Shay Jacobson, RN, MA, NMG, LNCC, CNLCP
Martha Kern

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The Affordable Care Act aimed much of its focus on reductions in Medicare spending, and we have all heard a great deal about hospital readmission rates over the past several years. Patients discharged from the hospital returned at a rather alarming – and costly – rate, and it was the mission of the ACA to exert considerable effort to limit this phenomenon.

Because hospitals are penalized for having high readmission rates, it would appear that Medicare believes hospitals are responsible or have somehow failed the patient who returns in 30 or fewer days. Many of us involved in the care of disabled individuals intuitively sensed that patients returning to the hospital shortly after discharge do so for myriad and complicated reasons, many of them completely unconnected to the hospital and the care they received.

A recent study published in the Journal of the American Medical Association indicates that in addition to hospital-controlled influences (infection management, improved coordination between inpatient and outpatient providers, etc.) there are a large number of patient characteristics that are significantly predictive of readmission. Adjustment for these patient characteristics accounted for roughly half of the observed differences between hospitals with high readmission rates and those with far lower rates:

Gender – there were fewer male patients at hospitals with high readmission rates;

Race — hospitals posting higher readmission rates treated more minority patients;

Marital status – hospitals with higher readmission rates treated more widowed or divorced patients;

Education – hospitals with higher readmission rates treated patients with lower levels of education;

Labor force status – hospitals with higher readmission rates treated more patients who were retired or disabled;

Total assets, household income and debt – hospitals with high readmission rates treated patients with less access to financial resources;

Disability – hospitals with higher readmission rates treated more disabled patients;

Medicaid enrollment — hospitals with high readmission rates treated more Medicaid recipients;

Smoking status – hospitals with higher readmission rates treated more current smokers;

Depression — high readmission hospitals had a greater number of depressed patients;

Cognition — poor cognition was more common at hospitals with higher readmission rates;

Self-rated health — patients reporting poor health were found in greater numbers at hospitals with high readmission rates;

Problems with ADLs and IADLs — problems with activities of daily living and instrumental activities of daily living were linked to higher readmission rates;

Mobility and agility issues – patients with mobility and/or agility issues were treated in greater numbers at hospitals with high readmission rates;

Household residents – patients living alone, or with three or more people, were seen in greater numbers at hospitals with high readmission rates;

Living children – patients with no living children were found in greater numbers at hospitals with high readmission rates;

Frequency of contact with friends – having more frequent contact with friends seemed to have a favorable impact on readmission rates.

As the authors of the study point out, hospitals treating healthier, more socially advantaged patients may find it far easier to avoid readmission penalties than those institutions serving patients in poorer health and with fewer resources. Many make the case that Medicare should adjust for these patient-driven characteristics so as to avoid penalizing hospitals for variables over which they have no influence.

Not included in this study but a pervasive and influential variable is a lack of formal or informal caregiver support in the community. Many of our clients are geographically separated from family, are estranged or isolated for other reasons, and have no one to assist them with even basic forms of follow-up after hospitalization. Professional services should be introduced to those who lack community-based support to help fill the gaps left by absent family. The availability of help outside the hospital can be the deciding factor between thriving at home versus returning to the hospital.

To read the original report, click here: http://archinte.jamanetwork.com/article.aspx?articleID=2434813

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