Medicine.
Not all readmissions are avoidable — sometimes a patient’s condition will worsen no matter what anyone does. But experts are convinced a substantial proportion of readmissions could be prevented if hospitals did more to educate patients, ensure they’re able to care for themselves, and coordinate their care with other medical providers.
The Obama administration hopes to trim Medicare readmissions by 20 percent and, under the Affordable Care Act, has started penalizing more than 2,200 hospitals that have higher-than-expected readmissions rates for seniors with heart failure, heart attacks and pneumonia. Medical centers risk losing up 1 percent of their annual Medicare reimbursement; that financial penalty will rise to 3 percent by October 2015. More medical conditions will be added to the list over time.
What does this mean to older adults and their caregivers? What can they expect as hospitals put into place programs to address readmissions and what can they do to prevent return trips to the hospital?
Ms. Gruman’s problems began in the hospital, when a day after surgery a nutritionist came to visit and tell her how to manage life without a stomach. “It was misguided to see me so soon after surgery, when I was loopy and could barely remember my name,” said Ms. Gruman, now a patient advocate and president of the Center for Advancing Health in Washington.
“When you’re in the hospital, you’re not operating on all cylinders,” she added. “You don’t really know until you’re home for a while and reality sets in what questions are going to be important, anyway.”
Here’s what she learned from the experience.
Lesson No. 1: If a patient isn’t ready to hear what a medical provider wants to say, meaningful communication becomes impossible. Ms. Gruman said she probably should have told the nutritionist, “I can’t possibly concentrate on what you’re telling me right now; it’s not a good time.” Speak up when you find yourself in a similar situation, feeling muddled or unable to concentrate.
The morning of her discharge from the hospital, the nurse responsible for her discharge didn’t help Ms. Gruman see the big picture: “No one said this is going to be a really big deal, adjusting to this change in your body, and you’ll have a lot of adjustment to go through.” What was missing, she said, was “any recognition of the magnitude of the time and attention my husband and I would have to spend attending to my recovery.”
Lesson No. 2: Handing someone a sheaf of papers and going over a set of instructions won’t guarantee a successful transition from the hospital to home. People need more. They need a human touch, emotional recognition, and a sense that they’re not going to be left on their own as they try to recover from the setback that brought them to the hospital.
Feel free to stop the person handling your discharge and say, “Wait, slow down, I don’t really understand how I’m going to get along day to day and how all this is going to work.” Don’t leave until you feel more comfortable.
At home, Ms. Gruman wasn’t sure about her health priorities. “I had a whole new digestive system, and I wasn’t sure how it functioned,” she said. “I wish I’d known more about eating, what to expect in terms of my energy level, how much I should try to exercise, if there was anything I needed to be monitoring.”
Lesson No. 3: Some people may be able to assimilate information in the hospital or upon discharge, but many cannot. It may take several days or even longer at home for people to understand what challenges in their recovery are most important.
Staffers also need to teach caregivers the skills they will need while the patient is still in the hospital. That’s the time to learn how to turn someone in bed, help with mobility, assist them in taking a bath, or assess their breathing or level of pain. Be willing to ask a nurse “show me how you do that” several times if necessary so you are not left in the lurch when you get home, Ms. Gruman said.
Many of you have undoubtedly had experiences with this issue; we’d be glad to hear about those in the comments. Later this week we’ll post some advice from experts.