Discharge can be an overwhelming and confusing time. But for patients with memory loss, the directions on medications, diet and ongoing self-care can be especially bewildering and out of reach after their return to home.
Among people with congestive heart failure (CHF), end-stage renal disease and chronic obstructive pulmonary disease, cognitive impairment is highly prevalent — yet in the early stages, it often slips by unnoticed by patients, family and caregivers with other things on their mind. Interestingly, these chronic illnesses are also known for their high readmission rates.
Connecting the dots, researchers at Henry Ford Hospital in Detroit decided to do something about it. Their strategy was two-pronged: screen patients with CHF for memory loss and, for those in whom it was present, make an intentional effort to educate their family or significant others on being more involved in their care at home.
The strategy, said clinical health psychologist Mark Ketterer, PhD, was “astonishingly simplistic but effective.”
In fact, it resulted in a 30% drop in 30-day readmission rates.
Dr. Ketterer and colleagues reported on their success in The American Journal of Accountable Care.
“Patients with memory loss often don’t do well with taking their medication on time, renewing their medication and just coping in their day-to-day surroundings,” said Dr. Ketterer. “If they’re in a medical setting such as a nursing home, a nurse or other provider is able to monitor them and make sure they’re doing these things reliably and consistently.
“Assigning a nurse to at-home patients is simply not feasible for manpower and cost reasons. We found that involving and educating the family about the forgetfulness we frequently see in patients and having them more involved in overseeing the care at home proved to be really successful in keeping patients from returning to the hospital.”
The identification-and-education strategy took place on an inpatient CHF unit. A health psychology service took the psychosocial history and baseline mental state of patients deemed at risk for cognitive impairment and educated the family of those subsequently identified with it on how to act as collaborators in care.
After one year, the average 30-day readmission rate on the unit was 16 percent, researchers reported. In comparison, the 30-day readmission rate on another cardiac unit was 21.5 percent. Average early readmissions for remainder of the hospital were 22.8 percent. The national average is 23 percent.
Because of manpower limitations, only 489 of 2,870 patients admitted to the CHF unit received the intervention that year. Researchers suspect the impact on readmissions might have been even higher if more patients and families had access to the services.
“We believe the present analyses represent a weak test of our hypothesis. Because we only intervened with about 20 percent of all CHF patients admitted [to the unit], when 50 percent or more were known to have cognitive impairment, the present results may be a conservative test of the effect,” they wrote. “Might a greater reduction have been observed if we saw 30 percent, 40 percent, or 50 percent of the CHF sample?”
Involving family in discharge instructions and care makes sense — and cents (lots of them, actually). The study concludes the intervention could save payers $117,700 for every 100 patients over the first month through avoided early readmissions.
“Thus,” researchers write, “the introduction of a health psychology service to a treatment team caring for CHF patients produces a higher ‘value’ of care — better outcomes with reduced costs.”
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