Following is the full conversation of Episode 1 of the Hospital Readmissions Reduction Podcast.
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|Michael: Welcome to the Hospital Readmission Reduction podcast, brought to you by BESLER Consulting. This is the podcast for hospital leaders seeking insights and strategies they need, to help reduce readmissions at their organizations. I’m Mike Passanante, your host for this podcast. And today’s topic is the role of communications in reducing hospital readmissions. We communicate all day long in our daily lives and it’s perhaps nowhere more important than when we’re leaving the hospital. To help us talk through that topic and understand more about it, we’re joined by Dr. Edward Niewiadomski. Doctor Ed has over three decades of experience in direct patient care and health care administration. He is the former Senior Vice President of Medical Affairs and Chief Medical Officer for a community acute care facility in New Jersey. Welcome, Doctor Ed.|
|Dr. Niewiadomski: Thank you, Michael. I’m very happy to be here this afternoon.|
|Michael: As I mentioned in our opener, communication plays a huge role in our lives. Can you talk to us a little bit about how it plays a role in reducing readmissions?|
|Dr. Niewiadomski: Yes. You were spot on in identifying communication as a real, very significant factor in reducing unplanned readmissions. We look at a patient upon discharge to enhance that communication and make sure they understand discharge instructions. Actually, communication with the patient and their families starts on day one of the admission. The patients and their families need to know what’s going on with their medical condition, what symptoms we’re looking for, and looking to when we give an intervention – for example, a diuretic or something along those lines – they know what to expect, and the patient will then have a better understanding. And once they have a better understanding of what is going on with their health issues, then they’re more apt to remember and able to impact outcomes for themselves upon discharge.|
|Michael: Let’s break this down a little bit. There’s different types of communication you can have in a hospital setting. Could you talk to us a little bit about written communication and how that affects readmissions?|
|Dr. Niewiadomski: Written communication is very important. There’s a discharge form that’s given to the patient, but written communication is much more than just a form that’s given to a patient. Written communication, not only between care providers and patients, but also among the care providers, is very important. I can tell you plenty of times when I took a few extra moments and actually read the nurse’s notes on what transpired with the patient, not only at the moment but in the day or that night or yesterday after I made rounds. It really sheds a lot of light on how the patient’s doing. Looking not only at nurses’ notes, but also other consultants’ notes, and taking into account what is happening with the patient on an ongoing basis. Another area to look at is look at the case managers. These case managers are very involved in the care of a patient and what’s happening on a day-to-day basis, and looking at the progress of care throughout the current episode – very, very important. It’s a very dynamic process and as much information you can get from reading what others have written in the medical record is very important.|
|Michael: Let’s put our focus on the patient and the family for just a minute. Talking about discharge plans, medication reconciliation, patient education – all these aspects – can you just expand on the role that those elements play and how you put together a comprehensive program that addresses that?|
|Dr. Niewiadomski: I think this topic really lends itself to the discharge process and the post-discharge period. Patients need to have an understanding of – first and foremost – what their diagnoses are, number one. Number two, just as important is an understanding of their current interventions, their current medications. Many studies have proven that when a nurse reviews a patient’s medication list – how to take it and why they’re taking it – there is much higher compliance along the way. The communication with the patient at that moment during discharge is very important. Also, making sure that you communicate to the patient what to look for, what symptoms to look for. For example, in heart failure patients, if they get a little more short of breath with minimal exertion. If they have a weight gain. If they see their ankles starting to swell. Those types of things, they need to be aware of these symptoms and need to address those symptoms immediately with either their primary care physician or with a nurse as soon as possible. An intervention could be administered immediately, and would then prevent a trip back to the emergency room and a subsequent readmission.|
|Michael: Staying with patients and families, for a minute. You’ve had an opportunity in your career, I’m sure, to talk with and discharge many patients from the hospital. Can you tell us some of the techniques that you found helpful in communicating discharge orders, or other things that patients might need to know when they’re leaving the hospital?|
|Dr. Niewiadomski: A couple of things come to mind. Number one, traditionally we have always left it up to the patients if they needed, say, a follow-up chest x-ray or a follow-up imaging study, we give them a phone number – it’s usually a 1-800 number – back to the hospital, “Call this number and we’ll set up an appointment to have a repeat chest x-ray done.” A lot of times, it doesn’t happen. Or they need to have a follow-up appointment, we need to have a lab test. Prior to discharge, if there are other studies that need to done in the post discharge period, we should have the patient leave the hospital with a specific date, time, and day of the week when they are to return back for that particular study. That is the number one way to make sure that that patient will have access back to the hospital for the imaging study.
Also, we have to make sure and talk about other social issues. For example, is transportation a problem? Do they have someone to drive them or can access public transportation? So knowing these things about the patient and where they’re being discharged to, can make sure that, again, we can reduce a readmission.
One other aspect is that we are now, as length-of-stay shrinks and is measured in two or three days versus weeks in years past, we need to make sure that all the lab studies and imaging studies that were done for the patient, we have the results or we’ll get the results even in the post-discharge period. We can avoid a readmission if a set of electrolytes comes back, for example. We know a patient is on diuretics, potassium, which is done the morning of the patient is discharged, maybe 3.1. Now, that’s not a critical value but if it goes unaddressed, the next time we look at it, it may drift down to 2.4 or 2.1 – then that now starts leading into a critical level which will then warrant a trip back to the emergency room, and again a readmission. So getting these results compiled and making sure we follow-up with test results back to the patient, even after discharge, is very critical.
|Michael: Beyond discharge, let’s just expand the conversation and talk about the whole care continuum. Because you have a patient arriving at the ED, they’re admitted, they undergo care. And then eventually, hopefully, they’re discharged. So how does a communication affect that entire care continuum?|
|Dr. Niewiadomski: Well, again, making sure the patient and the patient’s family has a plan in place that’s communicated very clearly with the patient and the family. And while we’re communicating that discharge plan and making sure they have access to care, access to their primary care physician for a follow-up visit or the medical clinic for a follow-up visit, we have to look at certain barriers that may be playing a role in – even though we might be saying the right things, we may be providing the right care plan in post discharge period – there may be barriers where the patient or the patient’s family may not have a good clear cut understanding.
Number one on the list is certainly a language barrier. We take care of patients that are from many different backgrounds today. We have to make sure that what we’re saying is what the patient is taking home, the message is clearly understood. We have to examine other socio-economic issues. Again, they have access to their medications, they have the ability to pay for their medications, they have the ability for transportation issues – all these things become clearly paramount in the post-discharge arena.
Patients and their families need to walk away from the hospital, from that discharge period, with a clear cut understanding of what the expectations are in the next one to five days post-discharge, or they can get into trouble very quickly. What we actually see in some of our readmission analytics, that from day of discharge to readmission for heart failure patients, it happen very quickly. That can happen anywhere between one and seven days in the post-discharge.
|Michael: So let’s just flip the coin and talk about caregivers for a minute, and how they can improve their communication amongst each other. So thinking about the medical record, what is available in the medical record that would help caregivers understand the best way to communicate with a patient?|
|Dr. Niewiadomski: Getting a medical record completed in a timely way, is very important. Certainly the history in physicals and consultant’s notes and such are done timely. Those reports should be transcribed and available in the electronic medical record. One item that seems to take a long time, and actually in New Jersey, we give our physicians 30 days to do a discharge summary.
If I had a patient coming back to my office that was just recently discharged from the hospital and if I don’t have a discharge summary, I may not know what transpired with that patient during that episode of care. And I say that for the very reason that most physicians, especially primary care docs, are turning the care of their patients over to a hospitalist group. And so we may not be there at the hospital every day looking and following the care of our patients. So to have these discharge summaries and all the reports available for the medical record, available to us in that post discharge follow-up visit is very important. And with those, if we have those readily available, that will make for a very productive follow-up visit with our patients.
|Michael: Looking inwardly as a physician, what do you think that other physicians and caregivers can do to improve their own communications with patients – either with style or beyond the substance itself – how do you think they can improve?|
|Dr. Niewiadomski: I think you look at some of the dimensions of performance. Certainly number one is the timeliness of completion of certain documents: consultative reports, history of physicals, and discharge summary is critical. That’s number one. But I think if you look along the entire continuum of care, the number one factor – and certainly I can refer back to my years as chief medical officer when I had to get involved in a particular case – invariably, the number one reason why there’s a problem that arises with a patient, the patient’s family, and the clinical team, is not because the improper care was being delivered or the wrong medication was being prescribed – it was essentially that there was a lack of communication of what was going on. And not only a lack of communication between the caregiver and the family or the caregiver and the patient, but among the caregivers.
And one thing I would caution the clinical team to be always aware of, is that we have many consultants on a case that interface with patients and their families. We want to make sure that we’re providing them a common and consistent theme, where one physician can’t say, “We may discharge tomorrow,” but the attending says, “We’re thinking maybe discharge in two days from now or even today.” So we have to have a constant and thorough message among the caregivers to the family and the patient. That can only lead to confusion, and actually the family may start looking at the clinical team with some concern that no one really knows what’s going on with my Mom or my wife or my husband, that type of thing. So we really need to have a constant message being delivered to the family by all the caregivers involved.
|Michael: If you had to leave our audience with one piece of advice as to how they can strengthen communication as a tool in their facility, what would you tell them?|
|Dr. Niewiadomski: I would say, whatever you’re thinking, make sure you document the medical record. If you’re a consultant, make sure you not only document it but convey that verbally back to the attending staff. Make sure that before we give any messages to the family, it’s the message that the entire team wants to impart to the patient and their family, not just a particular view that you may have. Make sure the clinical team is working from one playbook, rather than several.|
|Michael: That makes a lot of sense. Thanks again for coming in today. I think we’ve all once again learned a lot, and certainly appreciate your time.|
|Dr. Niewiadomski: Thank you, Michael.|