“What big Deal, Patients get re-admitted”, many are told
Anirudh is fed up with the frequent readmissions of his mother, Jayadevi and has no qualms of showing his frustration. ‘It is a painful process and especially I am far away in Bangalore and mother lives in Bhubaneshwar. Each time I have to fly down and imagine the inconveniences causing to my mother and my plight. Doctors give vague answers’. ‘What big deal’, the attitude of doctors and hospitals irks Anirudh.
Seniors continue to be readmitted to the hospital too frequently. But when it comes to explaining why, patients and providers are on Mars and Venus. The patients and relatives blame doctors and nurses. Doctors and nurses blame patients and relatives. And everybody blames the hospitals.
The problem, everyone seems to agree, is that hospital discharges are a mess. Patients don’t understand what they need to do after they go home: They don’t see their treating doctor (primary care doctor), they don’t take their medications properly, and they land back in the hospital. Do’s and Don’t are never explained. In short, no understanding of the clinical condition, prognosis, medications and management. That revolving door jeopardizes their health and costs patients crores of rupees, and more often inflict untold miseries.
Reducing readmissions should be a national priority, unfortunately in our country, even in the NABH, this is considered as a quality indicator with no penalty provision. Soumya Nair, my colleague who takes classes to nurses on transitional care practice emphasizes on the need for appropriate protocols for discharge. ‘Older adults with multiple chronic conditions complicated by other risk factors, such as deficits in activities of daily living or social barriers, experience multiple challenges in managing their healthcare needs, especially during episodes of acute illness. Identifying effective strategies to improve care transitions and outcomes for this population is essential’, Soumya Nair, who is also a practicing gerontologist, underlines the importance of care transitions, viz discharge planning.
She continues to explain that even though the strategies seem relatively inexpensive, they require greater collaboration and communication beyond the walls of the hospital, and that while hospitals are investing resources to improve patient care, they may not be investing in all the right areas. A study by Soumya listed the top four reasons for hospitalizations.
1. patients not understanding their condition and diagnosis
2. patient mismanagement of medications, especially elderly
3. patients ignoring the importance of follow up visits with their doctor
4. families unable to or not interested in the education for adequate supportive car
We have asked few of our known doctors and nurses who want to portray the patients, especially elders, in the dreaded term, non-compliant. From this health professional’s point of view, elders often are so anxious to leave the hospital the moment they stepped in and most of them are not honest about whether they can manage their discharge. ‘This hurrying and pressure from patients and their families is also another contributing factor. They say they understand instructions when they really don’t. They say they have caregiver help even if they are alone. Then, once they get home, they fall back on the same bad habits that got them hospitalized in the first place. And when they get sick, they go to the hospital and sometime to another hospital instead of consulting their primary care doctor’. Sums up one of the doctor we interacted who wish to stay incognito.
As we directly interact with infirm seniors, their story is completely different. Most of them dread hospitalization and considers overwhelming and terrifying. It is in the words of Byrappa uncle who is back from a two-week stay as “an alien world.” They say doctors expect them to understand complicated instructions and make decisions while they are in pain or in the thick haze of medication. Instructions are written in jargon that may be second nature to doctors, but is incomprehensible to their patients. No one has the patience to explain or counsel.
A new diagnosis of a chronic disease can be frightening to older patients. After the initial scare of hearing such news, they may need bit of counseling for understanding what to do. Most of the doctors assume patients who have been living with a disease for many years understand how to manage it, patients say they often do not (after all, if the disease was well-controlled, they probably wouldn’t be back in the hospital). Unlike the western nations, nurses have limited role in patient education in our country.
Another trend is that hospitals are under tremendous financial pressure to discharge patients quickly—a step that often puts more burden on discharged seniors to care for themselves. They are right. Hospitals are being pushed by insurance companies to both discharge quickly and prevent readmissions. This is a tricky situation. That’s why it is more important than ever that doctors and nurses learn to talk to patients and that hospitals vastly improve discharge programs that, too often, are the broken link in the health care chain.
Soumya recommends a solution that can help to eliminate these reasons for readmission and she says it is already at our disposal. Private nursing care is the key to effective post-hospital care. Private nursing care (Home Nursing) offers assistance with Activities of Daily Living (bathing, feeding, dressing, transferring, etc.) and can include assistance with light housekeeping, meal preparation, transportation and more. A skilled nurse oversees the care of each home care patient and can serve as an advocate to ensure the patient is meeting their recovery goals. This enables the client to focus on their recovery and eliminates anxiety over handling tasks on their own, all while drastically reducing the risk of hospital readmission. Again the immediate family who is busy earning a livelihood also relieved of the caregiving obligations.