The Readmission Problem: A Modest Proposal Seeking a Solution
It is certainly no secret that patient readmissions shortly after discharge from the hospital create major healthcare and social problems today in the United States and throughout the world.1, 2, 3, 4, 5, 6, 7, 8, 9 Given our ever increasing number of elderly, frail patients in the United States, it is not surprising that many of these individuals are readmitted soon after discharge. The reasons for frequent readmissions are numerous but include, among others, frailty with its attendant inability to follow discharge instructions carefully, some level of cognitive dysfunction in the very elderly, inadequate economic resources preventing patients from purchasing their medications, and failure of patients to understand the reason that brought them to the hospital in the first place. Everyone hates readmissions: The doctors think that they have failed when patients are readmitted, elderly patients almost always abhor being admitted to the hospital, and hospital administrators fear the economic penalties associated with recurrent readmissions.
In an attempt to decrease the volume of patients being readmitted, a number of strategies have been tested; almost all have failed to prevent readmissions, including a variety of sophisticated techniques involving some form of digital technology. A number of well-designed clinical trials involving repeated phone calls or other digital contacts to recently discharged patients did not demonstrate significant reductions in the volume of readmissions.4, 5 Other simpler protocols also have failed. It seems that this problem suffers from the recurrent syndrome that I entitle “seemed like a good idea at the time.”
One approach that has been shown to work was pioneered by the Veterans Administration. Mindy Fain, a professor of medicine at our medical school and one of the country’s leading geriatricians, was one of the early implementers of the Home-based Primary Care program at the Southern Arizona Veterans Hospital. This program uses a physician-led team who makes house calls to recently discharged patients with a record of frequent readmission. Members of this team, including nurses and social workers, were trained to establish patient goals of care, educate patients and families, and evaluate and treat patients following a predetermined protocol. For example, a patient with recurrent heart failure admissions might receive an intramuscular or intravenous injection of furosemide if the nurse noticed that recurrent fluid retention was evident.
This program resulted in substantial reductions in readmissions and a considerable reduction in the costs associated with readmission to hospital.10 My opinion is that this latter program was successful, whereas others have failed because of the “face-to-face” nature of the intervention involving assessment and therapy for the patient. The national Veterans Administration Home-based Primary Care program was the basis for the highly successful Independence at Home Medicare Demonstration pilot project, bringing primary care medical services to the homes of Medicare beneficiaries with multiple chronic conditions. This latter program improved quality, reduced readmissions, and saved more than $35 million in the first 2 years (M. J. Fain, MD, personal communication, October 2016). A bipartisan group of senators have introduced legislation to convert Independence at Home into a permanent national Medicare program (M. J. Fain, MD, personal communication, October 2016).
Keeping the concept of successful “face-to-face” interaction programs in mind, I suggest a reasonably low-cost strategy that might reduce readmissions and is easily testable. During the 2 years that I served as a cardiologist in the US Navy at the San Diego Naval Regional Medical Center, I was constantly impressed by the enthusiasm, professionalism, and ability of the Corpspersons with whom I worked. During my time in medical school at Harvard and followed by my training at the Peter Bent Brigham Hospital in Boston, I had never encountered this form of healthcare worker. It impressed me that intelligent high school graduates could perform demanding medical tasks having had only 19 weeks of training. Of course, there was considerable “on the job” training that continued after the initial Corpsperson educational program. These individuals functioned in an outstanding manner in the catheterization laboratory, noninvasive diagnostic area, coronary care unit, and ambulatory cardiology clinic.
After their time in the Navy, many Corpspersons went on to become full-time echocardiography or catheterization technicians in the private world, and others went on to further education eventually becoming physician assistants or nurses. I suggest that we study using this form of healthcare worker in our nonmilitary hospitals to reduce readmissions. The protocol that I envision is as follows:
The program would recruit intelligent, motivated, and unemployed high school graduates who would undergo a period of training, including didactic and hands-on clinical education that would prepare them for their work as Corpspersons. I would personally volunteer to be on the hospital committee that creates this curriculum and would be happy to be one of the faculty members once it was created. After training, these Corpspersons would be introduced to inpatients who were believed to be high risk for readmission. Informed consent would be sought for the Corpsperson to visit these patients at their homes after discharge from the hospital.
A formal protocol involving a checklist would be followed during the first and subsequent home visits with these high-risk patients. The Corpsperson would do whatever was possible to assist the patient in following discharge recommendations. Tasks might include going to the pharmacy to pick up medications, helping with shopping for food and other basics, and monitoring straightforward measures of recovery or failure thereof, wound care, appropriate medication administration, and other tasks, such as helping the patient with some daily hygienic measures. The Corpspersons would be in communication with a physician, nurse clinician, or physician assistant with knowledge about this particular patient. Changes in medication administration and other interventions could be introduced after the visit by the Corpsperson, who would then document the events of the visit in the electronic medical record along with any changes made in the medical program. If the patient appeared to be unable to perform normal activities of daily living, then the Corpsperson could discuss further interventions with the involved healthcare workers and social service personnel.
To test this new program aimed at preventing readmissions, I would suggest that Medicare or the National Institutes of Health sponsor a multicenter trial in which patients would be randomized to Corpsperson home visits versus regular phone calls from a healthcare worker who would seek to improve the postadmission process for the patient. The 2 groups would be followed with the primary outcomes being the numbers of readmissions in the 2 groups and healthcare costs. I predict that the Corpsperson intervention would significantly reduce readmissions and be highly cost-effective. Of course, the clinical trial will tell us whether I am correct in my assumptions.
Finally, I would recruit a substantial number of the individuals selected for the Corpsperson trial (as well as the subsequent program if the trial were to be successful) from minority, healthcare-disadvantaged communities, for example, lower socioeconomic Hispanic and African American regions of the country where readmission rates and health outcomes after hospital admission are known to be poor in comparison with communities with higher socioeconomic resources. The best of all possible results from such a program would be reduced hospital admissions and the creation of worthwhile and satisfying jobs in areas of our country where high unemployment exists.
As always, I welcome comments and discussion on our blog at amjmed.org.
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-Joseph S. Alpert, MD (Editor in Chief, The American Journal of Medicine)
This article originally appeared in the February 2017 issue of The American Journal of Medicine.