While the number of emergency departments (EDs) across the country has decreased, the number of ED visits has increased" (Garcia, Bernstein, & Bush, 2010).
And, according to the feature story in the July 2010 edition of Research Activities, one in four patients experiences revolving-door hospitalizations (Agency for Healthcare Research and Quality [AHRQ], 2010a). "As national health care costs continue to rise and policymakers become increasingly interested in ways to make the health care system more efficient, it is important to understand the characteristics of those individuals who use EDs-often in place of other sources of ambulatory care" (Garcia, Bernstein, & Bush, 2010). Those of us managing and practicing in home healthcare know exactly where these "other sources" might be-in patients' homes-and this has important implications for home healthcare as the federal government, state government, and others go through the intellectual violence of reframing the intervention-focused medical system to one that is prevention-focused and supports positive health behaviors.
"Over a 2-year period, roughly one-quarter of all hospital patients were readmitted for the same conditions that prompted their initial hospitalization," according to the latest data from the AHRQ (2010a). In fact, "according to the Federal agency's analysis of data on 15 million patients in 12 States in 2006 and 2007, more than a third of those who had hardening of the arteries, called coronary atherosclerosis, were readmitted at least once to the hospital during the period. Multiple readmissions were also seen for 30 percent of patients with uncomplicated diabetes, 28 percent with high blood pressure, and 21 percent with asthma" (AHRQ, 2010a). What is interesting about this statement is the use of the term "uncomplicated diabetes."
In the context of these findings (that 30% of multiple readmissions to hospitals were attributable to "uncomplicated diabetes"), it makes one think that all patients with diabetes are at risk or every home healthcare patient is at risk for a rehospitalization, and perhaps the term "uncomplicated diabetes" is an oxymoron when used in this context. Perhaps the definition needs to be revisited or fine-tuned. These findings are based on data in Hospital Readmissions and Multiple Emergency Department Visits, in Selected States, 2006-2007 (Steiner, Barrett, & Hunter, May 2010).
Take Away: Consider all home care patients with diabetes mellitus to be at risk for a rehospitalization and monitor and plan care with this belief system operationally. Monitor this patient population more closely, trace your findings, analyze a trend, and determine what seems to work and why (and consider a submission to Home Healthcare Nurse).
Interestingly, the 2010 National Center for Health Statistics Data Brief was focused solely on emergency departments. In the brief entitled "Emergency Department Visitors and Visits: Who Used the Emergency Room in 2007?" the authors (Garcia, Bernstein, & Bush) identified some trends that also have implications for home healthcare patients and practice. Among numerous findings, the most interesting included
* "Older adults (aged 75 and over), non-Hispanic black persons, poor persons, and persons with Medicaid coverage were more likely to have had at least one emergency department (ED) visit in a 12-month period than those in other age, race, income, and insurance groups."
* "Persons with Medicaid coverage were more likely to have had multiple visits to the ED in a 12-month period than those with private insurance and the uninsured."
* "Older adults-those aged 75 and over-were more likely to have had at least one ED visit in a 12-month period than people in younger age groups."
* "As family income increased, the likelihood of having one or more ED visits in the past year decreased. These income-related differences were more pronounced than those based on age or race/ethnicity."
* "Among Medicare beneficiaries aged 65 and over, dually eligible persons with Medicaid were more likely than those without Medicaid to have had one or more visits to the ED in a 12-month period."
Take Away: Identify and track all dually eligible patients-those patients having both Medicare and Medicaid as their insurance. The statistics support that these patients were more likely to have the highest utilizations. Maybe your state was not in the data pool of the 12 states studied, but there may still be opportunities to possibly prevent a readmission with detailed assessments and ongoing monitoring of the high-risk patients from this study. The "harmonization" of healthcare will continue to demand that providers of all types communicate and coordinate patient information across settings and transitions. The more effectively we can gather the data/information needed to care for patients and their histories and other information, the better!!
AHRQ's Research Activities (2010b) also published the following from a piece entitled: "Doctors Remain Remiss in Advising Overweight Patients About Healthy Eating." This information was sad to read: "Only about half of obese American adults were advised by their doctors to cut down on fatty foods in 2006, a rate that had not significantly changed since 2002, according to the latest data from the AHRQ." The Agency's survey also found that:
* "Obese black and Hispanic adults were less likely than whites to receive advice on food consumption (45 percent and 42 percent, respectively, compared with 52 percent)."
* "Poor obese adults were less likely than poor higher-income adults to be advised to cut down on high-fat, high-cholesterol foods, regardless of race or ethnicity (43 percent vs. 57 percent)."
* "Obese adults who did not finish high school also were less likely than those with a college education to be advised to cut down on fat (46 percent vs. 53 percent)."
* "Fatty foods add to weight gain and can clog arteries, thereby increasing a person's risk of heart attack or stoke. Black and Hispanic adults have higher obesity rates than whites, as do poor adults and those with limited education."
These findings are based on data from pages 77 to 79 in the 2009 National Healthcare Quality & Disparities Reports, which examines the disparities in Americans' access to and quality of healthcare, with breakdowns by race, ethnicity, income, and education (AHRQ, 2009).
Take Away: As healthcare moves to a proactive focus on prevention and promotion of healthy habits, this is the time for home healthcare organizations to provide this needed care and education-who better to role model and educate about healthy behaviors than a nurse? Seize this opportunity and do not assume the doctor or others have mentioned or educated patients about healthy eating and obesity. As we move into the revised world of health promotion, ask your patients what they know; what they have been told and not told about weight, exercise, smoking habits, and dietary habits; and educate your patients. This step may help decrease some of these hospitalizations and, more importantly, will contribute to improved health of our patient populations.
Tina M. Marrelli
REFERENCES