The reasons might shock even a grizzled veterans, says Scott Rusk, M.D., chief medical officer at Mercy Hospital in Portland, Maine. Rusk has been the physician champion of a pilot project in the cardiac department that uses analytics tools to understand the personal circumstances and personality traits that might put patients at risk for readmission.
Patients are asked dozens of questions, the answers to which are run though an analytics engine developed by the Patient Performance Institute and embedded in the cardiology group's electronic health record.
The analysis found the biggest barrier to medication and treatment compliance was fundamental-the patients didn't believe what their physicians were saying.
"I was absolutely floored by this-a significant percentage of our patients simply didn't believe what we were saying is true," Rusk explains. "They thought we were deceiving them when we said they needed to avoid salty foods, or take certain medications-it's almost like they think there was a conspiracy among cardiologists to keep them away from things they want to eat."
The Patient Performance Enhancement Test, as it's called, scores patients in 10 different domains such as emotional control, respect for authority, optimism levels and financial situation. Rusk, like his peers trying to unravel root causes of readmissions, knows there's something going on behind the scenes that's causing patients to behave badly, but has had problems putting a finger on it or understanding how to address those issues. "I don't know any cardiology groups that have psychiatrists or psychologists associated with their group, so we've had to rely on intuition and our own attempts to understand these psycho-social dynamics.
"Let's face it, the medical model is to let the patient lie to the physician. If obese patients gain three pounds in a month and you ask them if they followed the dietary plan, they're likely to tell you they did, even though you know and they know it's a lie. This data helps us get the underlying reasons why they didn't follow the treatment and felt compelled to lie, and that helps us address those issues. It gets you to the real roadblocks."
Saint Barnabas also struggles with medication adherence and recalcitrant patients, Larkin Carney says. But like Mercy, Saint Barnabas is working new angles in its readmissions efforts, in this case re-thinking how the hospital prepare patients for discharge. "We've focused a lot on optimizing our discharge processes and focusing on a specific diagnosis when they leave the hospital. But we're starting to think, did we do the best for that patient in terms of their overall health? Did we optimize them to go home and be able to take care of themselves?"
The reason those questions are so important, she says, is that most readmitted patients are there for reasons other than complications with their initial diagnosis.
A patient was readmitted for a bout of pneumonia, which was not their initial admission diagnosis. Did Saint Barnabas ensure they exercised their lungs during their inpatient stay? Did they get them up and walking enough? Or a patient is readmitted because their wounds are not healing. Did they have the right nutrition when they were in the hospital? Did they get enough protein in their diet to ensure their wounds would heal normally?
"Since looking harder at readmissions, we're putting protocols in place to ensure we are treating the patient in full before we discharge, and not focusing on just one diagnosis," Larkin Carney says. "That's something we can control in the hospital setting."
Barnabas Health is also ramping up its I.T. efforts around readmissions It's currently working with The Advisory Board Company, a health care consulting firm, to develop predictive modeling software for readmissions.
The health system is piloting other programs. In one, an electronic alert is fired off to care teams when a recently discharged patient shows up at one of the health system's EDs. That alert triggers a phone call between the ED staff and the patient's primary care physician, care manager, a pharmacist or other clinician involved in their care. Another pilot calls for an advanced nurse practitioner to oversee the tracking of cardiac patients, one of the more difficult groups to keep out of the hospital.
"What we're doing around readmissions are efforts that try to eliminate the fragmentation of care," Larkin Carney says. "That's really the heart of the issue-patients are getting bits and pieces of care from different providers, and all those pieces don't come together to make a whole."
Readmissions Analyzed
In the study "Diagnoses and Timing of 30-Day Readmissions After Hospitalization for Heart Failure, Acute Myocardial Infarction, or Pneumonia," published in January in the The Journal of the American Medical Association, researchers analyzed Medicare fee-for-service claims data for 30-day readmissions after hospitalization for heart failure, acute myocardial infarction and pneumonia. Here are a few findings, based on analyzed data from 2007 to 2009:
* The average age of readmissions was 80.3 years for patients originally hospitalized for heart failure, 79.8 years for patients originally hospitalized for acute myocardial infarction and 80 years for patients originally hospitalized for pneumonia.
* The majority of all readmissions occurred within 15 days of hospitalization: 61 percent of heart failure readmissions, 67.6 percent of acute myocardial infarction readmissions and 62.6 percent of pneumonia readmissions.
* Among all readmissions, approximately one-third occurred from day 16 through day 30 post-hospitalization.
* The median time period between hospitalization and readmission was 12 days for heart failure, 10 days for acute myocardial infarction and 12 days for pneumonia.
* For readmissions after a heart failure hospitalization, 87.5 percent were readmitted once, 9.7 percent were readmitted twice and 2.8 percent were readmitted three or more times.
* For readmissions after an acute myocardial infarction hospitalization, 97.4 percent were readmitted once, 2.4 percent were readmitted twice and 0.2 percent were readmitted three or more times.
* For readmissions after a pneumonia hospitalization, 95.1 percent were readmitted once, 4.3 percent were readmitted twice and 0.6 percent were readmitted three or more times.
