There are many factors contributing to the high cost of health care in the United States, and many of them are difficult to manage. On the other hand, some major factors contributing to total medical expense are relatively simple to measure, monitor, and control. One major source of high expenses is the cost of hospital readmission. A simple intervention such as home health service utilization may be the key to substantial reductions in total medical expense.
The expression “hospital readmission” refers to an individual who goes back to the hospital typically within 30 days of being discharged. For patients receiving Medicare, the readmission rate can be as high as 20%. Many hospital readmissions cannot and should not be prevented, but wide regional variations in readmission rates suggest that there is substantial room for improvement. Readmission can occur for any of a number of reasons, but one of the most common has to do with medications the patient was taking (or was supposed to take, but did not). In one study, up to 2/3 of hospital readmissions had to do with medication problems. Part of the problem may be that there was no one at home to help the patient with his/her medications.
The Problem of Adherence
Sometimes new medications prescribed by the hospital react badly with the patient’s existing medications, and the patient develops an adverse reaction. Other times after discharge the patient may not take new medications as prescribed. Such reasons for readmission are generally considered to be preventable.
Medication adherence is defined as “the extent to which patients take medication as prescribed” by their doctors. The category can be somewhat misleading, because sometimes a patient can take a medication exactly as prescribed and still need to be readmitted for an adverse reaction, such as an allergy. However, most readmissions related to medication adherence have to do with poor monitoring or follow-up with a patient following discharge. Another “set of eyes” on the patient and personalized medication education in the home could reduce these adherence problems.
Behavioral Health and Adherence
Patients discharged with a psychiatric diagnosis, such as a mood disorder or schizophrenia, are much more likely to have problems with medication adherence as compared to patients with other illnesses. Up to 15% of patients with psychiatric diagnoses are readmitted within 30 days. If the patient was receiving Medicaid or Medicare, the rates can be up to 75% higher. In one study, medication adherence problems were the number one reason for psychiatric hospital readmission.
There are other reasons why mentally ill patients are so often readmitted, and one major contributor may be that only about 1 in 100 such patients receives home health services following discharge, as opposed to 14% for non-psychiatric admissions. If more patients with psychiatric diagnoses were given access to home health services following discharge from the hospital, it’s quite possible that readmission rates could be reduced substantially.
Congestive Heart Failure and Adherence
The leading cause of hospital readmission in the US is congestive heart failure (CHF), with rates as high as 25% in the first month after discharge. There are many reasons for high rates of readmission for CHF. Some of them are not preventable in principle, e.g., natural progression of the disease. However, one study revealed that of the five major reasons for CHF readmission, three of them were preventable: poor medication adherence, inadequate social support at home, and poor follow-up with a member of the care team. Close follow-up with home health services could help CHF patients adhere to diet and medication recommendations. And a home-based provider would also help the patient recognize worsening symptoms before they are bad enough to warrant readmission.