The prodding by the Centers for Medicare and Medicare Services for hospitals to reduce their 30-day hospital readmission rates is by now nothing new. Hospitals continue to work on projects to keep patients out of the hospital safely and to avoid financial penalties for higher-than-expected readmissions for a growing number of conditions.

But while the quantity of hard data about readmissions continues to grow, less attention has been paid to a more vexing question: why do some patients frequently return to the hospital soon after discharge?

A paper recently accepted for publication by the Journal for Healthcare Quality suggests some answers. The authors, several of whom are faculty of the University of Colorado School of Medicine (see box 1), did not turn to computers or databases for sources. Instead, they went to the bedside to talk to the patients themselves.

“If we want to get to the bottom of why they come back to the hospital, we thought, ‘Why don’t we ask them?’” said Greg Misky, MD, a study co-author and hospitalist at UCH.

The paper draws on interviews of 18 patients – two of them uninsured, the rest covered by Medicaid – readmitted within 30 days of their previous discharge to UCHealth University of Colorado Hospital and Denver Health. The interviews, conducted by professional research assistants between February 2014 and January 2015, focused on eliciting from patients the stories of their care – what happened during previous hospitalizations, what happened at home after their discharge, what led to their readmission, what might have prevented it, and their health care experiences outside the hospital.

Root causes

The patients’ responses revealed five “themes” that contributed to patients coming back to the hospital (see box 2). Rather than pinning the readmissions solely to a refusal to adhere to their plans of care or indifference to their health, the authors concluded that unstable social situations and “health system failures” played major roles. They call for strengthening trust between patients and providers and encouraging patients to share in the decisions that affect their health.

A common theme was what the authors called “therapeutic misalignment” – a perception of patients that providers don’t always share their goals.

“All I want is a doctor that will listen to me and a nurse that will come in and talk to you…like you’re human,” one related. “Doctors need to understand that patients also know what’s wrong with them, and they know a little bit more about how to fix it,” another asserted. A third stated, “I would like to have a patient-doctor relationship with them, and I would like for him to listen to me, and listen to what I’m saying.”

“Their words are telling us where the problems are,” Misky said. “Reducing 30-day readmission rates shouldn’t be the be-all and end-all of what we do. We need to lessen the likelihood that patients fail.”

He readily acknowledged that the patients interviewed sometimes made bad decisions about their care and at times lacked accountability. They spoke bluntly of alcoholism, not asking about the reasons for taking their medications and outright ignoring medical advice. But the interviews frequently showed that “social fragility” played an important role in their declining health, Misky noted.

“They often have competing priorities,” he said, including holding on to their jobs or meeting their families’ other basic needs. Many struggle with living conditions that make it difficult to manage diseases like COPD, diabetes or heart failure. Lack of transportation, poor access to primary care and difficulties with basic health literacy also combine to hamper their efforts to stay well at the same time that they frustrate providers.

“As providers, we live in a different world than these patients,” Misky said. “Unless we walk in their shoes, we can’t envision how hard it is for them to succeed.”

Doctor disconnect

Yet Misky and his colleagues say that too often clinicians address their patients from across a perceptual divide created by notions of authority.

“Traditionally, providers are trained around a disease-centric focus with inherent expectations that patients should adopt our treatment plan,” they write.

In addition, they note that while coordinating care between and among providers is important, it’s not an end in itself, nor is it necessarily effective in improving patients’ health.

“Solutions must go beyond a discharge checklist or timely communication with an outpatient provider,” they assert.

As Misky elaborated, “Patients have lives, and the question is where does health care live within those complicated lives?” In tapping the patient perspective, he added, he and his colleagues hope to increase physician awareness of the practical problems they face – a frequent one being difficulty finding a place to live.

“There is no possibility of help from social workers, community health workers, home visits, or behavioral health counselors without access to housing,” Misky said.

The study points to a fundamental challenge for the health care system if it is to better serve people of low socioeconomic status. On the one hand, they would benefit from ready access to primary care, integrated with specialty and behavioral health care. On the other, they frequently reside in areas with shortages of the very services they need and difficulties getting to the ones that are available. That problem is often complicated by difficulty navigating the health care system, which in turn can lead to distrust of the providers whose job it is to help them.

Tools in place

The authors don’t purport to solve problems of access, although they point to the need for hospitals to form partnerships with community health workers as one solution. That approach produced encouraging results at UCH when it partnered with Aurora’s Metro Community Provider Network (MCPN), a nonprofit community health center, in the Bridges to Care (B2C) initiative. The project received strong support from UCH and School of Medicine leadership, notably Jennifer Wiler, MD, MBA, an associate professor and executive vice chair of the CU Department of Emergency Medicine.

Initially funded with a three-year federal grant, B2C identified patients frequently admitted to the emergency department and the hospital and connected those who agreed to a 60-day program, during which health care coaches and coordinators identified barriers to care, helped them learn skills to manage their health, and connected them to needed services. The project helped to decrease the number of ED visits and hospitalizations among B2C graduates significantly.

The grant ended in June 2015, but B2C continues, and UCH and MCPN continue to share the cost of a patient-resident liaison/community health care liaison: Randie Weiss, whose home base is the Emergency Department at UCH. Weiss is among a team of providers working with patients whose medical issues are complicated by social barriers, behavioral health issues, and addiction. Roberta Capp, MD, an assistant professor of Emergency Medicine at CU, directs ED Care Transitions, which aims to help patients gain access to services that meet not only their medical, but also their social needs.

Weiss concentrates on patients who have made at least three visits to UCH’s ED or have been frequently hospitalized within the past six months. She completes a screening to identify their needs and help to connect them with additional support and services. She pre-enrolls those who agree to it in the B2C program, where an MCPN care coordinator evaluates their situation and works to help them find resources and strengthen their ability to manage their own care.

Nurse case managers work with patients in the ED to get them home health care, home-based physical and occupation therapy and other services that can help them avoid admission to the hospital, Weiss added. The case managers also help to place patients in skilled nursing, acute and sub-acute rehab facilities, a guard against future readmissions, she said.

Help for underserved patients also comes from “patient champions” in the ED and case managers who work with patients on the hospital’s inpatient units and with those enrolled in Colorado Access, the health plan that covers Colorado’s Medicaid patients, Weiss noted.

All of this work is important, but it is just one piece of a puzzle that requires coupling clinical resources with recognition of the social barriers that make it difficult for many patients to make the most effective use of them, Misky said.

“We need more formal care coordination and expanded case management that is specific for these folks,” he said. “But we also need to be better in tune with their issues.”

Study authors

• Gregory J. Misky, MD (first author)
• Robert E. Burke, MD, MS
• Teresa Johnson, BA
• Amira del Pino-Jones, MD
• Janice L. Hanson, PhD, EdS
• Mark B. Reid, MD

Five themes contributing to readmissions

• Therapeutic misalignment, described as patients’ “compromised trust in their providers, care team and healthy system, often related to imperfect communication”
• Accountability (of patients for managing their own health)
• Social fragility
• Access failures
• Disease behavior (the progression of a disease after discharge)