“Because I Was Sick”: Seriously Ill Veterans' Perspectives on Reason for 30-Day Readmissions

Nurse-led supportive Coordinated Transitional Care (CTraC) program improves care for veterans with serious illness

BACKGROUND

The Coordinated Transitional Care (CTraC) program is a telephone-based, nurse-driven program shown to decrease readmissions. The aim of this project was to implement and evaluate an adapted version of CTraC, Supportive CTraC, to improve the quality of transitional and end-of-life care for veterans with serious illness.

METHODS

We used the Replicating Effective Programs framework to guide adaptation and implementation. An RN nurse case manager (NCM) with experience in geriatrics and palliative care worked closely with inpatient and outpatient care teams to coordinate care. Eligible patients had a life-limiting diagnosis with substantial functional impairment and were not enrolled in hospice. The NCM identified veterans at VA Boston Healthcare System during an acute admission and delivered a protocolized intervention to define care needs and preferences, align care with patient values, optimize discharge plans, and provide ongoing, intensive phone-based case management. To evaluate efficacy, we matched each Supportive CTraC enrollee 1:1 to a contemporary comparison subject by age, risk of death or hospitalization, and discharge diagnosis. We used Kaplan-Meier plots and Cox-Proportional Hazards models to evaluate outcomes. Outcomes included palliative and hospice care use, acute care use, Massachusetts Medical Orders for Life Sustaining Treatment documentation, and survival.

RESULTS

The NCM enrolled 104 veterans with high protocol fidelity. Over 1.5 years of follow-up, Supportive CTraC enrollees were 61% more likely to enroll in hospice than the comparison group (n = 57 vs. 39; HR = 1.61; 95% CI = 1.07-2.43). While overall acute care use was similar between groups, Supportive CTraC patients had fewer ICU admissions (n = 36 vs. 53; p = 0.005), were more likely to die in hospice (53 vs. 34; p = 0.008), and twice as likely to die at home with hospice (32.0 vs. 15.5; p = 0.02). There was no difference in survival between groups.

CONCLUSIONS

A nurse-driven transitional care program for veterans with serious illness is feasible and effective at improving end-of-life outcomes.

Safeguarding survival: Older persons with multiple chronic conditions' unplanned readmission experiences: A mixed methods systematic review

AIMS AND OBJECTIVES

The aim of this study was to create a holistic understanding of the psychosocial processes of older persons with multiple chronic conditions' experience with unplanned readmission experiences within 30 days of discharge home and identify factors influencing these psychosocial processes.

DESIGN

Mixed methods systematic review.

DATA SOURCES

Six electronic databases (Ovid MEDLINE (R) All 1946-present, Scopus, CINAHL, Embase, PsychINFO and Web of Science).

REVIEW METHODS

Peer-reviewed articles published between 2010 and 2021 and addressed study aims (n = 6116) were screened. Studies were categorised by method: qualitative and quantitative. Qualitative data synthesis used a meta-synthesis approach and applied thematic analysis. Quantitative data synthesis used vote counting. Data (qualitative and quantitative) were integrated through aggregation and configuration.

RESULTS

Ten articles (n = 5 qualitative; n = 5 quantitative) were included. 'Safeguarding survival' described older persons' unplanned readmission experience. Older persons experienced three psychosocial processes: identifying missing pieces of care, reaching for lifelines and feeling unsafe. Factors influencing these psychosocial processes included chronic conditions and discharge diagnosis, increased assistance with functional needs, lack of discharge planning, lack of support, increased intensity of symptoms and previous hospital readmission experiences.

CONCLUSIONS

Older persons felt more unsafe as their symptoms increased in intensity and unmanageability. Unplanned readmission was an action older persons required to safeguard their recovery and survival.

RELEVANCE TO CLINICAL PRACTICE

Nurses play a critical role in assessing and addressing factors that influence older persons' unplanned readmission. Identifying older persons' knowledge about chronic conditions, discharge planning, support (caregivers and community services), changes in functional needs, intensity of symptoms and past readmission experiences may prepare older persons to cope with their return home. Focusing on their health-care needs across the continuum of care (community, home and hospital) will mitigate the risks for unplanned readmission within 30 days of discharge.

REPORTING METHOD

PRISMA guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution due to design.

Socioeconomic and Health-Related Factors Affecting Congestive Heart Failure Readmissions

Congestive heart failure (CHF) readmissions are frequent and costly but preventable. The purpose of this study was to analyze socioeconomic and health-related factors of CHF readmissions by examining the relationship between 30-day readmissions of individuals with CHF and their payer status, race, ethnicity, primary language spoken, living arrangement, and comorbidities. This retrospective case-control study used secondary data from 450 CHF patients admitted to a not-for-profit Northern Virginia hospital from July 2014 to December 2017. Data were analyzed using χ 2 and logistic regression. Living arrangements and comorbid chronic renal failure (CRF) were statistically significant predictors of CHF readmissions; all other factors were nonsignificant. Patients who lived with family and those in assisted living facilities were less likely to be readmitted than those who lived alone (odds ratio [OR] = 0.2 and 0.5, respectively). Patients without CRF were less likely to be readmitted than those who had CRF (OR = 0.6). This study contributes data to inform community-based health programs tailored toward frequently readmitted individuals due to CHF exacerbation.

Older persons with multiple chronic conditions' experiences of unplanned readmission: An integrative review

BACKGROUND

As persons, 60 years of age and older live longer, they are more likely to develop one or more chronic conditions. Rising numbers of older persons with multiple chronic conditions (MCCs) will increase the need for home healthcare services and hospital services and unplanned readmissions will increase globally.

AIM

The aim of this integrative review was to explore the experiences of older persons with MCCs' unplanned readmission from home to hospital within 30 days of discharge using an integrative review.

METHOD

Whittemore and Knafl's method was followed to address the research aim. Four databases (Ovid MEDLINE, Scopus, CINAHL and Embase) were searched between 2005 and 2020, suitability for inclusion was assessed, and data were extracted and analysed using content analysis.

RESULTS

Thirteen articles (10 qualitative, one quantitative, and two mixed methods) were included in this review. Three themes emerged from the data that reflected older persons with MCCs' unplanned readmission experiences. These themes included (a) feelings of security, support and relief; (b) undesirable challenges at home (struggling to manage care and balancing support needs); and (c) unpleasant feelings and emotions (feelings of fear and mistrust, feelings of disappointment and loss, feelings of anxiousness and pressure).

CONCLUSION

Research about unplanned readmission to the hospital does not provide sufficient detail or understanding about older persons with MCCs' experiences or their psychosocial experiences. Addressing research gaps related to the psychosocial processes and factors associated with unplanned readmission is needed to expand the current understanding of the process and concept of unplanned readmission.

Instrumental support: A conceptual analysis

The aim of this paper was to use the Walker and Avant method of concept analysis to evaluate the concept of instrumental support in the context of hospital to home care transitions. Findings from this concept analysis suggest three defining attributes of instrumental support: informal support providers, tangible support, and unmet personal needs. Antecedents identified: a strong and supportive social network, an independently functioning adult, an illness resulting in hospitalization, a change in functional status, and the patient being discharged home from the hospital. Consequences of not having adequate instrumental support: unsuccessful recovery at home, increased risk for hospital readmission, decline in physical functioning, health complications, and increased risk of mortality. Empirical referents: patient's report of successful recovery, returning to an independent level of functioning, and the lack of hospital readmission or health complication. A model and a contrary case study were developed to provide examples of clinical cases related to instrumental support. Recommendations related to clinical practice include evaluating the availability/adequacy of instrumental support before hospital discharge and including the identified instrumental support person in the discharge planning process. There are proven benefits of having people within one's social network providing instrumental support during the home recovery period.

Scoping review: Social support impacts hospital readmission rates

AIMS AND OBJECTIVES

To review and synthesise the current literature on social support and hospital readmission rates.

BACKGROUND

Hospital readmission rates have not declined significantly since 2010 despite efforts to identify and implement strategies to reduce readmissions. After discharge, patients often report the need for help at home with personal care, medical care and/or transportation. Social factors can positively or negatively affect the transition from hospital to home and the extended recovery period experienced by patients.

METHODS

Published primary studies in peer-reviewed journals, written in English, assessing the adult medical/surgical population and discussing social support and hospital readmission rates were included. A Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was completed for this scoping review.

RESULTS

The search resulted in 2919 articles. After removing duplicates and reviewing content for the inclusion and exclusion criteria, 23 articles were selected for review. Social support is provided by those within one's social circle. There are several types of social support and depending on the needs to the patient, the type of social required and provided is different.

CONCLUSIONS

The most common form of social support needed at home for people recovering after a hospitalisation was instrumental support, tangible care in the form of assistance with daily personal and medical care, and transportation. Patients who lacked adequate social support after discharge were at an increased risk of hospital readmission.

RELEVANCE TO CLINICAL PRACTICE

Identifying factors, such as social support, that may impact hospital readmission rates is important for quality hospital to home care transitions. Assessing patients' needs and available social support to meet those needs may be an essential part of the discharge planning process to decrease the risk of hospital readmission.

Readmitted Patients With Heart Failure Sick, Tired, and Symptomatic: A Qualitative Descriptive Study From a Quaternary Academic Medical Center

BACKGROUND AND OBJECTIVE

Heart failure (HF) readmissions will continue to grow unless we have a better understanding of why patients with HF are readmitted. Our purpose was to gain an understanding, from the patients' perspective, of how patients with HF viewed their discharge instructions and how they felt when they got home and were then readmitted in less than 30 days.

METHODS AND RESULTS

We used a qualitative descriptive approach using semistructured interviews with 22 patients with HF. Most participants had multimorbidities, were classified as New York Heart Association class III (n = 13) with reduced ejection fraction (n = 20), and were on home inotrope therapy (n = 13). The overarching theme that emerged was that these participants were sick, tired, and symptomatic. Additional categories within this theme highlight discharge instructions as being clear and easily understood; rich descriptions of physical, emotional, and other symptoms leading up to readmission; and reports of daily activities including what "good" and "not good" days looked like. Moreover, when participants experienced an exacerbation of their HF symptoms, they were sick enough to be readmitted to the hospital.

CONCLUSION

Our findings confirm ongoing challenges with a complex group of sick patients with HF, with the majority on home inotropes with reduced ejection fraction, who developed an unavoidable progression of their illness and subsequent hospital readmission.

The Association of Advance Care Planning Documentation and End-of-Life Healthcare Use Among Patients With Multimorbidity

PURPOSE

Multimorbidity is associated with increased intensity of end-of-life healthcare. This association has been examined by number but not type of conditions. Our purpose was to understand how intensity of care is influenced by multimorbidity within specific chronic conditions to provide guidance for interventions to improve end-of-life care for these patients.

METHODS

We identified adults cared for in a multihospital healthcare system who died between 2010-2017. We categorized patients by 4 primary chronic conditions: heart failure, pulmonary disease, renal disease, or dementia. Within each condition, we examined the effect of multimorbidity (presence of 4 or more chronic conditions) on hospital and ICU admission in the last 30 days of life, in-hospital death, and advance care planning (ACP) documentation >30 days before death. We performed logistic regression to estimate associations between multimorbidity and end-of-life care utilization, stratified by the presence or absence of ACP documentation.

RESULTS

ACP documentation >30 days before death was associated with lower odds of in-hospital death for all 4 conditions both in patients with and without multimorbidity. With the exception of patients with renal disease without multimorbidity, we observed lower odds of hospitalization and ICU admission for all patients with ACP >30 days before death.

CONCLUSIONS

Patients with dementia and multimorbidity had the highest odds of high-intensity end-of-life care. For patients with dementia, heart failure, or pulmonary disease, ACP documentation >30 days before death was associated with lower likelihood of in-hospital death, hospitalization, and ICU use at end-of-life, regardless of multimorbidity.

A nurse practitioner-led effort to reduce 30-day heart failure readmissions

BACKGROUND

Heart failure (HF) affects over 6.5 million Americans and is the leading reason for hospital admissions in patients over the age of 65. Readmission rates within 30 days are 21.4% nationally, and 12% of those are likely preventable. Veterans are especially vulnerable to developing cardiac diseases requiring hospitalization and subsequent readmission.

LOCAL PROBLEM

The Southern Arizona Veterans Administration Health Care System has over 5,600 patients diagnosed with HF and a 30-day readmission rate of 21.65%. The aim of this quality improvement project was to reduce 30-day all-cause readmissions by 1% over 8 weeks.

METHODS

To reduce HF readmissions, the plan-do-study-act rapid-cycle method of quality improvement was used.

INTERVENTIONS

A dedicated multidisciplinary HF clinic was formed with a cardiology nurse practitioner, clinical pharmacists, and a dietician. A veteran-centered shared decision-making tool for setting self-care goals was implemented.

RESULTS

The readmission rate of patients seen in the multidisciplinary clinic (n = 33) was reduced by 0.2%. The percentage of veterans seen within 14 days increased from 30% to 54.5%. The average number of days between discharge and cardiology follow-up improved from 45 to 19 days. Veterans were able to set at least one self-care goal 87% of the time. Patient satisfaction with the multidisciplinary clinic was high at 93%.

CONCLUSIONS

Implementing a dedicated, multidisciplinary HF clinic reduced readmissions, improved timeliness of visits, and was well received. Use of a veteran-centered patient engagement tool resulted in more veterans setting self-care goals.

Insights in Public Health: Outpatient Care Gaps for Patients Hospitalized with Ambulatory Care Sensitive Conditions in Hawai'i: Beyond Access and Continuity of Care

Ambulatory care sensitive conditions (ACSCs) are conditions that can generally be managed in community-based healthcare settings, and, if managed well, should not require hospital admission. A 5-year, mixed methods study was recently concluded that (1) documented disparities in hospitalizations for ACSCs in Hawai'i through quantitative analysis of state-wide hospital discharge data; and (2) identified contributing factors for these hospitalizations through patient interviews. This Public Health Insights article provides deeper context for, and consideration of, a striking study finding: the differences between typical measures of access to care and the quality of patient/provider interactions as reported by study participants. The themes that emerged from the patients' stories of their own potentially preventable hospital admissions shed light on the importance of being heard, trust, communication, and health knowledge in their relationships with their providers. We conclude that improving the quality of the relationship and level of engagement between the patient and community/outpatient providers may help reduce hospitalizations for ACSCs in Hawai'i and beyond. These interpersonal-level goals should be supported by systems-level efforts to improve health care delivery and address health disparities.

Preventability of Hospital Readmissions From Skilled Nursing Facilities: A Consumer Perspective

Purpose of the Study

A structured interview was conducted with Medicare patients readmitted to a private, tertiary teaching hospital from skilled nursing facilities (SNFs) to assess their perspectives of readmission preventability and their role in the readmission.

Design and Methods

Data were collected at Vanderbilt University Medical Center using a 6-item interview administered at the bedside to Medicare beneficiaries with unplanned hospital readmissions from 23 SNFs within 60 days of a previous hospital discharge. Mixed analytical methods were applied, including a content analysis that evaluated factors contributing to hospital readmission as perceived by consumers.

Results

Among 208 attempted interviews, 156 were completed, of which 53 (34%) respondents rated their readmission as preventable. 28.3% of the 53 consumers attributed the readmission to hospital factors, 52.8% attributed it to the SNF, and 18.9% believed both sites could have prevented the readmission. The primary driver of the readmission was a family member/caregiver in 31 cases and the patient in 24 of the 156 cases, amounting to 55 (35.3%) consumer-driven readmissions. Contributing factors included: premature hospital discharge (16.3%); poor discharge planning (16.3%); a clinical issue not resolved in the hospital (14.3%); inadequate treatment at the SNF (69.4%); improper medication management at the SNF (20.4%); and poor decision-making regarding the transfer (14.3%).

Conclusions and Implications

Interviewing readmitted patients provides information relevant to reducing readmissions that may otherwise be omitted from hospital and SNF records. Consumers identified quality issues at both the hospital and SNF and perceived themselves as initiating a significant number of readmissions.

Qualitative study of perspectives concerning recent rehospitalisations among a high-risk cohort of veteran patients in Connecticut, USA

OBJECTIVES

Veterans Affairs (VA) patients are at risk for rehospitalisation due to their lower socioeconomic status, older age, poor social support or multiple comorbidities. The study explored inpatients' perceptions about factors contributing to their rehospitalisation and their recommendations to reduce this risk.

DESIGN

Thematic qualitative data analysis of interviews with 18 VA inpatients.

SETTING

VA Connecticut Healthcare System, West Haven Hospital medical inpatient units.

PARTICIPANTS

All were aged 18+ years, rehospitalised within 30 days of most recent discharge, medically stable and competent to provide consent.

MEASUREMENTS

Interviews assessed inpatients' health status after last discharge, reason for rehospitalisation, access to and support from primary care providers (PCP), medication management, home support systems and history of substance use or mental health disorders.

RESULTS

The mean age was 71.6 years (11.1 SD); all were Caucasian, living on limited budgets, and many had serious medical conditions or histories of mental health disorders. Participants considered structural barriers to accessing PCP and limited PCP involvement in medical decision-making as contributing to their rehospitalisation, although most believed that rehospitalisation had been inevitable. Peridischarge themes included beliefs about premature discharge, inadequate understanding of postdischarge plans and insufficiently coordinated postdischarge services. Most highly valued their VA healthcare but recommended increasing PCPs' involvement and reducing structural barriers to accessing primary and specialty care.

CONCLUSIONS

Increased PCP involvement in medical decision-making about rehospitalisation, expanded clinic hours, reduced travel distances, improved communications to patients and their families about predischarge and postdischarge plans and proactive postdischarge outreach to high-risk patients may reduce rehospitalisation risk.

Social and clinical determinants of preferences and their achievement at the end of life: prospective cohort study of older adults receiving palliative care in three countries

Background

Achieving choice is proposed as a quality marker. But little is known about what influences preferences especially among older adults. We aimed to determine and compare, across three countries, factors associated with preferences for place of death and treatment, and actual site of death.

Methods

We recruited adults aged ≥65-years from hospital-based multiprofessional palliative care services in London, Dublin, New York, and followed them for >17 months. All services offered consultation on hospital wards, support for existing clinical teams, outpatient services and received funding from their National Health Service and/or relevant Insurance reimbursements. The New York service additionally had 10 inpatient beds. All worked with and referred patients to local hospices. Face-to-face interviews recorded most and least preferred place of death, treatment goal priorities, demographic and clinical information using validated questionnaires. Multivariable and multilevel analyses assessed associated factors.

Results

One hundred and thirty eight older adults (64 London, 59 Dublin, 15 New York) were recruited, 110 died during follow-up. Home was the most preferred place of death (77/138, 56%) followed by inpatient palliative care/hospice units (22%). Hospital was least preferred (35/138, 25%), followed by nursing home (20%) and home (16%); hospice/palliative care unit was rarely least preferred (4%). Most respondents prioritised improving quality of life, either alone (54%), or equal with life extension (39%); few (3%) chose only life extension. There were no significant differences between countries. Main associates with home preference were: cancer diagnosis (OR 3.72, 95% CI 1.40–9.90) and living with someone (OR 2.19, 1.33–3.62). Adults with non-cancer diagnoses were more likely to prefer palliative care units (OR 2.39, 1.14–5.03). Conversely, functional independence (OR 1.05, 1.04–1.06) and valuing quality of life (OR 3.11, 2.89–3.36) were associated with dying at home. There was a mismatch between preferences and achievements – of 85 people who preferred home or a palliative care unit, 19 (25%) achieved their first preference.

Conclusion

Although home is the most common first preference, it is polarising and for 16% it is the least preferred. Inpatient palliative care unit emerges as the second most preferred place, is rarely least preferred, and yet was often not achieved for those who wanted to die there. Factors affecting stated preferences and met preferences differ. Available services, notably community support and palliative care units, require expansion. Contrasting actual place of death with capacity for meeting patient and family needs may be a better quality indicator than simply ‘achieved preferences’.

Electronic supplementary material

The online version of this article (10.1186/s12877-017-0648-4) contains supplementary material, which is available to authorized users.

Self-Care Among Older Adults With Heart Failure

Background: It is estimated that 5.7 million Americans are living with heart failure (HF) today. Despite the fact that HF is one of the most common reasons people aged 65 years and older are admitted into the hospital, few studies describe the self-care in this older adult population. Purpose: The purpose of the study was to review the current literature on self-care in this population to better understand the influence of selected factors on self-care and health outcomes. Methods: A literature search was completed and resulted in including 28 studies. Results: Multiple factors have been reported as barriers to self-care including depression and presence of peripheral arterial disease. Factors having a positive effect on self-care are male gender, number of cardiologist referrals, and self-efficacy. There were few studies that described the association between cognitive functioning and self-care. There is a lack of strong evidence to support the association between self-care and health outcomes such as readmission rate, but recent studies suggest that a 30-day readmission is not a valid predictor of health outcomes. Implications: The assessment of the psychological factors and health care resource utilization patterns that may influence self-care is recommended. More research that addresses the role of cognitive factors in influencing self-care is needed.

Perceptions of Hospital-Dependent Patients on Their Needs for Hospitalization

In the United States, older adults account for a significant proportion of hospitalizations, and a subset become hospital-dependent, for reasons that are unclear. We conducted a qualitative study to explore these individuals' perspectives on their need for hospitalizations. Twenty patients hospitalized at an academic medical center underwent semistructured qualitative interviews. Criteria for selection included age 65 and older, at least three hospitalizations over six months, admission to the medical service at the time of the study, did not meet criteria for chronic critical illness, was not comfort measures only, and did not have a conservator. Interviews were audiotaped, transcribed, and inductively analyzed. The major themes derived were the necessity and inevitability of hospitalizations ("You have to bring me in here"), feeling safe in the hospital ("It makes me feel more secure"), patients hospitalized despite having outside medical and social support ("I have everything"), and inadequate goals-of-care discussions ("It just doesn't occur to me"). Results suggested that candid discussions about health trajectories are needed to ensure hospitalization is consistent with the patient's realistic health priorities. Journal of Hospital Medicine 2017;12:450-453.

Thirty-Day Inpatient Readmissions for Asian American and Pacific Islander Subgroups Compared With Whites

Asian and Pacific Islander (API) 30-day potentially preventable readmissions (PPRs) are understudied. Hawaii Health Information Corporation data from 2007-2012 statewide adult hospitalizations ( N = 495,910) were used to compare API subgroup and White PPRs. Eight percent of hospitalizations were PPRs. Seventy-two percent of other Pacific Islanders, 60% of Native Hawaiians, and 52% of Whites with a PPR were 18 to 64 years, compared with 22% of Chinese and 21% of Japanese. In multivariable models including payer, hospital, discharge year, residence location, and comorbidity, PPR disparities existed for some API subpopulations 65+ years, including Native Hawaiian men (odds ratio [OR] = 1.14; 95% confidence interval [CI] = 1.04-1.24), Filipino men (OR = 1.19; 95% CI = 1.04-1.38), and other Pacific Islander men (OR = 1.30; 95% CI = 1.19-1.43) and women (OR = 1.23; 95% CI = 1.02-1.51) compared with Whites, while many API groups 18 to 64 years had significantly lower PPR odds. Distinct PPR characteristics across API subpopulations and age groups can inform policy and practice. Further research should determine why elderly API have higher PPR rates, while nonelderly rates are lower.

Pathways to potentially preventable hospitalizations for diabetes and heart failure: a qualitative analysis of patient perspectives

BACKGROUND

Potentially preventable hospitalizations (PPH) for heart failure (HF) and diabetes mellitus (DM) cost the United States over $14 billion annually. Studies about PPH typically lack patient perspectives, especially across diverse racial/ethnic groups with known PPH health disparities.

METHODS

English-speaking individuals with a HF or DM-related PPH (n = 90) at the largest hospital in Hawai'i completed an in-person interview, including open-ended questions on precipitating factors to their PPH. Using the framework approach, two independent coders identified patient-reported factors and pathways to their PPH.

RESULTS

Seventy-two percent of respondents were under 65 years, 30 % were female, 90 % had health insurance, and 66 % had previously been hospitalized for the same problem. Patients' stories identified immediate, precipitating, and underlying reasons for the admission. Underlying background factors were critical to understanding why patients had the acute problems necessitating their hospitalizations. Six, non-exclusive, underlying factors included: extreme social vulnerability (e.g., homeless, poverty, no social support, reported by 54 % of respondents); health system interaction issues (e.g., poor communication with providers, 44 %); limited health-related knowledge (42 %); behavioral health issues (e.g., substance abuse, mental illness, 36 %); denial of illness (27 %); and practical problems (e.g., too busy, 6 %). From these findings, we developed a model to understand an individual's pathways to a PPH through immediate, precipitating, and underlying factors, which could help identify potential intervention foci. We demonstrate the model's utility using five examples.

CONCLUSIONS

In a young, predominately insured population, factors well outside the traditional purview of the hospital, or even clinical medicine, critically influenced many PPH. Patient perspectives were vital to understanding this issue. Innovative partnerships and policies should address these issues, including linkages to social services and behavioral health.

Improving Heart Failure Outcomes in Ambulatory and Community Care: A Scoping Study

Despite a large body of literature testing interventions to improve heart failure care, care is often suboptimal. This scoping study assesses organizational interventions to improve heart failure outcomes in ambulatory settings. Fifty-two studies and systematic reviews assessing multicomponent, self-management support, and eHealth interventions were included. Studies dating from the 1990s demonstrated that multicomponent interventions could reduce hospitalizations, readmissions, mortality, and costs and improve quality of life. Self-management support appeared more effective when included in multicomponent interventions. The independent contribution of eHealth interventions remains unclear. No studies addressed management of comorbidities, geriatric syndromes, frailty, or end of life care. Few studies addressed risk stratification or vulnerable populations. Limited reporting about intervention components, implementation methods, and fidelity presents challenges in adapting this literature to scale interventions. The use of standardized reporting guidelines and study designs that produce more contextual evidence would better enable application of this work in health system redesign.

From discharge to readmission: Understanding the process from the patient perspective

BACKGROUND

Patient engagement is critical in delivering high-quality care. However, literature investigating patient perspectives on readmissions is lacking.

OBJECTIVES

To understand patients' beliefs and attitudes about 30-day readmissions and to elucidate areas for improvement aimed at reducing readmissions.

DESIGN

In person survey.

SETTING

Academic medical center and affiliated community hospital.

PATIENTS

Patients with 30-day readmissions to medicine and cardiology services.

MEASUREMENTS

Patient readiness, attitudes toward readmissions, discharge instructions, ambulatory resources, and follow-up care.

RESULTS

Of 479 eligible patients approached for interviews, 230 (48%) were interviewed. Of these, 28% reported not feeling ready for discharge, and this correlated with inadequate symptom resolution, poor pain control, and concerns about self-care. Sixty-five percent remembered reviewing discharge paperwork, but over 22% could not identify critical information on this paperwork. Eighty-five percent reported having a primary doctor; however, only 56% of patients who received a contact number on discharge called a physician before returning to the hospital. One-third of patients knew where to obtain same-day care outside of the emergency room. Lastly, patients reported feeling more relieved than burdened upon readmission (7.7 [standard deviation {SD} 2.8) vs 5.9 [SD 3.4]; P < 0.001, scale of 1-10).

CONCLUSIONS

By engaging readmitted patients we have illuminated areas for future interventions, including better symptom management and self-care planning before discharge, more clarity in discharge instructions, promoting awareness of outpatient resources, and improved alignment of patient and provider attitudes about readmissions. As the United States strives to reduce readmissions, attending to the patient perspective is critical in informing appropriate avenues for quality improvement. Journal of Hospital Medicine 2016;11:407-412. © 2016 Society of Hospital Medicine.