Leaving hospital? Heed care tips or you may return
Ignoring information about what to do at home to get better is one of the primary risks for preventable re-hospitalizations
WASHINGTON (AP) — Michael Lee knew he was still in bad shape when he left the hospital five days after emergency heart surgery. But he was so eager to escape the constant prodding and his roommate’s loud TV that he tuned out the nurses’ care instructions.
“I was really tired of Jerry Springer,” the New York man says, ruefully. “I was so anxious to get out that it sort of overrode everything else that was going on around me.”
He’s far from alone: Missing out on critical information about what to do at home to get better is one of the main risks for preventable re-hospitalizations.
“There couldn’t be a worse time, a less receptive time, to offer people information than the 11 minutes before they leave the building,” said readmissions expert Dr. Eric Coleman of the University of Colorado in Denver.
Hospital readmissions are miserable for patients, and a huge cost – more than $17 billion a year in avoidable Medicare bills alone – for a nation struggling with the price of health care.
Now, with Medicare fining facilities that don’t reduce readmissions enough, the nation is at a crossroads as hospitals begin to take action.
“Patients leave the hospital not necessarily when they’re well, but when they’re on the road to recovery,” said Dr. David Goodman, who led a new study from the Dartmouth Atlas of Health Care that shows different parts of the country do a better job at keeping people at home after they leave the hospital.
The Dartmouth study was commissioned by the Robert Wood Johnson Foundation, which invited The Associated Press as a partner to explore, through focus groups it organized, what happens at the hospital level that makes readmissions likely.
In Portland, Oregon, nurses at Oregon Health & Science University start teaching heart failure patients on the patients’ first day in the hospital what they’ll need to do at home. The nurses don’t wait until the patients’ last day in the hospital.
In Salt Lake City, a nurse acts as a navigator, connecting high-risk University of Utah patients with community doctors for follow-up treatment and ensuring both sides know exactly what’s supposed to happen when they leave the hospital.
Some techniques are emerging as key, Coleman said:
Having patients prove they understand by teaching back to the nurse.
Role-playing how they’d handle problems.
Finding a patient goal to target, like the grandmother who wants her heart failure controlled enough that her feet don’t swell out of her Sunday shoes.
You’d be mad at having to return your car to the mechanic within a month, yet re-hospitalization after people get their hearts repaired too often is treated as business as usual, laments Dr. Ricardo Bello, a cardiac surgeon at New York’s Montefiore Medical Center.
Heart surgeons try to prevent hospital readmissions by re-examining patients two to three weeks after they go home. But Montefiore patients tend to be readmitted sooner than that.
So last fall, Bello’s team began a special clinic where nurses check heart- surgery patients about a week after they go home, at no extra charge. That way, the nurses have a chance to re-teach those discharge instructions when people are more ready to listen.
Plus, for that first month at home, patients are supposed to wear a bracelet with a phone number to reach Montefiore’s cardiac unit, 24 hours a day with any worries.
“It changed my conception of dealing with a doctor,” said Michael Lee, 60.
Montefiore surgeons repaired a life-threatening crack in Lee’s aorta, the body’s main blood vessel, but his recovery derailed days after getting home. He quit some medications. He was scared to wash the wound that ran from chest to navel, an infection risk. He developed a scary cough and called that special clinic in a panic.
It turned out the cough was a temporary nuisance – but nurses discovered a real threat: Lee’s blood pressure was creeping up, a risk to his healing aorta. Those pills Lee quit were supposed to keep it extra low, a message he’d missed. And some hands-on instruction reassured Lee that he could handle his wound without tearing it.
Without the clinic, “he’s definitely somebody we would have been called to see in the emergency room,” said physician assistant Jason Lightbody.
In heart failure, a weakly pumping heart allows fluid to build up until patients gasp for breath. Spotting subtle early signs — like swelling ankles or creeping weight gain — is crucial.
But at the Oregon Health & Science University, nurse practitioner Jayne Mitchell spied as patients were told what to watch for as they were discharged. She noticed, they barely paid attention.
The new plan: Learn by doing.
Every morning, hospitalized patients weigh themselves in front of a nurse, record the result and get quizzed on what they’d do at home. Gained 2 pounds or more? Call the doctor for fast help. Lots of day-to-day fluctuation? A weekly log can help a doctor tell how a patient is faring.