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Reduce readmissions by tackling patient, system issues

SAN DIEGO — Identifying at-risk conditions of patients and issues in transitions of care, as well as counseling the patient using a dialogistic and reflective approach, may help reduce readmissions to hospitals, according to an ACP Internal Medicine Annual Meeting presentation.

Understanding the target population is the first step in reducing readmissions, Vicente J. Velez, MD, FACP, FHM, from the department of hospital medicine at Cleveland Clinic, said. Adverse conditions, such as anemia, cancer, chronic heart failure, pneumonia and acute MI, are predictors of readmissions, he said. Patients who have previously been readmitted and those with sepsis or low socioeconomic status are also more likely to be readmitted, he said.

Hospitalists should communicate with the PCP and discuss end-of-life and goals of care with the patient at the time of discharge, as missing opportunities to do so also contribute to readmission, Velez said. Other strong factors of readmissions include the ED’s decision to admit patients and discharging patients too soon, he said. He also noted that a patient’s Care Transition Measure (CTM-3) score is strongly associated with readmissions.

Once at-risk conditions are identified, hospitalists should engage and counsel patients on their goals by “planting a seed,” Velez said. “This will increase the likelihood of adherence, comprehension or change — merely telling someone to do something has less of an impact,” he continued. Hospitalists should present patients with a clear and concise diagnosis and frame information in the context of the patient’s perspective and avoid convincing a patient to comply with therapy based on science or regulation of information, fear and/or shaming, he advised.

“Once you get a patient’s perspective, it’s not enough,” Velez said. “It’s important to acknowledge and understand and let the patient know that we indeed listen by reflecting things back, either nonverbally or briefly restating the fact or emotional content, and by allowing things to flow without interruption or redirection.”

According to Velez, hospitalists can explore a patient’s perspective by considering the following factors: vital activities (how the illness disrupts a patient’s daily activity), ideas (a patient’s view on what is happening), expectations for care and worries. Counseling patients should be a dialogue, rather than a monologue, he said. The conversation between the hospitalist and patient should be based on ARIA (assess, reflect, inform and assess), Velez said. Using open-ended questions, hospitalists should assess what the patient knows about their diagnosis and treatment, how much and what type of education the patient desires or needs, the patient’s treatment preferences, as well as their health literacy; reflect the patient’s meaning and emotion; inform the patient while considering their perspective and preferences; and assess the patient’s understanding and emotional reaction to the information provided, he said. This approach, customized to the patient’s concerns, helps hospitalists gain trust and control, Velez said. – by Alaina Tedesco

Reference:

Velez VJ. MTP 056: Reducing Readmissions by Improving Adherence: Helpful Tools for the Hospitalist. Presented at: ACP Internal Medicine Annual Meeting; March 29-April 1, 2017; San Diego.

Disclosure: Velez reports no relevant financial disclosures.