The fall and the rise

Prodded by my anecdotal experience of patient readmissions from skilled nursing facilities and a literature demonstrating a large percentage of cost variability in post hospital care I have increasingly focused on care transitions

Successful ‘recovery’ may be reduce to two considerations, the fall – how patient’s initial vitality is impacted by the point on the continuum of disease severity in which they seek care as well as the efficacy and efficiency of their treatment; and the rise – the period after effective treatment is complete and we seek to restore their initial or improved status. Vitality goes by many names and measures, frailty, activities of daily living (ADL), exercise tolerance. We can measure co-morbidities but there is little to do in the short term to change them. The frail cannot be improved upon in the ED.

Severity of illness frames efficiency and efficacy. Preventative care and screening provides long-term benefit but cannot improve the presentation upon admission. Efficiency is the time required to diagnose and initiate appropriate care will in term frame efficacy. That is, in part, why the large effort at initial antibiotic management of pneumonia or door to needle time for tPa, or time to catheterization for myocardial infarctions. Efficacy is the physical demands of therapy. The patient with CHF diagnosed as pneumonia, or vice versa, who waits 24-36 hours for appropriate care has a more exhausting, less efficacious, treatment experience than the patient immediately started on appropriate care. The septic patient that waits a day or so for an abscess to be identified and drained or antibiotics to be more targeted, has a more exhausting experience than the same patient identified and managed in the ED. Efficacy is difficult to quantify because the delays in diagnosis or management may be overshadowed by appropriate care itself. Six weeks of a nephrotoxic antibiotic is unchanged by a 24-hour delay in initiating therapy. While we can identify and measure aspects of our fall, they are essentially little changed by our actions and their combination determines the patient’s functional abilities at the time of transition.

Three factors affect recovery - the rise - post hospitalization; social networks, income and educational status. Social networks augment care after hospitalization. Married patients with a helping spouse do best, single patients with the relatively broad social networks, predominantly women, are next and patients with sparse networks, predominantly males, do the worst. Patient needs may overwhelm their social network, because their spouse is frail, the child distant, there is no transportation them to appointments, or no one is comfortable assisting in their care. But this just serves to emphasize the primacy of a social network in recovery.

Strategic substitution for sparse or inadequate social networks support recovery and prevent readmission. Acute rehabilitation and skilled nursing facilities are, short and long-term substitutes respectively, for social networks. Home health care is a substitute available at a lower cost to society but at greater cost to the patient and family.

Educational level supports the ability to navigate bureaucratic systems and avail yourself of services. Discharge planners and nurse navigators are successful substitutes and adjuncts for educational deficiencies. These dedicated and largely unrecognized and under appreciated professionals have made great strides in navigating placement activities. But monitoring subsequent compliance with transitional plans is outside of their scope.

The mending and reinforcement of a patient’s social network is a long-term concern involving more than issues of healthcare. The patient’s social network is another immutable ‘given’ and substitutes require funding. What are missing are measures of how well we choose the right substitutes and how well those substitutes work. This undertaking is further complicated because failures in this arena accrue to the hospital, not the physician and we rarely are explicitly aware of the functional recovery of our patients over time. Amputation of a limb without readmission but with no functional recovery is a failure not a success. Exacerbation of COPD resulting in a homebound patient without readmissions is a near miss, not a success. We will not be able to control the costs of these near misses and failures until we acknowledge them and connect care over time. This may be the promise as well as the challenge of bundled care and payment reform.