Readmissions News: What is the importance of patient engagement in reducing readmissions?
Dr. Kagan: We’ve all been in that same situation –you ask the patient if they understand how to take his or her medications or how to follow his or her instructions and the patient just blindly nods in agreement. Only to end up in the emergency room three days laterwith complications of medication management –or what we often term “noncompliance.” My residency professor always taught me that there is no such thing as a noncompliant patient, you just haven’t figured out how to engage them properly.
Patient engagement is tricky, and it’s no secret that it plays a critical role in health outcomes, and certainly helps to reduce hospital readmissions for high-risk patients. However, we often fail as a health system to really understand how ready our pa-tients are to engage. Doctors, nurses and case managers often work in a paternalistic manner, telling the patient, “You have to do X, Y and Z” without ever thinking about how to get the patient to buy in. We expect them to want the same things we do or speak our language and, quite frankly, they often don’t. It’s not because they do not care; writing them off is not the solution.
For example, health care providers might have a goal of getting a patient’s Hemoglobin A1c to 6.0. Doing so requires blood sugar checks, insulin dosing, diet changes and so on. Patients, however, don’t walk around thinking about their A1c level. Their goal might simply be to go grocery shopping without assistance, or climb stairs on their own. Figuring out how to take medical goals and turn them into tangible life goals is really how you begin the process of engagemennt.
This also applies to medication. We know offering comprehensive recovery instructions to everybody leaving the hospital is important, but it’s not enough to simply provide a listof medications. Instead, those instructions should be tied to how the patient lives his or her life. So, you can say, “Here are the pills you take in the morning when you brush your teeth, here are the pills you take when you eat lunch, here are the pillsyou take before bed.” Family members or caregivers, who are part of the larger care team, also need to hear these instructions.
Readmissions News: How has L.A. Care Health Plan incorporated the ideas and practices that you’ve talked about?
Dr. Kagan: I am the Senior Medical Director at L.A. Care Health Plan, the largest publicly-operated health plan in the country, and we recently started a pilot aimed at lowering readmissions through patient engagement with our members in the Antelope Valley of Southern California. We first identify members who are in the hospital, and using an internally developed predictive model, we score each on their likelihood of being readmitted within 30 days. The scores go to our UM nursing staff to triage appropriately.
When a member is determined to be at risk of readmission, we send an L.A. Care nurse to the hospital bedside of that member to start to build a relationship before discharge. That means it won’t be a random person calling the member on the phone 48 hours after discharge to see if they are taking their medications. An L.A. Care social worker, part of the overall care team, often accompanies the nurse to the bedside visit. It’s our belief that this face-to-face meeting is going to go a long way in getting the member to engage, and the relationship continues once the member leaves the hospital.
In this pilot, the nurse also makes a home visit to assess the member’s medical needs and the social worker visits to assess social needs. We have to meet the member where he or she is, and often there are social factors that will impact health outcomes. If we don’t help the member address those barriers, hospital readmission is much more likely.
We have identified a number of social factors that can act as barriers to healthy outcomes including, transportation, food security, and housing. Follow up care is tough without transportation. If you can’t eat a healthy meal, all the pills in the world won’t bring down your blood pressure. Wound care is nearly impossible if you are living on the streets.
As a Medicaid plan, we provide members with transportation to medical appointments. We also have a new online resource directory that all members of the care team and the members themselves can use to access food and housing assistance.
Readmissions News: Any final thoughts that you would like to leave our readers with?
Dr. Kagan: It’s important for the care team to understand that it’s not just about getting the meds right, and going to a follow-up appointment. It’s about understanding all of the different
components of a patient’s life to help that person live better. In the end, trust might be the most important thing needed to improve patient engagement. A patient will trust the care team if they are truly listening. Thepatient will tell you what they need, and what they can and cannot do. Listening will help the team understand how do create a better care plan for each patient. That will ultimately improve health outcomes and reduce readmissions.