A 73-year-old woman with congestive heart failure is being prepared for discharge from the hospital. The patient has heart failure with reduced ejection fraction and has been admitted to the hospital twice in the past 60 days. Medical history is notable for ischemic heart disease, chronic obstructive pulmonary disease, and hypertension. Vital signs are normal. Pulmonary examination shows normal respiratory effort and no crackles, and there is no peripheral edema. The patient asks to stay in the hospital for a few additional days and says, "I feel fine right now, but I am worried that if I go home, I might end up back in the hospital again." Which of the following is the most appropriate response to this patient's request?
Reducing hospital readmission | |
Patient |
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Coordination |
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Patient |
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Congestive heart failure carries a high rate of hospital readmission. The potential reasons for readmission are numerous and variable and can include premature discharge, inadequate outpatient follow-up, inadequate social support, dietary indiscretion, and medication errors (eg, missed or duplicate prescriptions). In addition, patients may not thoroughly understand how to take their medications, what each medication is for, or what to do if their symptoms begin to relapse.
Predischarge counseling typically begins with exploring patients' level of understanding and health literacy (ie, ability to process basic health information and make appropriate health decisions). Patients should have an opportunity to express their questions and concerns about factors at home that may lead to readmission. If possible, education should be provided by a multidisciplinary team (eg, pharmacist, physical therapist) that can address specific aspects of care. In addition, follow-up phone calls and telemonitoring (eg, blood pressure checks) after discharge may be helpful.
(Choice A) Friends and family members can often help patients by assisting with activities of daily living, reinforcing treatment plans, and alerting outpatient providers to early signs of clinical decompensation. However, it would be premature to enlist others to help before understanding the reasons for readmission.
(Choice B) Nursing home (ie, skilled care facility) transfer is appropriate for patients who require technically advanced interventions (eg, dressing changes, intravenous antibiotics) that cannot be provided at home. Postacute care for heart failure typically involves oral medications that do not require skilled services.
(Choice C) Improper diet (eg, unrestricted sodium intake) is a common reason for heart failure readmission. However, the clinician should first assess the patient's current level of understanding, and the patient should be allowed to explain the reasons she thinks contribute to readmission.
(Choice E) This patient has been clinically stabilized and is unlikely to benefit from continued stay. Predischarge counseling should focus on factors at home that could lead to readmission rather than on reasons to stay in the hospital.
Educational objective:
Predischarge counseling should begin with exploring patients' level of understanding and health literacy. Patients should have an opportunity to ask questions and express their concerns about factors at home that could lead to readmission. If possible, education should be provided by a multidisciplinary care team, and the plan for home care and follow-up should be clear.