A health care chaplain at the University of Alabama Medical Center in Birmingham commented recently that, "Hospitals are very good at curing us but not at making us whole." This was Drexel Rayford, who manages a program to support patients after they leave the hospital and are on their own. He finds and trains friends, neighbors, and family members of the patients to help with their follow-up care. It has reduced readmission rates dramatically. On the other side of that same coin, David Newman, M.D., wrote in the New York Times about increased readmissions caused by patients who develop additional stress or illness by virtue of simply being in the hospital and thus must be readmitted. With sometimes inedible food, noisy machines that prevent sleep, and lack of personal attention can cause what is now known as post-hospital syndrome.
Hospitals have begun to look for ways to make the inpatient experience less stressful with improved décor, food, even allowing patients to wear their own clothing rather than the undignified hospital gown. Indeed, hospitals need to reduce readmissions or lose money, and patients need to find support outside the hospital so they are not readmitted. There are no definitive studies about how many readmissions within 30 days are preventable, but hospitals with excessive readmissions face increased penalties. A study published in the New England Journal of Medicine found that nearly one-fifth of Medicare patients discharged from a hospital, about 2.6 million seniors, have an acute medical problem within 30 days that necessitates another hospitalization. Hospitals face increased penalties from Medicare patients hospitalized with cancer or heart disease, or chronic obstructive pulmonary disease (COPD), who are readmitted within 30 days.
If you have ever been hospitalized you know how many health care professionals -- doctors, nurses, technicians, therapists on several shifts -- come into your room to talk with you. You have little time t o learn their names or understand their roles, let alone what they are telling you about your condition. At discharge hospitals often provide patients with incomprehensible instructions, forgetting they're too weak to get to the pharmacy, providing no coherent follow up. Not to mention language and cultural barriers. Health professionals often focus on issues related to the acute illness that precipitated the hospitalization but ignore what the stress of being hospitalized has done.
Many hospitals are developing transition programs designed to guide patients through the discharge process and provide follow up care. For example, if you were hospitalized with a heart condition, a nurse meets with you to get an understanding of your condition and how it was managed leading up to hospitalization. Then, while you are still in the hospital, the nurse begins to lay the groundwork that will lead to a successful care transition. He or she helps you find appropriate ways to pay for health care transportation, prescriptions, nutrition and social work. In other words, they serve as communications bridge between you and your health care team. They speak with doctors, nurses and therapists when there are language or cultural barriers.
"My job is to reinvigorate the support team networks in this building with medical staff, case managers, social workers, etc.," said Drexel Rayford in Birmingham, mentioning a particular team of nurse practitioner and two registered nurses who have been working with people with COPD. They identify two families associated with the ER. He coaches the patient and the primary care giver and then find folks in the community who can be trained in practical and emotional needs.
"Readmission is not always for a medical reason," Rayford says. "Some of these folks need bird dogging." For example, a man who was re-admitted over and over and finally Medicare said they would not reimburse the hospital, so everybody's motivated. Rayford said they found three or four people connected to this patient through family, neighbors and church. He describes how they organize the teams.
We ask them, who in this group likes to take notes? Okay, that person, Sally, can keep track of things. Bill can drive him to his appointments or to Walmart to pick up his prescription. So we have Sally to coordinate, Betty who likes to cook his gumbo for him, say twice a week, and Bill who can bring the meal over. "Then there's the person who plays the Andy Griffith board game with him and so on."
Rayford admits that some teams may fizzle, but the majority of cases are successful. After all, most of the support team members are only spending an hour a week, so it is not a huge burden. The hospital appreciates them, and lets them know it. When the uniformed guard at the entrance greets them they feel empowered.