Hospitals across the country are investing in clinical tools and personnel to solve the long-standing, increasingly expensive problem of readmissions, but hospitals are finding certain patients keep coming back for repeat visits.
According to a first-of-its-kind survey in the Annals of Emergency Medicine, one of the main reasons for readmissions is that patients with chronic and complex conditions may prefer hospital care when faced with uncertainty over their ailments and limited choices for immediate consultation.
That kind of sentiment poses a vexing problem for health systems, now that 30-day Medicare readmissions are coming with financial penalties and as emerging research links longer hospital stays to infection risks, which also are increasingly being penalized by public and private payers. At the same time, understanding what brings patients back to hospitals may also offer some clues to meeting their needs the first time, or post-discharge in other settings.
The source of the readmissions challenge and the main driver of Americans’ use and perceptions of hospital care is largely the emergency department, according to the study’s authors, Kristin Rising, MD, and colleagues. Nearly one-third of all acute care visits and half of hospital admissions originate in the emergency department – and after patients are discharged, it’s back to the ED that they turn when anxiety, pain or symptoms develop.
“Post-discharge factors, including perceived inability to access timely follow-up care and uncertainty and fear about disease progression, are primary motivators for return to the ED,” wrote Rising and colleagues, summarizing the results of 60 interviews with patients visiting the EDs following a previous discharge from two University of Pennsylvania Health System hospitals in Philadelphia.
“Many patients prefer hospital-based care because of increased convenience and timely results,” they found.
Most patients did not report problems with discharge instructions and only one-third expressed concerns with their clinical care. But after leaving the hospital, many soon had fear or uncertainty about their condition, which ultimately brought them back. Even though most had a primary care physician, they felt they could get expedited evaluations at the ED.
As one patient said: “when I do call my family doctor, sometimes I can’t get through to them because they be so busy during the week, so I have to come to the emergency room and see what they could do for me.”
Said another: “I was referred to Frankford Clinic. And the only problem with the Frankford Clinic is they don’t have the facility. They don’t have the laboratory facility that can bring back the answer right away, like the hospital does. I had to wait two days. So, if I go to the clinic I have to wait two days and in two days’ time I could be dead.”
Rising, an emergency physician at Thomas Jefferson University Hospitals, and her colleagues at Penn Medicine believe their findings illuminate two issues that health systems should note.
“First, patients need more reassurance during and after episodes of care, especially in times when there is not a clear explanation for the cause of their symptoms,” they wrote. “Excellent care by clinical standards may not equate with excellent care by patient standards.” Clinicians and patient assisters at hospitals need to be “more proactive” in addressing patient concerns before discharge.
Also, “patients do not have ready access to needed advice from providers in between their scheduled visits or inpatient hospital stays,” they wrote. “This is in part due to the ‘reactive nature’ of U.S. medicine.”
No matter how well informed patients are at discharge, Rising and colleagues suggest developing new or more reliable ways to help providers and patients connect post-discharge, “perhaps through novel telemedicine methods,” home visits or same-day scheduling with primary care providers.
Expanded home-based services in particular is one area more health systems are investing in. For example, Ascension Health, the nation’s largest nonprofit health system, is launching a joint venture with the outsourcing company Envision Healthcare to deliver home care, hospice care and infusion therapy.