Tennessee Center for Patient Safety – Spring 2015 Regional Meetings – Readmissions Breakout Session
Compiled List of Readmission Contributing Factors, by Category, from Fishbone Analysis
FINANCIAL
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Lack of money for transportation
Lack of money for medications
Lack of adequate financial reimbursement for palliative care
Employers
Regulations around home care, rehab, and SNF
Financial system designed to reimburse sickness not wellness
Lack of personal accountability
Physicians over treat – physicians are rewarded for finding more problems
Physicians ordering meds with no regard to cost
POST ACUTE PROVIDERS
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Not getting discharge summary or history & physical
Lack of primary care providers
Medical desert – lack of access to health care – ER only option
MCO, TennCare, self pay – lack of post-acute care providers
Shortage of post-acute care providers doing specialty procedures (dialysis, IV antibiotics, wound care, psych)
Lack of services needed
Lack of cultural understanding
Language barriers – translation
Insurance approval
Criteria for readmissions
Post-acute provider buy-in
Physician-to-physician communication
Electronic medical record
Home Health says, “Go to ER”
Protocols for actions to take for change of status (SOB or fever)
Staff shortages in post-acute care providers limit admission access
Not enough psych beds who can care for medical problems
Lack of patient liaison
Lack of patient/family education - end of life
PALLIATIVE CARE
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Physician unwilling to discuss palliative care or implement
Confusion between palliative care and hospice
Financial reimbursement does not match time invested in care
Healthcare worker resistance
Lack of community and social support
CLINICAL CARE
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Inadequate discharge teaching or home care
Lack of education and understanding
Inadequate post-op teaching
Follow-up care with physicians
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Premature discharges
Limited time for evaluation before discharge
Adverse events
Medication errors
HAI
Other errors such as wrong blood transfusion
CHF patients readmit at night due to nocturnal hypoxia
Lack of care coordination
Misdiagnosis communication
Less experienced care team
Post discharge patient portal use and access
Inappropriate length of stay
Lack of time - hospitalists and nursing
Management of comorbidities
Clinical indicated readmissions
Multidisciplinary communication
CARE TRANSITIONS
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Timeliness and follow-up, who is making appointment
Lack discharge planners / resources
Patient non-compliance
Correct physician fax number to send discharge summaries
Identifying primary care physician
Lack of adequate and comprehensive teaching
Discharge education materials too complicated
Lack of assessment for low literacy or low health literacy
Not truly using teach back with patient/family education
Don’t ask patient, “Why are you back?”
Discharge patient education
Only managing chief complaint
Lack of coordination acute or chronic conditions
EMAR accessibility
Eligibility of home health or facility
Knowing who is accountable for the steps in the process
Not getting discharge summary
Follow-up appointment
ACO appointment availability
Lack of patient navigation and coordination of care
No communication re: test results
Pending tests
Poor handoff communications
Underutilization of SNF and hospice
Delay discharge summary
Poor medication reconciliation
Poor discharge planning
Late discharges
Coordination of discharge planning among caregivers
Pt accountability – managing care
Discharge medication reconciliation
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Care transitions – lack of collaborations
Transportation access
Discharge plan developed in first 24 hours
Access to primary care provider relationships
Shortage of primary care provider availability
Access to medications
Patient/Family centered care – understanding home situation
COMMUNITY
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Rural access
Population health
Transportation
Lack of knowledge from case management standpoint
Disparities
Lack of resources
Transitional clients – homeless and migrant
Homeless – no self-care – go to ER
Community uninsured
No pharmacy at night
Community difficulty scheduling transportation
Lack of resources to pay for public transportation
Access transportation missing follow-up appointments
Lack of public transportation
Cultural issues and lack of outreach programs (educational, EMT assessment)
Ability to pay and get medications
Lack of DME qualification availability
Mental health services
MEDICATIONS
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Inadequate discharge teaching on medications
Not understanding how and when to take medications
Understanding dosage and how to take
Patient education and understanding of home medications
Lack of money
Financial resources
People can’t afford medications
Medication reconciliation
Brand – vs – generic
Formulary substitutions ordered to continue at discharge
Prescription not refilled
Other family member takes medications (control)
Lack of access
Not taking because of side effects
Lack of knowledge of what medications they are taking
Too many medications by too many providers
Patients don’t understand side effects and actions of medications
Some patients may not understand available technology
PATIENT/FAMILY
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Patient accountability
Patient engagement
Beliefs/values/culture
Education and comprehension
Family support
Health care priorities
Social status
Psych problems contribute to noncompliance
Financial resources
Living environment / hygiene
Family knowledge of post care needs
Lack of adequate prep for discharge
Staff training – specialized team for chronic conditions
Lack of education and knowledge
Lack of family support
Family engagement during hospital stay
Insurance limitations for in hospital or post discharge
Lack of finances to buy supplies, meds, etc
Lack of support services to assist
Patient/family not aware of support services
Lack of coordination among providers – whom to call with problems
Lack of “quick” follow-up access post discharge
Lack of family to provide care/support
Need for nurse navigator or advocate
Lack of understanding of discharge plan
Language barriers
Lack of transportation
Low literacy to understand care
Patient sees different providers – duplicate therapy causes adverse effects
Lack of total pharmacy oversight
Communication “too complex” info – clear instructions
Patient is sick with multiple conditions – nearing end of life possibly – patient/family fear of not seeking care
Finances insufficient
Information overload on discharge care
Adherence
Physician admits patient at request of family who may be employed at the hospital
Assessing health literacy and literacy
PHYSICIAN
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Inadequate data from hospital for where physicians stand
Reading discharge summaries
Lack of flexibility from clinic based on physician schedule
Access to physician when patients do not have insurance
No primary care provider
Lack of formal coordination between hospital and physician
Type of patient for elective surgery – comorbidities
Multiple physicians involved
ED physician doesn’t know patient history and admits for abnormal test findings that may be patient’s norm
Admit for inpatient rather than observation
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Not up-to-date on latest evidence-based care
Lack of communication between direct care physician and primary community physician
Engagement in culture of safety, learning from harm and near misses, etc
Initial antibiotics wrong
Follow-up when patients miss appointments
Ease of making appointments – placed on hold, weekends and after hours
Understanding of payment methods
Physician ignorance patient to follow-up with primary care provider and primary care provider throws away prescription
Physician says, “Go to ER,” rather than see in office
Lack of access to patient not communicating they received new medication while in hospital
Physician not communicating with one another regarding patient care
Pt not following up with primary care provider or don’t have a primary care provider
CHRONIC DISEASE
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Mental health - substance abuse
Family support
Money
Transportation
Socioeconomic issues
No primary care provider
Lack of resources
Disease – lack of ability to manage – lack of management skills
Chronic disease – lack of education (COPD, asthma, diabetes)