Many hospitalized patients are reluctant to raise concerns about their care, which reduces opportunities for improvement.
Encouraging patients to speak up about problems that occur during hospitalizations can improve patient experience and safety, recent research indicates.
Patients are uniquely qualified to raise concerns about care because they are present for the entire episode of care. Earlier research has shown most patients do not raise concerns or file formal complaints, with hesitancy to speak up linked to several factors such as an expectation that complaining will not make a difference.
The lead author of research published this month in BMJ Quality & Safety told HealthLeaders that health systems and hospitals have nothing to lose in asking patients about their concerns.
"From an institutional perspective, I don't think there is a downside to encouraging patients to speak up. However, institutions that do this should be prepared to take the next step and respond to patients who bring up concerns," said Kimberly Fisher, MD, an associate professor in the Department of Medicine at the University of Massachusetts Medical School in Worcester, Massachusetts.
Fisher's research team, which examined data from more than 10,000 patients, published several key findings.
48.6% of patients reported experiencing a problem during their hospitalization
30.5% of patients did not always feel comfortable raising concerns
Patients who had the highest likelihood of not speaking up were older, had worse overall and mental health, were admitted from the emergency department, and did not speak English at home
Mental health was a strong predictor of unlikelihood to speak up, with patients who had poor mental health nearly four times as likely to not feel comfortable raising concerns compared to patients who had excellent mental health
Patients who were not always comfortable raising concerns gave lower ratings for nurse communication, physician communication, and the hospital overall
"The most common type of problem that patients report is inadequate communication—they didn't get the information that they wanted, they didn't get their questions answered, or things were not explained to them in a way that they could understand," Fisher said.
Taking an active approach
To maximize the number of patients who raise concerns, health systems and hospitals should take an active approach, she said.
"Directly asking patients whether they have any concerns and conveying a sincere desire to hear from patients is essential in encouraging patients to speak up. We learn about many more—by an order of magnitude—concerns and problems in care with an 'active outreach' approach in which someone inquires of patients as to whether they've had any problems, as compared to just setting up and publicizing mechanisms—websites, phone numbers, or email addresses."
Care team members are well-positioned to ask patients whether they have concerns, Fisher said. "If it comes from someone on the care team, you are not fragmenting care by introducing yet another cook into the kitchen."
Health systems and hospitals need to be prepared for patient feedback, Fisher said. "When you ask a patient if there is a problem and a concern is raised, the response cannot be saying nothing. You can't ask people to raise their hands and speak up about something and not be ready to respond."
Rising to mental health challenge
Encouraging patients with poor mental health to speak up is daunting and will require further research, she said.
"In conditions that require patient activation and engagement, it's clear that poor mental health can be a barrier to doing what they need to do to take care of themselves. It's a cross-cutting problem. It's not just about speaking up—it affects managing diabetes, heart failure, and other conditions. Mental health can impact many health management behaviors."
Enlisting friends and family members could be an effective technique to help patients with poor mental health speak up, Fisher said.
"One approach that we have found helpful in getting patients' concerns heard that could be useful for patients who have a mental health barrier to speaking up is having friends or family members involved and available to speak up on their behalf."
In earlier research that she conducted, Fisher found patients were much more likely to express concerns if a friend or family member was in the room than if the patient was alone.
"We often think of people who are unable to advocate on their behalf as impaired, but there are a lot of people who are not particularly impaired but still find speaking up a hard thing to do."
Survey data collected from children's hospital leaders targets primary patient-safety challenges. Find out what other focus areas topped the list.
The journal Pediatrics recently published a list of 24 children's hospital patient-safety challenges ripe for research. The list was developed from survey data collected from more than 100 children's hospital leaders and parents.
James Hoffman, PharmD, MS, chief patient safety officer at St. Jude Children's Research Hospital in Memphis, Tennessee, and Stephen Muething, MD, chief quality officer at Cincinnati Children's Hospital Medical Center, spoke with HealthLeaders recently about the top five patient-safety research priorities identified in the list.
"The intent was for researchers to take this list and know where to focus their efforts," says Hoffman, who helped craft the list of 24 research priorities and served as lead author of the Pediatrics article that details the patient-safety challenges list.
In 1999, the Institute of Medicine publishedTo Err Is Human: Building a Safer Health System, which included the alarming statistic that as many as 98,000 Americans were dying annually due to medical errors. Estimates of annual patient deaths due to medical errors have since risen steadily to 440,000 lives, which make medical errors the country's third-leading cause of death.
In a February 2019 policy statement, the American Academy of Pediatrics noted that medical errors "affect as many as one-third of all hospitalized children," citing articles in JAMA and Pediatrics.
Following are the top five pediatric patient-safety focus areas in prioritized order.
1. Achieving high reliability
"The discussions about the necessity of building a high-reliability culture have been relentless among our children's hospitals over at least the past five years at all levels—from the boards to the CEOs to the clinicians," Muething says.
Hoffman says achieving high reliability is consistent with the goals of the Solutions for Patient Safety network, a group featuring 130 children's hospitals that supported the effort to identify the top 24 research priorities. "Embracing high-reliability principles is a huge focus for SPS—it's a common thread across the organization."
The experience of striving for high reliability at St. Jude Children's Research Hospital demonstrates the need for examining how to implement high-reliability initiatives, Hoffman says.
"We have a relatively new quality and patient care strategic plan, where we worked to adopt high-reliability principles, and we have wrestled with putting principles into place and finding out what the principles really mean."
2. Maintaining a safety culture
Improving safety requires more than effort to prevent common harms such as central line infections, adverse drug events, and falls, Muething says.
"You are not going to get anywhere near your [patient-safety] goal unless you build a culture where people are talking about safety and are focused on safety everywhere they go. It's not as simple as creating processes or getting the right equipment—everybody in the organization needs to be thinking about safety every day."
Establishing a safety culture requires commitment, Hoffman says. "It's easy to do your safety culture survey once every year, or once every other year. It's a whole other matter to go deeply into your results, look at every unit, and actually do something. That's what we try to do at St. Jude."
3. Improving the speed and accuracy of predicting patient deterioration
Most children's hospitals have made a commitment to share information on patient safety, and predicting patient deterioration has become a top priority, Muething says. "The leading hospitals with the research groups are putting a lot of energy into these areas. We have researchers, IT, and clinicians working on this."
"There is also a parent component to this—patient deterioration was the highest rated challenge by the parents," Hoffman says
4. Encouraging open communication between families and care teams
Engaging with patients and families is essential at children's hospitals, Muething says. "In pediatrics, patient and family engagement is second nature to us. I'm a pediatrician, and you learn early on that you are not getting anywhere in taking care of a child unless you learn how to work effectively with the rest of the family."
For pediatric care teams it is not innate to know how to engage families effectively, he says.
"You have to learn how to gauge—as quickly as you can—how much information and detail a particular family wants and how active they want to be in making decisions. You can't treat every family the same. Some families want to be active and want to know every detail. Other families can be stressed out—they don't want that much detail."
Pediatric care teams need more evidence-based approaches to engaging patients and their families, Hoffman says. "Everywhere you look in patient safety, there is a communication opportunity. We need to have more standardized methods and approaches for communication. There are various approaches out there. One is I-PASS for care handoffs."
5. Detecting sepsis in pediatric patients
To advance patient safety, detection of sepsis is equally as important as speedily recognizing patient deterioration, Muething says. "Because children's hospitals have been sharing information with each other, we know that recognizing clinical deterioration and sepsis are the most common causes of preventable serious harm at children's hospitals."
Improving sepsis detection capabilities is a paramount concern at children's hospitals, Hoffman says. "It's very top of mind in pediatrics."
Learning about patient safety from children's hospitals
While there is still work for hospital leaders to do to increase pediatric patient-safety, Hoffman says adult acute-care hospitals can benefit from adopting approaches to patient safety occurring at children's hospitals.
The high level of cohesion in the children's hospital community promotes the sharing of patient-safety information and data.
Children's hospitals routinely include patients and family members on teams dedicated to preventing harm.
There is widespread establishment of patient and family advisory councils at children's hospitals. These advisory councils have been established at 40% of hospitals nationwide, according to research published in 2014.
To achieve fundamental change, healthcare leaders and their teams face multiple challenges such as establishing an enterprise-wide strategy.
Health systems, hospitals, and physician practices are under pressure to improve care and grow market share.
The drivers of transformational change include the imperative to deliver safer care, the shift from volume-based to value-based business models, and efforts to boost quality of care.
A Press Ganey report published Tuesday features three steps to achieve transformational change at healthcare organizations.
"We describe the key considerations for creating a transformational road map and present the steps needed to build an organizational culture that supports patient-centered care and a purpose-driven workforce that can deliver it," the report says.
1. Establish an enterprise-wide strategy
To achieve transformative change, direction has to come from the top of the organization and all teams must understand their role, the report says. "Healthcare CEOs and senior leaders must be aligned on the strategic vision and the path needed to reach it, and they have to consistently and transparently communicate both to the entire organization."
There are four elements to crafting an enterprise-wide strategy:
An assessment process determines the organization's performance level and the divide between baseline performance and ideal performance. The assessment effort should have several components, including leadership surveys and stakeholder interviews.
Healthcare organizations should determine the interdependencies across safety, quality, patient experience, and workforce engagement. Organizations with many silos in their operating model will face a greater need for redesigning processes than organizations that have reduced silos.
Transformational plans require benchmarks and metrics to set goals, measure performance, and guide strategy adjustments.
An integrated dashboard should give the CEO and other top leaders a comprehensive view of the organization's performance.
"Rolling out an integrated balanced score card is the first step to ensuring leaders begin to understand the interdependencies of various performance verticals. Starting with the Board to every level of the organization, all leaders need to have visibility to the data," James Merlino, MD, chief transformation officer at South Bend, Indiana-based Press Ganey, told HealthLeaders.
2. Build a change-receptive culture
Healthcare organizations that are committed to transformational change should gauge their readiness for innovation, the report says. "During periods of large-scale disruption, an organization's ability to pivot quickly and nimbly is predicated on the degree to which its culture—organizational values, beliefs, and work practices—is aligned with the strategic vision."
There are five components to evaluating readiness for change:
Assessing the engagement and resilience of physicians, nurses, and other staff members
Determining whether the workforce understands why change is desirable
Finding out whether employees are aligned with the organization's transformational vision
Ensuring the workforce is ready to move away from the status quo
Establishing confidence in the leadership's ability to guide change and the organization's commitment to devoting necessary resources
3. Develop an integrated data and management strategy
Harnessing data is essential to transformational change at healthcare organizations, the Press Ganey report says. "As with all enterprise-wide, business-critical initiatives, the data strategy should have executive sponsorship and a governance structure to ensure ongoing alignment with organizational objectives."
There are six ingredients for an effective integrated data and management strategy:
Data should be scientifically rigorous with large sample sizes.
The data platform should have multiple layers that allow the organization to examine both broad measures of performance and narrow performance variables.
Establishing key performance indicators is crucial to measure, evaluate, and track initiatives.
Engineering cross-functional capabilities helps leaders work as strategic partners and enables engagement.
A premium should be placed on communication such as sharing updates at regular intervals during the transformation process.
Leaders should hold themselves and their teams accountable, even when insights gained from data indicate that adjustments are needed in strategy or implementation of change.
"Healthcare organizations can improve accountability of leaders by setting clear expectations and goals, establishing key performance indicators, and creating an accountability loop to monitor performance and course correct when necessary. These are some of the basic tenants of an operating model that every healthcare organization should have to help improve and sustain performance," Merlino said.
At national level, the annual cost of index admissions for sepsis are estimated at more than $23.3 billion.
The annual estimated cost of sepsis readmissions is about half the annual cost of all four of the conditions in Medicare's Hospital Readmissions Reduction Program, recent research shows.
"In our study, the estimated annual cost of sepsis readmissions amounted to more than $3.5 billion within the United States. When compared to $7.0 billion for the four conditions (AMI, CHF, COPD and pneumonia) targeted by the Hospital Readmissions Reduction Program (HRRP), this accounts for a significant under-recognized burden on the U.S. healthcare system," the researchers wrote in the journal CHEST.
Sepsis is the body's extreme reaction to an infection, which can result in life-threatening symptoms such as multiple organ failure. Annually, more than 1.5 million people get sepsis in the United States, with about 250,000 fatalities.
The economic impact of sepsis on a national scale is significant, the CHEST researchers found in their study, which featured more than 1 million index admissions.
The annual cost of index admissions for sepsis was estimated at more than $23.3 billion
The mean cost per sepsis readmission within 30 days of discharge was $16,852
30-day readmissions after an index admission for sepsis accounted for 13% of all sepsis-related hospitalization costs
The lead author of the CHEST research, Shruti Gadre, MD, told HealthLeaders that sepsis readmissions are likely expensive because of intensive care unit treatment, antibiotics administration, and invasive procedures.
Sepsis readmissions are expensive relative to the HRRP conditions most likely because of the acuity of sepsis patients, said Gadre, a member of the Department of Pulmonary, Allergy and Critical Care Medicine at Cleveland Clinic's Respiratory Institute.
"The hypothesis is that sepsis patients are sicker when they get readmitted to the hospital. They require ICU-level care and may have multi-organ involvement compared with patients with AMI, heart failure, COPD, and pneumonia, which may lead to higher costs."
Anticipating readmissions
For patients who had an index sepsis admission, 17.5% were readmitted within 30 days. Gadre and her research team identified predictors of sepsis readmissions.
Infection was the most common cause for 30-day readmissions, accounting for 42.16% readmitted patients. Sepsis accounted for 22.86% of readmissions.
The other most common causes for sepsis readmissions were gastrointestinal (9.60%), cardiovascular (8.73%), pulmonary (7.82%), and renal (4.99%) conditions.
"Our findings serve to create awareness among clinicians, administrators and policy makers alike regarding patient populations that are vulnerable to sepsis readmission and thus increased utilization of resources. Although it may be necessary to readmit some patients, the striking rate of readmission demands efforts to further clarify the determinants of readmission and develop strategies in terms of quality of care and care transitions to prevent this adverse outcome," the research team wrote.
Strategies adopted to address burnout include sponsoring social events to enhance connections between physicians.
From 2014 to 2017, physician burnout increased five percentage points at Massachusetts General Hospital Physicians Organization in Boston, according to research published today.
Other research indicates that nearly half of physicians nationwide are experiencing burnout symptoms, and a study published in October found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction. Burnout has also been linked to negative financial effects at physician practices and other healthcare organizations.
The research published today in Journal of the American Medical Association found exhaustion and cynicism were the primary drivers of increased burnout at Mass General's physician organization. The research was based on survey data collected from more than 1,700 physicians.
The survey data showed exhaustion increased from 52.9% in 2014 to 57.7% in 2017, and cynicism increased from 44.8% in 2014 to 51.1% in 2017.
The exhaustion finding was particularly troubling, the JAMA researchers wrote. "We found physicians were more vulnerable to emotional exhaustion than any of the other subscales of burnout. Physicians reporting high levels of exhaustion were more likely to reduce their clinical schedules, reduce the number of patients in their practice, leave the practice, or retire."
The researchers noted that physician turnover has several costs including patient and clinician distress as well as the expense of replacing physicians, which can be as high as three times a doctor's annual salary.
Primary care physicians reported higher levels of exhaustion compared to medical specialists. "These findings may be associated with the amount of time primary care physicians spend documenting on the EHR and serving as the clinicians responsible for the management of patients' multiple complex medical and social problems," the researchers wrote.
Burnout data points
The JAMA article has several other key data points.
Early-career physicians who had less than a decade of practice experience since their training were more susceptible to burnout than veteran physicians.
The higher burnout rate in 2017 may be linked to implementation of a new electronic health record system because average time devoted to administrative tasks increased from 23.7% in 2014 to 27.9% in 2017, and increased time spent on administrative tasks was linked to higher burnout.
Several favorable working conditions were associated with lower odds of burnout: workflow satisfaction, positive relationships with colleagues, time and resources for continuing medical education, opportunities to impact decision making, and having a trusted adviser.
Addressing physician burnout
The lead author of the research, Mass General physician organization CMO Marcela del Carmen, MD, MPH, told HealthLeaders that the physician group has implemented several efforts to reduce burnout.
"We have allocated funding to each of our 16 clinical departments to develop and institute initiatives to mitigate burnout in their departments. We have central efforts including sponsoring social events to enhance connectivity amongst the faculty, efforts to improve our use of the electronic health record through personal- and practice-level training, and funding to support peer-to-peer coaching programs, yoga, and meditation sessions."
Del Carmen's research team also suggested that burnout prevention efforts could be tailored for early-career physicians, who reported relatively high dissatisfaction with department leadership, relationships with colleagues, quality of care delivery, control over work environment, and career fit.
"These findings point to potential opportunities in this vulnerable group to mitigate burnout, such as initiatives that promote community building and networking and harnessing effective leadership," the researchers wrote.
Exporting best practices from high-performing hospitals and establishing regional referral centers can level variation in hospital networks' clinical outcomes.
There are two primary strategies for health systems to limit variation in their hospital networks, researchers say in an article published this week in JAMA Surgery.
The number of hospitals joining networks has doubled over the past decade. The motivations for network formation include strategic allocation of resources, improved administrative efficiency, and opportunities to create centers of excellence.
The JAMA Surgery researchers investigated whether networks of hospitals affiliated with U.S. News & World Report honor roll hospitals delivered a consistent level of care in three service lines.
"It remains unclear whether these multihospital networks are able to deliver a uniform standard of care. While some networks may provide consistent outcomes, others may offer disparate levels of quality across affiliated hospitals despite sharing the same mission or brand," the researchers wrote.
The researchers analyzed data for colectomy, coronary artery bypass graft, and hip replacement at 87 hospitals in 16 networks. Surgical outcomes at affiliated hospitals varied widely. For example, mortality rates varied from 1.1-fold to 4.1-fold.
The research team highlighted two strategies to limit clinical outcome variation in hospital networks.
1. Exporting quality
To limit variation, hospital networks can export delivery models that achieve high quality at top-performing hospitals to all affiliates. Sharing best practices across the entire network can potentially generate better clinical outcomes at all network hospitals.
2. Referral centers
Networks can try to achieve better collective outcomes by centralizing care at referral centers that treat rare conditions, high-risk patients, and volume-sensitive procedures.
"In this scenario, higher or more variable adverse event rates would manifest in networks that fail to restrict complex services to hospitals with limited experience managing complications or to those that lack specific resources, such as 24-hour intensivist staffing," the researchers wrote.
Executing corrective strategies
Gauging the performance of hospitals in a network is essential to limiting variation in clinical outcomes, the researchers wrote. "Networks should monitor variations in outcomes to characterize and improve the extent to which a uniform standard of care is being delivered."
Focusing on service lines is imperative. "Networks that fail to critically evaluate their service lines to align expertise and resources appropriately will demonstrate more variability in quality across their affiliates," the researchers wrote.
Engaging clinicians is another key element in limiting variation, they wrote. "Beyond service-line reorganization, it will be increasingly important for networks to determine how to integrate clinicians into these multihospital quality improvement efforts. Clinician input is critical to all aspects of delivery system redesign but may be particularly relevant to quality improvement."
Focal points in neonatology include better communication with families and sepsis screening.
Maternal mortality and sepsis detection are two of the most vexing challenges in obstetrics and neonatology.
Neonatologist Meg Prado, MD, who was recently appointed as president of Women's and Children's Services at Nashville-based Envision Physician Services, recently discussed these challenges with HealthLeaders.
Prado joined Envision in 2001, practicing as a neonatologist at Miami Children's Hospital. She most recently served as vice president of Women's and Children's Services for Envision. Prado began her new role in February.
She received her medical degree from the University of Miami and completed both her residency and fellowship at Jackson Memorial Hospital in Florida.
The following is a lightly edited transcript of Prado's conversation with HealthLeaders.
HL: Why did you pick neonatology as your specialty?
Prado: When I was in medical school going through all the rotations, I tended to have an affinity for the higher energy and intensive care situations. Once I did my rotation in the neonatal ICU, the deal was pretty much sealed because I already knew I wanted to go into pediatrics, and I wanted to improve healthcare for infants.
HL: Has practicing as a neonatologist lived up to your expectations?
Prado: It has been so much more than what I expected because of the life lessons learned from the parents and their babies.
For example, I was taking care of a baby that was born prematurely, and at a couple months old he was just not progressing the way I wanted him to. By this time, I would have expected this little baby to be off his respiratory support, taking a bottle, or nursing from his mother. He just didn't have the ability to do that because of his lung disease.
I remember taking the parents into the room and telling them how sorry I was that the baby was not as healthy as I wanted him to be. They said, "Dr. Prado, it's not your fault. You're doing everything you can for the baby, and when it's time for him to get better, he will get better."
HL: What are the main trends in neonatology?
Prado: The primary trends are in the softer areas, which include improving communication with parents and families, and not just when a baby is in a NICU. We need to have access to a woman when she gets admitted to a labor ward if she has broken her water early and is at high risk of infection or delivering prematurely. We need to talk with families ahead of time to let them know national and center-based data, so parents can know what to expect for the long-term outcome of their infant.
Including parents on rounds can help them know that their opinions matter. While I am not going to necessarily let a father or mother make an important decision that I need to make as the attending physician, involving them on rounds and making them feel they are part of the decision-making process is vital.
Good medicine is not just good diagnosing and treating, but also making sure we are open and transparent, which is vital to trust and reducing litigation. Even if you have an adverse outcome for a patient, if you have communicated fully the chances of a claim being filed are less likely.
Another trend is introducing skin-to-skin contact early—when you allow a parent to hold a small premature infant even when the baby is on a ventilator or has central lines in place. We need to buy into this idea because we know babies' vital signs stabilize when they are being held by their caregiver. It can potentially improve neurodevelopmental outcomes.
Another major focus is improving nutrition. Neonatologists need to do everything they can to optimize the use of breast milk, especially in low birthweight infants. At Envision, we believe this is best practice, so we work with our hospital partners to make sure that breastfeeding is encouraged. When breastfeeding cannot occur for any reason, we promote the use of donor milk.
HL: You have overseen the development of an innovative neonatal sepsis screening tool. How can we rise to the challenge of screening babies for sepsis?
Prado: The primary challenge of sepsis screening is deciding which infants need antibiotics at birth. At the birth of neonatology, the philosophy was if a baby was sick enough to be in a NICU the baby was sick enough to be on antibiotics. The idea was that any baby who was in a NICU was predisposed to an infection and warranted antibiotics.
In recent years, the increasing instances of antibiotic-resistant organisms in the community as well as in hospitals has prompted calls to decrease use of antibiotics. My concern is the pendulum could be swinging against antibiotics too far. We could be dismissing signs of infection and not administering antibiotics in symptomatic infants.
After an adverse outcome, one of our doctors in Phoenix developed a sepsis screening tool for babies over 34 weeks—babies under 34 weeks are very small and physicians have to exercise their best judgment on whether to start antibiotics. We use a sepsis calculator developed by Kaiser Permanente in conjunction with the baby's symptoms.
HL: Gauge the country's effort to reduce maternal mortality.
Prado: As physicians, we are making sure that the issue is being brought to the forefront and that we are aggressively addressing the issue with proper policies and protocols. However, we are addressing the problem after it has already occurred. It would be better to address poor health challenges before they happen.
As a society, we should be making every effort possible to be healthier because the downstream effects are contributing to increased maternal mortality.
One of the things that has been happening on the OB-GYN front is reducing C-section rates, especially for first-time pregnant women who are at relatively low risk—they only have one baby and the baby's head is presenting down. There's a big effort across the country to reduce the C-section rate, which hopefully will affect maternal hemorrhage.
Capacity coaching helps older patients with multiple health conditions who are overwhelmed by their illnesses and treatment.
A new approach to health and wellness coaching encourages patients to build the capacity to adapt, endure and function at the highest level possible with their illnesses and treatment.
About three quarters of Americans over the age of 65 are living with multiple chronic conditions. A recent systematic review of controlled trials and quasi-experimental studies found coaching interventions for chronic conditions had statistically significant positive impacts on patient health such as physiologic, behavioral, and psychological well-being.
In an article published last month in Mayo Clinic Proceedings, capacity coaching was presented as an effective intervention for the increasing number of older patients with comorbidities.
"Health and wellness coaching brings considerable strengths to the table in healthcare as a method for changing behaviors to prevent and treat chronic illness and in the physiologic, behavioral, psychological, and social outcomes for patients. However, the growing population of patients living with multimorbidity may need a slightly different approach to coaching—one that focuses on strengthening their capacity to adapt and thrive with chronic illness," the authors wrote.
'Help overwhelmed patients'
The lead author of Mayo Clinic Proceedings article told HealthLeaders that capacity coaching addresses an unmet need among older patients with multiple chronic conditions.
"Healthcare has not evolved to care for these patients in the ways consistent with their needs. Specifically, patients living with multiple chronic conditions are often overwhelmed by the work they must do to care for their illnesses—appointments, medication taking, dietary restrictions, and physical activity. These tasks exceed their capacity to cope with them alongside everyday life," said Kasey Boehmer, PhD, MPH, assistant professor of health services research at Rochester, Minnesota-based Mayo Clinic.
For this population of patients, healthcare providers should strongly consider capacity coaching rather than traditional health and wellness coaching, she said.
"Traditional health and wellness coaching was not designed for overwhelmed patients dealing with multimorbidity, which is why we developed capacity coaching. This type of coaching, offered within the healthcare setting, holds the potential to help overwhelmed patients by reducing their treatment burden and increasing their capacity for self-care and overall quality of life."
Capacity coaching and orienting care
This new form of health and wellness coaching can help orient a patient's care, Boehmer said.
"A capacity coach looks at the patient holistically, beginning by understanding what's going on in their life and what's going on in their healthcare. Then, they work simultaneously with the patient's healthcare team to reduce their treatment burden and the patient directly to increase his or her capacity for self-care."
A capacity coach can help orient care in several areas, she said. "Treatment burden is reduced by actions such as reducing numbers of appointments, simplifying medication taking, and improving overall coordination of the patient's care."
The treatment intensity and 24-hour monitoring at skilled nursing facilities could drive lower readmission rates compared to home care.
The rate of readmissions for patients discharged to home health care is 5.6 percentage points higher than for patients discharged to skilled nursing facilities, new research shows.
For hospitals across the country, readmissions have become a crucial metric with quality and financial dimensions. A hospital's readmission rate is a key indicator of care quality and the effectiveness of discharge planning. Since 2012, Medicare has been penalizing hospitals financially for readmissions linked to several targeted conditions such as pneumonia.
In an article published recently in JAMA Internal Medicine, researchers examined data from more than 17 million hospitalizations, with 61.2% of patients discharged to a skilled nursing facility (SNF) and 38.8% discharged to home with home health care services.
The researchers found that "marginal patients"—individuals who could reasonably be discharged to either home health care or a SNF—had a higher rate of hospital readmission if they were discharged to home health care. The research team speculated that the disparity could be caused by two reasons.
"In providing institutional care, SNFs are able to provide 24-hour monitoring of patients, which may be effective at recognizing complications early and preventing unnecessary readmissions," the researchers wrote.
"Skilled nursing facilities are also able to provide a higher level of treatment intensity compared with home health care visits and can thus effectively treat patients who might require hospitalization if they were at home," they added.
Cost considerations
The researchers also found that Medicare reimbursement for home health care was significantly lower than SNF care.
While SNF care may be more effective in limiting readmissions, home health care is less costly for the Medicare program, the researchers wrote.
"The reduction in readmissions comes at a cost for Medicare, as institutional postacute care is associated with higher Medicare payments than is providing postacute care at home. Even after accounting for the lower costs from fewer readmissions from SNFs, the total amount paid by Medicare for hospitalizations and postacute care during the 60-day posthospital period is lower for patients discharged to home compared with those discharged to an SNF."
Medicare reimbursement rules could be a factor in the lower performance of home health care in preventing readmissions, the lead author of the research told HealthLeaders.
"Because of the payment rules for home health by Medicare, it limits the intensity of care that can be provided at home. For example, patients can receive one visit per day at most. More flexibility in the way home health care is delivered would allow more intensive services to be provided in the home, which could help prevent readmissions," said Rachel Werner, associate chief for research in the Division of General Internal Medicine at the University of Pennsylvania in Philadelphia.
Postacute care is a significant element of Medicare spending—pegged at more than $60 billion in 2015.
Reimbursement reforms and policies could be influencing patient discharge decisions.
For example, Medicare's Hospital Readmission Reduction Program, which features financial penalties for readmissions, could be encouraging hospitals to discharge patients to the SNF setting, Werner's research team wrote. "These incentives may push hospitals to favor the use of high-acuity settings such as SNFs, and our results suggest that this strategy may be effective at reducing readmissions."
Other payment models could encourage hospitals to discharge patients to the home health care setting, they wrote. "Alternative payment models such as accountable care organizations and bundled payments hold providers accountable for costs of care across settings and clinicians, an incentive that may push patients toward lower-cost care."
Community consulting pharmacists work with patients' prescribers and pharmacies for as long as a year after hospital discharge.
A medication management intervention to avoid patient harm that has been proven effective in the hospital setting also appears effective in the community setting.
Adverse drug events occurring outside the hospital setting have been increasing, according to the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance Project. From 2013 to 2014, the rate of emergency department visits for adverse drug events was estimated at 4 per 1,000 people. From 2004 to 2005, the rate was estimated at 2.4 per 1,000 people.
The Pharm2Pharm medication management intervention, which has demonstrated effectiveness in the hospital setting, can reduce adverse drug events in the community setting, recent research shows.
"The Pharm2Pharm model is an effective way to address the growing problem of community-acquired medication harm among high-risk, chronically ill patients. This model demonstrates the importance of deploying specially trained pharmacists in the hospital and in the community to systematically identify and resolve drug therapy problems," the researchers wrote.
The model features a hospital consulting pharmacist role and a community consulting pharmacist role. There are three facets to the community consulting pharmacist role.
Working with patients' prescribers and pharmacies for as long as a year after hospital discharge to enhance drug therapy regimens
Focusing on medication issues to reduce hospital utilization, especially in the time period soon after hospital discharge
Prioritizing medication management according to the patient's health goals and concerns
The recent research examined 189,000 hospital admissions from 2010 to 2014. The researchers found 70% of medication harm codes were community-acquired. On a quarterly basis, the Pharm2Pharm intervention reduced the rate of admissions with community-acquired medication harm by 4.28 admissions per 1,000 admissions.
"We found that the majority (70%) of medication-related harm seen among older inpatients during a 5-year period was community-acquired, suggesting the importance of targeting ambulatory and other community settings for improvement," the researchers wrote.
Boosting health and lowering costs
The Pharm2Pharm model generates population health benefits and lowers costs, the lead author of the research told HealthLeaders.
"It's all about better care and outcomes for patients and lower costs for payers," said Karen Pellegrin, PhD, MBA, director of continuing education and strategic planning at the University of Hawaii at Hilo's Daniel K. Inouye College of Pharmacy.
Reducing hospitalizations is a crucial element of decreasing healthcare spending, she said.
"Pharmacists are the medication experts who can work with patients across their prescribers in community settings to prevent medication-related hospitalizations. Hospital care is the biggest cost in our healthcare system, accounting for one-third of all healthcare spending in the U.S. at $1.1 trillion in 2017, according to the Centers for Medicare & Medicaid Services."
The Pharm2Pharm model has been shown to slash hospitalizations for adverse medication events, she said. "Pharm2Pharm strategically deploys pharmacists to fill a major gap in care—who's minding the medications? We achieved a 264% return on investment in our pharmacists because they reduced hospitalizations by optimizing the medication regimens for high-risk patients."
Training pharmacists
The Daniel K. Inouye College of Pharmacy provides training that prepares pharmacists to implement the Pharm2Pharm model.
"Best practice medication management and communicating effectively with patients and physicians are essential components of our training program, which is now available in an online, interactive, self-guided, six-hour continuing education program," Pellegrin said.
Medication management is a key element of the training, she said.
"Best practice medication management is not medication reconciliation or patient education—though these are important, and pharmacists do these well. Best practice medication management means systematically identifying and resolving drug therapy problems—first indication, effectiveness, and safety problems, and only then patient adherence problems."
