Problems fall into two boxes; easy and difficult. An easy problem to solve is “Do you want fries with your order.” A more complex problem, one I faced two weeks ago was helping my daughter buy a dress for the eighth-grade dance. I have some experience buying clothes, and some experience going to dances, and even some experience buying clothes to wear to dances. My eighth-grade dance outfit included bell-bottoms, a puka-shell necklace, platform shoes, and long hair. Ergo, I felt reasonably well-equipped to guide my daughter. She did not share my confidence, nor did she choose any of the dresses I recommended.
What if most difficult problems were not so difficult? It is easier to get our arms around difficult problems. We know how to acquit ourselves to suss out solutions. We have meetings, someone drafts and agenda, somebody else brings the bagels. We employ subject matter experts—people with PhDs and MDs. Hire a few consultants. People join the meeting using Facetime, others take notes on their iPads.
That is how we handle difficult problems. That is also how we handle problems that we assume are difficult even if it turns out that the problems are not difficult. For the next three minutes, let us agree to lay aside the oracles of our profession and consider if reducing readmissions and facilitating population health management should be moved from the difficult column to the easy column.
If you choose to continue reading, some of you will conclude that Paul is having a stupidity, and others, hopefully, will conclude that Paul may have had an epiphany.
Washington University in St. Louis reports that twenty percent of patients are readmitted within thirty days of discharge. Modern Medicine reports that twenty-five percent of patients are readmitted within two years.
Kaiser Health News reported that readmission rates are not budging. According to AHANews.com, readmission rates for 2012 dropped from an average of 19% from 2006-2011 to 18.4%–perhaps a budge. Budging or not, it appears that in spite of all of the emphasis and all of the efforts to decrease readmissions, the rate of readmissions remains relatively static.
If the current efforts are not working, what if we tried something else?
Please pay particular attention to the wording of these two Top 5 lists. The first list seems to lay the blame for readmissions squarely on the patients. The second list, my list, suggests there is plenty of blame to go around, and could equally be parsed to include hospitals.
I will argue in a second that the ownership of the blame is irrelevant, and that the solution is neither patient-centric nor hospital-centric—it is both. I will also argue that the solution could easily decrease readmissions by double-digits. But please don’t throw metaphorical tomatoes at your monitor without understanding the entire argument.
The Top 5 reasons for patient readmissions according to the Dartmouth study, Care About Your Care are:
- Patients may not fully understanding what’s wrong with them
- Patients may be confused over which medications to take and when
- Hospitals don’t provide patients or doctors with important information or test results
- Patients do not schedule a follow up appointment with their doctor
- Family members lack proper knowledge to provide adequate care
Written a little differently—my way:
- The hospital does not ensure that patients understood what’s wrong with them
- The hospital does not ensure that the patients understood which medications to take and when
- The hospital does not provide patients or doctors with important information or test results
- The hospital does not ensure that patients scheduled a follow up appointment with their doctor
- The hospital does not ensure that family members had the proper knowledge to provide adequate care
What observations can be made and what conclusions should be drawn from the above information?
According to the Top 5 list patients and their families lack the information that would keep them out of the hospital. And who has the information that the patients and their families lack? Say it with me, the hospitals.
So, what do we need to reduce readmissions? The patients need information from the hospitals. And, here it comes, the hospitals need information from the discharged patients.
Let’s look at two patients, both with very similar issues who were discharged. The first patient goes home with their discharge orders and receives a call from the hospital asking how they are doing. The second patient goes home and is watched daily, and their health is assessed daily. Which of the two patients is most likely not to be readmitted?
While the answer is obvious, we all know that if a patient is going to be watched and assessed the entire time they are away from the hospital that they may as well remain in the hospital. Unless. What if there was another way to implement that approach?
Let’s begin with the notion that hospitals need a way to ensure that patients and their families have all the information they may need, and that patients ensure that the hospitals have timely (hourly and daily) access to all the information they may need about their condition.
What information is needed by the hospital to lay the foundation for a viable solution?
- The hospital needs access to the right patient information to assess a turn in the patient’s condition.
- The hospital needs to assess the patient’s information early enough to prevent the need for the patient to be readmitted or to go to ED.
- The hospital needs to be able to use that information to know when to contact the patient and to know what to do to prevent the patient’s conditioning from worsening.
- The hospital needs to provide care to the patient that prevents the patient from needing to be readmitted or prevents the patient from going to ED.
What is needed by both the hospital and its patients?
- A timely and accurate way for patients to tell the hospital what the hospital needs to know
- A timely and accurate way for the hospital to tell the patient what the patient needs to know
- A way for both parties to assess the information
- A way of knowing how and when to communicate that either party’s information requires action.
What do they need, when do they need it, and how do we make it happen? Instead of hospitals wishing they had access to real-time information about their discharged patients, and patients wishing they had real-time access to more information about their status, why not make that information available?
What if, prior to discharging a patient, the hospital added the patient to the hospital’s “Discharged Patient Portal?” The hospital may even provide the patient with a smart-device, with a killer user-interface, to allow the patient to get all of the information the patient needs, AND, to provide the hospital with all of the information the hospitals needs about the patient.
Our cars can do this. They can tell us, based on the data they collect, when we need to see a mechanic. Why can’t we create the same interaction between discharged patients and their hospital?