{"id":9650,"date":"2017-02-23T09:32:58","date_gmt":"2017-02-23T16:32:58","guid":{"rendered":"https:\/\/www.uchealth.org\/today\/?p=9650"},"modified":"2026-04-02T15:25:59","modified_gmt":"2026-04-02T21:25:59","slug":"rx-preventing-hospital-readmissions-listen","status":"publish","type":"post","link":"https:\/\/www.uchealth.org\/today\/rx-preventing-hospital-readmissions-listen\/","title":{"rendered":"Rx for preventing hospital readmissions: listen"},"content":{"rendered":"
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The prodding by the Centers for Medicare and Medicare Services for hospitals to reduce their 30-day hospital readmission rates is by now nothing new. Hospitals continue to work on projects to keep patients out of the hospital safely and to avoid financial penalties for higher-than-expected readmissions for a growing number of conditions.<\/p>\n

But while the quantity of hard data about readmissions continues to grow, less attention has been paid to a more vexing question: why do some patients frequently return to the hospital soon after discharge?<\/p>\n

A paper recently accepted for publication by the Journal for Healthcare Quality suggests some answers. The authors, several of whom are faculty of the University of Colorado School of Medicine (see box 1), did not turn to computers or databases for sources. Instead, they went to the bedside to talk to the patients themselves.<\/p>\n

\"Greg
Greg Misky, a hospitalist at UCH, and study co-authors sought out patients to understand the factors that drive hospital readmissions.<\/figcaption><\/figure>\n

\u201cIf we want to get to the bottom of why they come back to the hospital, we thought, \u2018Why don\u2019t we ask them?\u2019\u201d said Greg <\/a>Misky, MD, a study co-author and hospitalist at UCH.<\/p>\n

The paper draws on interviews of 18 patients \u2013 two of them uninsured, the rest covered by Medicaid \u2013 readmitted within 30 days of their previous discharge to UCHealth University of Colorado Hospital and Denver Health. The interviews, conducted by professional research assistants between February 2014 and January 2015, focused on eliciting from patients the stories of their care \u2013 what happened during previous hospitalizations, what happened at home after their discharge, what led to their readmission, what might have prevented it, and their health care experiences outside the hospital.<\/p>\n

Root causes<\/strong><\/h3>\n

The patients\u2019 responses revealed five \u201cthemes\u201d that contributed to patients coming back to the hospital (see box 2). Rather than pinning the readmissions solely to a refusal to adhere to their plans of care or indifference to their health, the authors concluded that unstable social situations and \u201chealth system failures\u201d played major roles. They call for strengthening trust between patients and providers and encouraging patients to share in the decisions that affect their health.<\/p>\n

A common theme was what the authors called \u201ctherapeutic misalignment\u201d \u2013 a perception of patients that providers don\u2019t always share their goals.<\/p>\n

\u201cAll I want is a doctor that will listen to me and a nurse that will come in and talk to you\u2026like you\u2019re human,\u201d one related. \u201cDoctors need to understand that patients also know what\u2019s wrong with them, and they know a little bit more about how to fix it,\u201d another asserted. A third stated, \u201cI would like to have a patient-doctor relationship with them, and I would like for him to listen to me, and listen to what I\u2019m saying.\u201d<\/p>\n

\u201cTheir words are telling us where the problems are,\u201d Misky said. \u201cReducing 30-day readmission rates shouldn\u2019t be the be-all and end-all of what we do. We need to lessen the likelihood that patients fail.\u201d<\/p>\n

He readily acknowledged that the patients interviewed sometimes made bad decisions about their care and at times lacked accountability. They spoke bluntly of alcoholism, not asking about the reasons for taking their medications and outright ignoring medical advice. But the interviews frequently showed that \u201csocial fragility\u201d played an important role in their declining health, Misky noted.<\/p>\n

\u201cThey often have competing priorities,\u201d he said, including holding on to their jobs or meeting their families\u2019 other basic needs. Many struggle with living conditions that make it difficult to manage diseases like COPD<\/a>, diabetes or heart failure. Lack of transportation, poor access to primary care and difficulties with basic health literacy also combine to hamper their efforts to stay well at the same time that they frustrate providers.<\/p>\n

\u201cAs providers, we live in a different world than these patients,\u201d Misky said. \u201cUnless we walk in their shoes, we can\u2019t envision how hard it is for them to succeed.\u201d<\/p>\n

Doctor disconnect<\/strong><\/h3>\n

Yet Misky and his colleagues say that too often clinicians address their patients from across a perceptual divide created by notions of authority.<\/p>\n

\u201cTraditionally, providers are trained around a disease-centric focus with inherent expectations that patients should adopt our treatment plan,\u201d they write.<\/p>\n

In addition, they note that while coordinating care between and among providers is important, it\u2019s not an end in itself, nor is it necessarily effective in improving patients\u2019 health.<\/p>\n

\u201cSolutions must go beyond a discharge checklist or timely communication with an outpatient provider,\u201d they assert.<\/p>\n

As Misky elaborated, \u201cPatients have lives, and the question is where does health care live within those complicated lives?\u201d In tapping the patient perspective, he added, he and his colleagues hope to increase physician awareness of the practical problems they face \u2013 a frequent one being difficulty finding a place to live.<\/p>\n

\u201cThere is no possibility of help from social workers, community health workers, home visits, or behavioral health counselors without access to housing,\u201d Misky said.<\/p>\n

The study points to a fundamental challenge for the health care system if it is to better serve people of low socioeconomic status. On the one hand, they would benefit from ready access to primary care, integrated with specialty and behavioral health care. On the other, they frequently reside in areas with shortages of the very services they need and difficulties getting to the ones that are available. That problem is often complicated by difficulty navigating the health care system, which in turn can lead to distrust of the providers whose job it is to help them.<\/p>\n

Tools in place<\/strong><\/h3>\n

The authors don\u2019t purport to solve problems of access, although they point to the need for hospitals to form partnerships with community health workers as one solution. That approach produced encouraging results at UCH<\/a> when it partnered with Aurora\u2019s Metro Community Provider Network (MCPN), a nonprofit community health center, in the Bridges to Care (B2C) initiative. The project received strong support from UCH and School of Medicine leadership, notably Jennifer Wiler, MD, MBA, an associate professor and executive vice chair of the CU Department of Emergency Medicine.<\/p>\n

Initially funded with a three-year federal grant, B2C identified patients frequently admitted to the emergency department and the hospital and connected those who agreed to a 60-day program, during which health care coaches and coordinators identified barriers to care, helped them learn skills to manage their health, and connected them to needed services. The project helped to decrease the number of ED visits and hospitalizations among B2C graduates significantly.<\/p>\n

The grant ended in June 2015, but B2C continues, and UCH and MCPN continue to share the cost of a patient-resident liaison\/community health care liaison: Randie Weiss, whose home base is the Emergency Department at UCH. Weiss is among a team of providers working with patients whose medical issues are complicated by social barriers, behavioral health issues, and addiction. Roberta Capp, MD, an assistant professor of Emergency Medicine at CU, directs ED Care Transitions, which aims to help patients gain access to services that meet not only their medical, but also their social needs.<\/p>\n

Weiss concentrates on patients who have made at least three visits to UCH\u2019s ED or have been frequently hospitalized within the past six months. She completes a screening to identify their needs and help to connect them with additional support and services. She pre-enrolls those who agree to it in the B2C program, where an MCPN care coordinator evaluates their situation and works to help them find resources and strengthen their ability to manage their own care.<\/p>\n

Nurse case managers work with patients in the ED to get them home health care, home-based physical and occupation therapy and other services that can help them avoid admission to the hospital, Weiss added. The case managers also help to place patients in skilled nursing, acute and sub-acute rehab facilities, a guard against future readmissions, she said.<\/p>\n

Help for underserved patients also comes from \u201cpatient champions\u201d in the ED and case managers who work with patients on the hospital\u2019s inpatient units and with those enrolled in Colorado Access<\/a>, the health plan that covers Colorado\u2019s Medicaid patients, Weiss noted.<\/p>\n

All of this work is important, but it is just one piece of a puzzle that requires coupling clinical resources with recognition of the social barriers that make it difficult for many patients to make the most effective use of them, Misky said.<\/p>\n

\u201cWe need more formal care coordination and expanded case management that is specific for these folks,\u201d he said. \u201cBut we also need to be better in tune with their issues.\u201d<\/p>\n

Study authors<\/strong><\/p>\n