How to Stay Out After You Get Out

The last thing anyone wants after spending time in the hospital is a return trip… yet almost one in five Medicare patients who are discharged from a hospital will be back within the month, according to a recent New England Journal of Medicine (NEJM) study. For patients with heart failure, it’s even higher — the readmission rate is about one in four.

Why are these numbers so high, and is there anything patients and family members can do to prevent this from happening? I called Eric Howell, MD, associate professor of medicine at Johns Hopkins University School of Medicine and chief, division of hospital medicine at Johns Hopkins Bayview Medical Center, to ask for advice. Dr. Howell is himself a hospitalist (a physician who specializes in the care of hospital patients), so he has much to say about this problem and how to prevent it from happening.

First of all, he pointed out that some repeat visits are inevitable simply because some patients are quite sick. “Patients with chronic diseases, such as heart failure, diabetes, renal failure or chronic obstructive pulmonary disease (COPD), are vulnerable to emergency situations which, in turn, can lead to readmission even with the best care,” he noted.

Preventable Causes of Readmission

Dr. Howell identified several reasons why readmissions often happen and shared advice on what patients (and their loved ones) can do to reduce the likelihood of landing back in the hospital…

Transition plan. A key contributor to the problem of frequent readmissions, in Dr. Howell’s opinion, is inadequate preparation for the patient’s transition from hospital to home. “Patients typically spend about a half-hour with a doctor on the day of discharge,” says Dr. Howell. “But it takes much longer than that for patients to learn how to take care of themselves after a complicated hospital stay, particularly one that is shorter than it used to be, as is the case with many hospitalizations.”
What to do: Patients being discharged should understand their medical condition, the related test results, and what they need to do to manage their illness or recovery. Make sure you clearly understand how to take a new prescription, including how to adjust dosages if necessary. Get detailed written instructions on how to carefully monitor aspects of your condition — for instance, heart failure patients are told to weigh themselves daily and to call the doctor if there is a significant change, because this is a sign of trouble.

Confusion at home. With limited guidance before leaving the hospital, it’s common for patients to feel overwhelmed once they get home, most especially those who live independently without others around to remind them what to do. This can lead to mixing up or missing doses of medicines… forgetting specific instructions… problems caring for surgical wounds… and difficulty in performing the prescribed exercises to prevent pneumonia or to speed healing. Also, patients may not recognize early symptoms that should trigger a call to the doctor, so that minor problems don’t become major ones.
What to do: If possible, someone else (a friend or family member) should be with you during the discharge discussion to take notes and help you remember the instructions.

Who’s in charge? Another issue is that patients don’t always know which doctor should be called if a problem arises when they are at home. Since many hospital patients are admitted through the emergency room, it’s not unusual that your primary-care physician (and not everyone even has one) wouldn’t know you were in the hospital at all. Then, given the increasing reliance upon hospitalists to oversee in-patient care, your personal doctor may or may not have been involved during your hospital stay. So, Dr. Howell says, you can’t just assume that your doctor has been updated with your latest information or discharge instructions.
What to do: When you return home, call your doctor, at minimum. Better yet, schedule a visit so he/she can take over your care. Dr. Howell strongly suggests asking your hospitalist to contact your doctor when you are discharged to open up communication and share information about your condition and treatment. “When doctors communicate, there are fewer errors and less likelihood the patient will need to be readmitted to the hospital,” notes Dr. Howell.

The Empowered Patient: Take Responsibility

It is less likely that you will have to head back to the hospital if you take steps at the time of discharge to learn how to manage your own care. Dr. Howell provided this checklist of proactive patient steps to facilitate a safe and healthy transition from hospital to home…

From your discharging doctor (or nurse)…

  • Get a clear and complete explanation of what is wrong… a list of medications you need to take and their dosage instructions, along with information on why each one is important… and details of all other aspects of your care at home, including what you should eat, how wounds should be dressed and so on.
  • Ask the hospitalist whether he/she has spoken to your primary-care physician — if not, request that this be done.
  • Ask about signs and symptoms you should be on the lookout for… learn which ones require a call to the doctor… and find out which doctor you should call (the hospitalist or your personal physician) if a problem does arise.
  • Make sure you get copies of your discharge summary and your medical records, both of which you then can take to your own doctor at your next visit. (While the hospital will send the discharge summary to your doctor, this can take 30 days — which can be too long.)

Once home, make an appointment with your own doctor to follow up. Bring all related paperwork, along with the name of the hospitalist who discharged you who can provide more information on your condition and treatment, if that turns out to be necessary. The more information everyone (including you) on your health-care team has, the better off you will be.