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A recent article in the local newspaper identified that 41 of 43 hospitals in the Philadelphia market would receive penalties of up to 1.25% of their Medicare payments due to their high levels of readmissions for patients with congestive heart failure (CHF), pneumonia and acute myocardial infarctions. It has been estimated that 1 in 10 of hospital admissions are actually avoidable readmissions for the same diagnosis. The readmission may be for an exacerbation of the previously treated issue, the lack of adherence to the recommended regimen, an inability to access medications, treatments or post-acute support services, a lack of health literacy, or a combination of all of these factors.
Nurses traditionally have had the responsibility to teach their patients about their disease processes, medications, signs and symptoms to report and to recognize adverse effects of treatments, however with the advent of Diagnosis Related Groups (DRGs) in 1984, the length of stay was decreased and the amount and quality of information provided to patients has changed. We rely on home health nurses to do the bulk of the education for the Medicare patient, however the nurse may not come to the home until the second or third day after discharge.
What happens to the Medicare beneficiary who leaves the hospital after being treated for CHF? Does the patient know which medications to take, have access to get the new medications filled, know the difference between generic and trade names of the same medications, have an appointment in hand for when to return to the physician, have transportation arranged for this appointment, and does the patient have the strength to obtain food and prepare that food in accordance with the diet prescribed?
One of the hospital systems quoted in the article identified their plan to reverse the re-hospitalization trend through the use of telehealth. Although telehealth systems provides a method of accessing patients’ vital signs and to connect electronically with them in their homes to teach and monitor their disease processes, the basic causes of re-hospitalization will not be addressed: the need for nutritional support for this vulnerable population. Patients with CHF have endurance issues and will be less likely to shop for food and cook a balanced diet. They will instead send someone for cold cuts, fast food or take-out (ie, foods high in sodium), despite the prescription of a low-sodium diet. Unless we start at the basics, providing connections to Meals on Wheels or other sources of balanced nutrition, unless we address the logistics of having the patient access their new prescriptions or return to the physician via transportation, we will likely not be able to make much headway with the problem of re-hospitalization.
