Lack of Follow-Up as a Major Reason for Readmission

When a patient is admitted to the hospital the issue to tackle is not necessarily only the immediate course of evaluation and treatment, but to also address what lies ahead of the initial admittance. The lack of follow-up care post hospital discharge is a matter of contention within the United States healthcare system and a direct causation of high readmittance rates (Jackson et al., 2015). Post hospital discharge, patients often encounter issues amidst recovery that cause them to be readmitted to the hospital. Statistically speaking, one in five patients with an initial admittance to a hospital make a repeat visit and around 30% of revisits are made over the course of a month (Van Walraven et al., 2004). Additionally, one-half of patients readmitted within 30 days of hospital discharge do not have nor have had follow-up care before their readmission to the hospital (Jackson et al., 2015).

Hospital readmissions are costly and increasingly common and the issues that patients encounter post discharge in most cases can be properly evaluated and minimized by an office visit to a primary care provider or by a follow up from the emergency room (ER) physician. High readmission rates has significant costs for both hospitals and the patients and continuity of care and mandated clinical follow up care are keys to preventing and narrowing unnecessary hospital readmissions in addition to improving the continuity and excellence of care each patient receives. Hospital readmissions are associated with unfavorable patient outcome however, it can also affect the financial health of the hospitals and the insurance companies. The Medicare beneficiaries which include the elderly have high rates of hospital readmissions and have the highest hospital spending on readmissions (Andreasen et al., 2015). Hospital readmissions cost Medicare $26 billion annually and about $17 billion is spent on preventable readmissions. These high costs can be easily avoided by a follow up from the ER physician or the primary care provider. However, the lack of follow up in the US health care system is due to lack of clarity on who is responsible for the follow up and there is no actual guideline for doctors to abide by in regards to follow up (Callen et al., 2015).

Lack of follow up can have major consequences for the quality of care and can have suboptimal patient outcomes. Patients do not have the adequate knowledge about their health and self-care. After hospital discharge, patients tend to fail to follow up and lack to adhere to post discharge instructions which subsequently leads to poor health outcomes and readmission. Many patients do not have a follow up appointment after discharge and have the confusion that whether the primary care provider or the ER physician is in charge for their follow up care. Another factor that leads to patients’ lack of follow up is not scheduling an appointment due to the patients’ limited knowledge about their health and many perceive returning to emergency department as an easier and more efficient way. There are also many barriers that are associated with patients’ lack of follow up and keeping their appointment. These barriers include transportations issues, lack of health insurance, commitment to work, not being able to get an appointment and co-payments (Misky et al., 2010). Due to patients’ limited knowledge about their health and the importance of follow up, the physicians and hospitals should be responsible to implement follow up care with the patients.

Hospitals and doctors ethically and professionally are devoted to provide the best care for the patients. However, they do not have any form of incentive to reduce readmission and consequently reduction in readmissions might cost them and lead to loss of revenue (revenue loss). Hospitals receive payments from insurances through inpatient prospective payment system, in which they receive a fixed payment per inpatient admission and diagnosis (James, 2013). Additionally, hospitals do not receive any reimbursements from the insurances for the costs of post-discharge follow up and interventions. Therefore, hospitals do not have any form of financial incentive to implement strategies to reduce the hospital readmissions. Moreover, the ER physicians do not have any form of obligation to follow up with the patients after discharge.

According to a survey conducted by myself, Ramina Bagheri, the results suggested that out of 25 individuals, 72% (18 out of 25) of the participants never received a follow up care after the discharge, but rather only received a recommendation from the ER physician to follow up with other primary care providers. Further questions from the survey provided insight that 44% (11 out of 25) individuals returned into ER after their initial visit.

The transition from inpatient to outpatient is a critical in stage of recovery and primary care providers play a significant role during this period. In emergency departments, patients are often treated by a physician other than their regular primary care provider and after their initial visit patients tend to lack timely follow up with their primary care provider. Without a consult with their primary care provider this can result in recurrent admissions to the hospital. According to a study done in 2010, the results showed that about 33% of the patients did not abide by the ER physician’s recommendations to follow up with their primary care provider (Misky, 2010).

Another issue that arises within healthcare and is linked to lack of follow up care is the lack of continuity and coordination of care between ER physicians and primary care providers. Poor transfer of information and delayed communication between the hospital physician and the primary doctor is prominent in the United States Healthcare system (Mageean, 1998). These limitations makes it difficult for the primary care provider to find access to patient’s records and information’s which can lead to misdiagnosis. Without sufficient communication between the initial ER physician and the primary care provider, illnesses are left to progressed and individuals are not fully treated for the medical condition they presented to the emergency department.

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Reducing hospital readmissions is a current priority for the health care system in the United States, however, reducing hospital readmissions are complex and not straightforward. New interventions by both the policy makers and the hospitals are needed to tackle this issue and to reduce the costs and to improve the quality of care received by the patients. Policy makers should implement a new policy that imposes a financial penalty on hospitals with high rates of readmissions. Implementation of this policy, allows hospitals to employ new and clever strategies to reduce the preventable hospital readmissions and to provide a better care for the patient.

A study done by the Yale University, offers some strategies and suggestions that hospitals can employ to reduce the readmission rates. These strategies include “partnering with community physicians, partnering with local hospitals, having nurses reconcile medications, arranging follow-up appointments prior to discharge, sending discharge papers to patients' primary care provider and assigning staff to follow up on test results after discharge” (Bradley et al., 2012). These strategies are relatively inexpensive and simple however they need greater collaboration from other parties as well.

According to Dr. Emily Rose, Emergency medicine doctor and chief resident at Los Angeles County/USC medical center, team approach and holistic care is the most effective way and much more is needed to implement which is beyond the hospitals boundaries. She also added that the focus of healthcare has never been on educating the patients and there are many factors that affect the patients well-being which are often overlooked. Interventions such as targeting health education, accessibility to resources, reducing barriers and educating about the consequences of the lack of follow up (Gust et al., 2011). These strategies are important to empower the patients to have responsibility for their care and are needed to improve adherence to follow up.

There are many modifiable factors that are associated with poor outcomes that keeps surfacing when the care is handed from the ER physician to the primary care provider. Coordination of care is one significant factor which can improve the quality of patient care. Direct coordination and management of care after discharge can improve continuity of care and information. To implement coordination of care, hospitals should immediately send the patient information and diagnosis to their primary care provider after discharge and require patients to make a follow up appointment with their primary care provider. However, the issue that arises is that patients tend to miss their follow up apportionments and statistically speaking only half of the patients show up to their follow-up appointment (Breathett et al., 2017). To mitigate this issue, hospitals and primary care providers should work as a team to reduce the barriers to follow up for the patients and by offering new strategies for follow up. These new strategies include, offering appointment at patient’s home, videocall appointments, telemedicine and providing transportation. Prioritization of follow up care after hospital discharge among hospitals and primary care providers is necessary.

There are many ways to tackle this multifaceted issue within the health care system, which not only include work done by ER physicians and primary care providers but insurance companies should be included as well. Insurance companies should have the authority to require essential follow up care appointments with the primary care provider post hospital discharge by mandating follow up appointments. Mandatory follow up appointments can impact the high readmittance rates significantly and can improve the quality of care received by the patient. Mandatory follow up appointments would be necessary in orders for insurance companies to insure and cover the costs of initial hospital visit. Criteria in regards to post discharge follow up appointment should be based on patients status and needs. The “one-size-fits-all” discharge protocol that is currently being implemented in the healthcare system should be removed and follow up should be based on patient’s needs and condition. However, mandated follow up appointment arises logistical issues concerning uninsured patients and their ability, or inability to access a primary care provider for follow-up care would undoubtedly arise (Jackson et al., 2015). Accordingly, the responsibility would then fall on the hospital itself to help such patients secure needed follow-up care. If patients are required to schedule follow-up appointments with a primary care provider concerning the reason(s) for their initial admittance and to follow-up on treatment progress, the number of hospital readmittances would greatly reduce in number. This reduction in remittances would be combined with increasingly efficient and thorough medical care and treatment.

Currently, some hospitals have initiated financial incentives for physicians to see patients within seven days of discharge, such as bonus payments and billing at the highest evaluation (Jackson et al., 2015). Such programs have garnered a great deal of success, but these incentives primarily lie on the physician and have little to do with the patient. If these already implemented financial incentives were coupled with mandated follow-up appointments required by insurance companies before payment and coverage is dispersed, there is a real possibility to improve lacking follow-up care and decrease correlated hospital readmittance rates.

Lack of follow up is an important issue that significantly affects the patient, the physicians and the hospitals. New strategies and interventions are required to tackle this issue and to reduce the high readmittance rates. New policies such as enforcing penalties on hospitals, improvement of continuity of care, and mandated follow up care can significantly lower the readmittance rates. However, regardless of enforcement of these new policies there will be inevitable readmittances to hospitals but the overall goal is to lower the rate of admittances, as the total elimination of them is circumstantially impossible. There will continue to be readmittances to hospitals post discharge, but the number would be significantly lower with optimal and mandated follow-up care. Having continuity of care and timely outpatient follow-up is a key component in not only successfully reducing high readmission rates post hospital discharge, but improving the commitment to and quality of care every member of society needs and merits.