DIR Return Create A Forum - Home
       ---------------------------------------------------------
       Commissioning Forum
  HTML https://commissioningforum.createaforum.com
       ---------------------------------------------------------
       *****************************************************
   DIR Return to: Community Care
       *****************************************************
       #Post#: 58--------------------------------------------------
       What patients are at high risk of readmission?
       By: admini5 Date: May 11, 2015, 4:04 am
       ---------------------------------------------------------
       Combining what can be gleaned from claims with retrospective
       record reviews of patients with readmissions has provided a list
       of patient characteristics that are often associated with
       re-hospitalization. Though most of the reported data are for the
       Medicare population, care teams in hospitals use this
       understanding to identify especially high-risk patients who may
       benefit from more intensive discharge planning and follow-up.
       Socio-demographic and healthcare history characteristics likely
       also add risk of readmission to hospital patients more broadly.
       The ability to combine characteristics into more precise risk
       prediction for specific patients (beyond merely the number of
       risk factors) would be of great interest clinically, as well as
       extremely useful in risk-adjusting readmission rates for
       comparing hospitals or rating performance. According to the most
       recent evaluation of available models (including those employing
       primary data in real time), none deals with the full range of
       potential patient factors (overall health and function, illness
       severity), most had poor predictive ability, and none supported
       triaging patients with respect to specific interventions to
       reduce risk.23 This leaves clinical teams in hospitals able to
       predict which patients may have a difficult transition
       post-discharge but not much insight into how best to address
       risks and where to focus efforts.
       Care-related contributors to readmissions
       In addition to patient characteristics that appear to put
       patients at risk, retrospective review of medical records has
       shown an association between readmissions and breakdowns in care
       during the hospitalization and immediate post-discharge period.
       These are more likely to be influenced by process improvement
       than, for instance, unpreventable progression of disease.
       Care Gaps during Stay
       [list]
       [li]Patient safety (especially medication- and
       infection-related)[/li]
       [li]Medication reconciliation not completed or inaccurate at
       admission or discharge[/li]
       [/list]Patient Factors
       [list]
       [li]Lack of understanding of post-discharge plan of care [/li]
       [li]Lack of understanding of what to watch for (warning signs),
       how to respond[/li]
       [li]Non-compliance with any or all elements of post-discharge
       self-management and care[/li]
       [/list]Lack of Timely Post-Discharge Care
       [list]
       [li]No appointments available or no relationship with PCP[/li]
       [li]Logistics, such as no transportation[/li]
       [li]Primary care physician unaware of hospitalization[/li]
       [/list]Communication
       [list]
       [li]Delayed, lacking or inadequate communication with next
       provider of direct care[/li]
       [li]Lacking or inadequate communication with home care provider
       (including family)[/li]
       [/list]Both medical errors (especially medication-related) and
       surgical complications, such as infections, are associated with
       readmissions. Patients with one patient safety incident during
       the initial hospitalization had double the risk of readmission
       (28% versus 14%), according to one study. A recent broad-based
       study (patients of all ages) in Canada found that 9.3% of all
       patients readmitted were returned for complications of surgery,
       with infection after surgery the most common diagnosis.
       Medication reconciliation is important in preventing
       post-discharge medication-related events that can lead to
       readmission. One study found that elderly patients with
       discrepancies at discharge were more than twice as likely to
       experience a readmission.
       Patients discharged to the community are substantially on their
       own for many aspects of their recovery. If they (or assisting
       family members) fail to understand ongoing treatment and warning
       signs or do not comply with recommended treatment and follow-up
       for a variety of reasons, readmissions are more likely. Lack of
       timely post-discharge care turns out to be an important risk
       factor. One analysis of Medicare claims showed that one-half of
       patients with a medical condition readmitted within 30 days did
       not have a physician visit within that period (no claim
       submitted). A subsequent study confirmed that hospitals with
       heart failure patients experiencing earlier physician follow-up
       (generally within one week of discharge) had lower rates of
       readmission for these patients.
       For further information, please visit :
  HTML http://assets1.csc.com/health_services/downloads/CSC_Preventing_Hospital_Readmission.pdf
       *****************************************************