What's wrong with care transitions? Ask patients
Study uses current patients to ID problem areas
The patients who come into hospitals are often very ill and not in the best state. But give them a chance to help improve care, and if they are able, they are almost always willing. At least that's the experience that Jennifer Lee, MD, has had as a hospitalist at New York Presbyterian Medical Center/Weill Cornell Medical College in New York City. She made talking to patients part of her work for a study published in the November 2013 issue of the Journal of Hospital Medicine that looked at how to better understand — and thus improve — patient care transitions.1
The study was designed to look at the various roles around the patient, the issues that connect them to him or her, and how they impact care. The hope is that with increased understanding and study, there will be better ammunition to fire at unplanned readmissions.
Lee was interested in looking at transitions because despite years of research, nothing much seems to have changed — "the needle hasn't moved," she says. "The patients are sicker, more complicated, and they don't have the support that there used to be. We move away from our families, and the patients who come in often don't have anyone who is close to them. There are a lot more factors that come into play in trying to keep them healthy."
In looking for ways to prevent readmissions and keep patients from falling through the cracks, researchers are seeing some answers, but they are often prohibitively expensive. Or seemed to be in the past.
One of the elements of her work that is different from many others is her use of existing patients for focus groups as part of the study. Not former patients or just family members, but actual patients. Getting patients involved in quality improvement and patient safety projects is recommended by many national organizations, but given the reality — Lee's comment above about sicker patients, for instance — it's not always easy to do. Some manage, but for large hospitals, it can be difficult, says Lee, and many have informal rosters of former patients and family members they use.
But in this case, Lee was able to make it work. She calls them a "captive audience that has a lot to say." Getting their perspective was a vital part of her study, she says. "There are things you think you know and maybe you take them for granted. But you hear it actually verbalized and it makes so much sense. There is a wealth of information you have access to through them."
Her research doesn't just focus on the patient, though, but on getting information from the other team players — physicians, nurses, social workers.
A given role may be played by someone else; for instance, a social work or visiting nurse role may be played by a daughter or next door neighbor, she says. In these times when families are far flung, finding out who plays that role could be key to eliciting key information. For instance, knowing that the house smells of urine, or that there are rodent droppings — that would be important to know before discharging a patient back to that home, she says.
In her paper, Lee and her colleagues used patient and care team interviews to come up with five patient-centered themes that can have an impact on transitions of care and readmissions.
They are teamwork — as in having a good team that collaborates and communicates; health system navigation and management — this may require more institutional or governmental change to make it manageable for everyone, or more dedicated people to help older sicker people learn to navigate it; illness severity and health needs — obviously sicker patients have greater needs and are more likely to bounce back; psychosocial needs — taking into account not just what their status is under usual circumstances, but what they are under these new and more stressful ones; and medications — what they take, can they get it, do they understand it all, and will they comply.
All of these areas have spheres of influence that intersect with various actors around the patient — the roles Lee spoke of before.
If any lesson can be taken from her research at this early stage, it is about improving communication between all team members, whether they are people you have always worked with in the hospital or are people you are just getting acquainted with outside your facility. Lee notes that the organizations that have made a dent worth talking about in readmission rates are the ones like Mayo, which have extremely robust accountable care organizations set up, with a large degree of communication between primary care providers, social workers, visiting nurses and the inpatient providers who took care of the patient before discharge.
"We don't have the kind of connectivity here that they have there, so I don't know if we can have as great an impact on the numbers as they have," says Lee. "But I think we can improve patient satisfaction and patient safety."
As research continues, Lee encourages everyone to be familiar with the American College of Physicians transition guidelines (http://www.acponline.org/acp_news/misc/apr11/page%20252.pdf). And then start talking — not just to other team members, either. Talk to patients. If they are coherent, you can get useable information from them. Lee still asks questions of patients from the study template — some as simple as checking phone numbers and others more complex and related to medications. She asks about the home situation, knowing that the social worker will, too.
At the very least, the extra time Lee takes with the patients provides them with more education. At most, she gains valuable information from the patients. "It can be eye-opening."
Reference
- Lee JI, Cutugno C, Pickering SP et al. The patient care circle: a descriptive framework for understanding care transitions. J Hosp Med. 2013 Nov;8(11):619-26. doi: 10.1002/jhm.2084. Epub 2013 Oct 12.
For more information on this topic, contact Jennifer Lee, MD, Division of Hospital Medicine, New York Presbyterian Medical Center. New York, NY. Email: [email protected].
