Running head: Avoiding readmissions 12
Avoiding readmissions
Sandra Blair Ekimoto
NUR 513
October 10, 2011
Dr. Lisa Ousley
The Institute of Medicine’s (IOM) 1999 report, To Err Is Human, showed the majority of medical errors in hospitals resulted from faulty systems and processes and recommended the adoption of process-improvement techniques to identify inefficiencies, ineffective care, and preventable errors. The lack of scientific health services literature inhibited the acceptance of quality improvement methods in health care at that time. Since then nursing research has increased to recommend positive practice change, implement systematic assessments of patient for outcomes analysis, and ensure patient protection (informed consent, ensuring scientific value and always respectful) in research efforts (Hughes, 2008). Six Sigma’s DMAIC method (define, measure, analyze, improve, and control) is acceptable for these efforts and provides precision and accuracy in experimental procedures for evidence-based practice (EBP) for nurses. The following report will compare different theories and EBP recommendations to help hospitals gain competitive advantage with improved processes related to readmissions.
Healthcare costs
Healthcare spending was 9% of the gross domestic product (GDP) in 1980, as of 2006 it was closer to 16%. The Medical Expenditure Panel survey (MEPS) by the Agency for Health Care Research and Quality (AHRQ) links individual and household data by demographics, health status, health conditions, health insurance, employment, and income in an effort to understand the use and expenses for health care. The MEPS 2002 study showed that five percent of the population spent half of the health care dollars and that 45% ranked their physical health in fair or poor condition. The five most expensive health conditions found were heart disease, cancer, trauma, mental disorders, and pulmonary conditions. Interesting to note that health maintenance organizations (HMO) showed that their effect is neutral on this population (Stanton, 2006). This is a driving force in health care, which would be prudent to focus on to reduce the spending of health care dollars.
The, After Hospitalization: a Dartmouth Atlas Report on Post-acute Care for Medicare Beneficiaries, study showed that 30-day readmissions cost an estimated $17.4 billion annually and that 50% of these patients had not followed up according to the discharge orders prescribed by the treating physician (Clark, 2011). The EMTALA regulation (1986) requires that hospital emergency rooms (ER) in the United States (US) must provide emergency medical care to patients who present with life threatening conditions (Austin, 2011). Many of these patients are non-compliant, recently incarcerated, mentally ill, acquired sexually transmitted disease, substance abusers, indigent; undocumented immigrants, victims of trauma, victims of domestic violence, sexual assault, and patients without third-party insurance coverage. Although hospitals can reduce their tax base by providing this type of service (charity care), the reduction of benefits by governmental and private health plans is increasing this group of patients (Sheffield, Young, Goldstein, & LoGerfo, 2006)
The 30-day readmission study recommended improved discharge planning and care coordination so that patients have 1) the medications they need, 2) the means to have prescriptions filled, and 3) coordination of follow-up appointments prior to discharge (Clark, 2011). The Centers for Medicare and Medicaid Services (CMS) also added 30-day readmission rates as one of the quality indicators in hospital performance in the treatment of heart failure, heart attack, and pneumonia. Starting October 2012 the Affordable Care Act’s, hospital readmission reduction program requires that hospitals must have proven interventions in place, including: 1) ensuring patients are clinically ready for discharge , 2) reducing infection risk, 3) reconciling medications, 4) improving communication with community providers responsible for post-discharge patient care, 5) improving care transition and 6) ensuring that patients understand their care plans upon discharge (Denniston, 2011) . Hospitals that have low rankings for readmissions will receive reduced payments from CMS. This is an example of EBP with consequences in place for non-compliance.
Application of theory
According to Lewin’s change theory (1947), when driving forces push to make change it causes a disequilibrium, which leads to unfreezing. Unfreezing is stressful. People will resist change either overtly or covertly (restraining forces) so approach to change must use a systematic process, clear communication, transparent direction plus rewards for good behavior and consequences for bad behavior. Physicians that care for non-compliant patients can notify a patient that they are being discharged from their care because of non-compliance. Hospital ERs cannot notify patients that they won’t care for non-compliant patients because of the EMTALA regulation.
If the concepts of self-care health deviation and deficits (Orem, 1971) along with the chronic illness trajectory framework (Corbin Strauss, 1992) are analyzed with change theory , the aforementioned are representative of disequilibrium in a patient’s health status. The Trajectory Framework’s stable phase follows the acute phase. A patient should be in the stable phase they are discharged to a lower level of care. The expectation of the acute phase is that the patients will remain stable in the alternate plan of care (skilled nursing, home care, telehealth nursing, etc.) coordinated. If a patient does not respond to the discharge plan of care, the risk for readmission increases. From Corbin and Strauss’ point of view the responsibility for the patient to return to the stable phase is on the professional—not the patient. This does not empower health care providers with consequences for bad behavior. From a management point of view, this would be an unrealistic expectation. Lewin’s equation for behavior (B=P, E) accepts that both a person’s inborn tendencies (nature) and experiences in life (nurture) account for their behaviors. When dealing with restraining forces a manager is allowed to deal with overt resistance with dialogue and research. Covert resistance, on the other hand can require an action plan. This would provide consequences for bad behavior.
Patient-centered care encourages patients to become active participants in their own care, provides access to services that focus on individual needs plus offers avenues for patients to easily receive advice and counsel from health professionals. Nurses can help patients with chronic illness and improve their quality of life by increasing their motivation to learn self-care skills, accept health care responsibility, and live with their chronic disease positively. This is empowerment--a process that creates hope, confidence and, encouragement to move in a healthy direction in their lives. For this to work patients need the elements of power, authority, choice, mutual help (Chen, 2010) and accountability.
Analysis
Nursing interventions that allow both professional and patient accountability would be a good addition to the Trajectory Framework. By having this type of systematic process the moving process (movement of thoughts, feelings, and behaviors in a more productive way) can be more successful leading to healthy lifestyle choices that become habits (refreezing). Theory derivation develops new theories. Taking the self-care deficit concept, the chronic illness trajectory framework process and change theory into consideration--the addition of painful consequences could be advantages when dealing with patients who practice noncompliant or unhealthy behaviors. This is a hard sell, especially when patient-centered care is supposedly the solution to better health care outcomes.
Conclusion
If hospitals have the burden of providing uncompensated care (charity care) to the point where they lose money instead of maintaining a profit they will not be able to continue the mission to serve their communities. This is a threat to their survival and risk management mitigation can aid a hospital in this. Solutions proposed to deal with patients at risk for readmission include 1) seamless integration of services within an integrated health and social services network, 2) multidimensional assessment to systematically assess where a patient falls in risk for readmissions, 3) provide the best care for chronically ill people at the first opportunity to ensure optimal efficiency of the health and social care system, 4) general practitioners need to provide early and targeted interventions in the community for the chronically ill living at home and in care homes, 5) ERs need to deliver services for the chronically ill by aligning Emergency Physicians with Geriatricians and multidisciplinary teams, 6) early coordinated discharge planning and integrated multidisciplinary care must support patient independence. If these efforts fail 7) consequences for non-compliant patients need to be available for health care providers (including hospital ERs) and 8) patients in the downward and dying phases of the Trajectory Framework process need to be informed that they meet palliative or hospice care. Healthcare should be a privilege, not an entitlement and when patients don’t engage in recovery paths, eventually alternate options that conserve valuable resources should be allowed without risk.
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