Ask Dr. Hallberg: After hospital discharge, many patients ultimately return

About one in five people discharged from a hospital for heart failure, heart attack or pneumonia return within 30 days, according to an article in the current issue of the Journal of the American Medical Association.

Readmissions are costly for patients and insurers, including the federal government. Hospitals with high readmission rates now face fines from the Centers for Medicare and Medicaid Services. The change was part of the federal health care overhaul.

MPR's regular medical analyst Dr. Jon Hallberg discussed the latest JAMA issue, which focuses entirely on hospital readmission, with All Things Considered host Tom Crann. Hallberg is a physician in family medicine at the University of Minnesota and medical director of the Mill City Clinic.

Tom Crann: Why all this attention on this subject now?

Dr. Jon Hallberg: It's a huge issue and has been a big issue for years, decades, in fact. It's something that many of my colleagues have frankly devoted some of their academic careers to, trying to figure out how do you decrease this readmission rate. But I think that one of the main reasons that an entire issue of JAMA is focused on this is that the Centers for Medicare and Medicaid Services are now fining hospitals if they violate this readmission rate based on certain conditions.

Crann: Give us an example, a couple of examples here, of where this is happening. What types of things are we talking about?

Hallberg: They're really looking at three conditions right now. They're looking at pneumonia, heart attacks and congestive heart failure. I think heart failure is a really good one because someone gets admitted, their heart, the pump, isn't working properly, fluid is backing up, new meds are given to a patient, and the patient goes home.

And the fact is this is a very evolving kind of condition. It's very hard to predict how it's going to respond, and I think this is one thing that's got physicians and other health care workers concerned is how do you try and predict how someone's bad condition is going to turn out.

Crann: It sounds to me like an issue of coordination of care, from the care one receives in the hospital to the care you get with your doctors outside the hospital. Take us through that process. There's a discharge process. There's a report. Who sees that and how does it work?

Hallberg: It's so complicated ... Most of my patients are hospitalized in the same system that I practice in, so we share a common electronic medical record, so theoretically I know when someone gets admitted. I see what's happening in the hospital, and I know when they've been discharged.

But gone is the day when I would be the one that would be admitting my patient and rounding on them and going to clinic and coordinate everything. We really have to rely on pretty careful coordination. Unfortunately, that just doesn't happen as much as we would like it to happen.

Crann: Things such as medications — there may be a different list for the patient when they come out of the hospital than when they went in.

Hallberg: I was just talking to a colleague about this, that if a person goes into the hospital on, let's say eight to 10 different medications, they're in the hospital and they come home. The chance that the two medication lists will match up is often very low because the hospital has a formulary. Their pharmacy will give a different medication even if it's the same class (of medications). Often these things are not reconciled. And that frankly is one of the things I always do when I see people when they've gotten out of the hospital is to try and make sure they are at least on the right medications.

Crann: There is wisdom to minimizing hospital stays from the patient perspective, a lot of reasons, including cost, to try to keep the cost down, but is that part of this picture?

Hallberg: There's no way that we can deny the cost of hospitalization is part of this. And I think it's important to know that these days when people are in the hospital they are sick. People do not go to the hospital when they're not very sick, and they don't linger once they've started to recover.

There's all kinds of pressures. One of them is just a health care pressure. People who are sick have certain microbes, and there are certain things happening, and complication risks can go up the longer you stay, so we do want to get people out for that, but there are also financial pressures, of course.

Crann: We have talked about continuity of care when it comes to — ideally someone should go to the same provider over time. Is this an issue of continuity of care from being in the hospital to being not in the hospital?

Hallberg: I think because things are so separated now that we've got people like me, clinicians, especially in the major metropolitan areas. I mean we're in the clinic all the time. And then there are our colleagues who are the hospitalists who are in the hospital all the time.

There's just not the same kind of overlap that there once was, and so it's the right hand needing to talk to the left, and we do that pretty well electronically, assuming we're in the same system.

And if you're in a different system: if you go to one kind of a clinic and you're in a different kind of hospital, then you've got to get things the old-fashioned way through a fax or mail or hand-delivered reports. It's very tricky.

Crann: What would make all of this better then?

Hallberg: I keep thinking of this image. I was driving back from North Dakota after giving a talk a couple years ago and drove through Fosston, Minn. On Main Street, there was a clinic attached to a hospital attached to the nursing home with an emergency room.

And I thought, you know, there's something really beautiful about that. There's no lack of communication because everything's happening in one space. And I think a future direction is going to be, 'How can we use technology to create that kind of wonderful, seamless approach to things?'

I'm not sure that technology is always the answer, but I think that's going to be one of the answers. I'd love to see the day when that kind of image, that mental image, is a reality in how we take care of people.

(Interview edited and transcribed by MPR reporter Madeleine Baran.)

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