By Andrew Miller, MD, MPH
As confusing as the healthcare debate has been over the past year, one of the farthest-reaching changes now taking place in the practice of medicine has nothing to do with new legislation. Instead, it is the emerging role that we — as patients and families — are expected to play. Increasingly, health professionals are asking patients to be part of the healthcare team. This is especially true for older adults.
If you are a senior about to be released from the hospital, you have a one in five chance of being re-hospitalized within 30 days of your discharge. For some health conditions, such as heart failure, heart attack (acute myocardial infarction), pneumonia, and chronic obstructive pulmonary disease (COPD), hospital readmission rates are even higher. Many of these re-hospitalizations may be preventable.
New Jersey is one of only 14 states chosen to participate in a national pilot program to help identify the best ways to ensure coordination as you move from one care setting to the next, from hospital to home, or to a nursing home, a rehabilitation facility, or within a hospital. These movements are referred to as “care transitions.”
The New Jersey Care Transitions Project (NJCTP) focuses on seniors at high risk of re-hospitalization. While the project is concentrating on 44 communities in Burlington and Camden counties, the lessons being learned have statewide implications. National data shows that re-hospitalization rates decline when people become more knowledgeable about and involved in their own healthcare.
If you are about to be discharged from the hospital, you should:
Ask the nurse or doctor three questions — “What is my worst problem?” “What do I need to do?” “Why is it important for me to do this?” Be sure you understand the answers.
Ask the social worker or nurse about help you may need when leaving the hospital and how you can get that help.
Once home, you should:
Review all discharge information, including when to make appointments with doctors for follow-up care;
Read up on the new medications prescribed in the hospital, fill the prescriptions, and make an updated list of medications;
Contact the doctor right away if you are having problems with your illness or have questions about your treatment plan.
Another way to take more control over your healthcare and help ensure you receive the most appropriate care is by using a personal health record (PHR). A summary of your overall health, the PHR also includes a list of all medications you are taking. The very act of compiling a PHR gives you a deeper understanding of your own health, allowing you to make informed decisions. It also helps doctors and other healthcare providers better coordinate your care.
While some of the provisions in the recent health care reform legislation will take years to come into effect, educated and motivated patients and their families can have an impact now in avoiding re-hospitalization.
Andrew Miller, MD, MPH is co-leader of the New Jersey Care Transitions Project and Director of Physician Services at Healthcare Quality Strategies Inc. (HQSI), the nonprofit Medicare quality improvement organization (QIO) for New Jersey. Free PHRs are available on the HQSI website, www.hqsi.org.
Miller, who is board certified in Public Health and General Preventive Medicine, is a graduate of Princeton University and Columbia University’s College of Physicians and Surgeons, and he earned his MPH at the Harvard School of Public Health.
Miller and his wife, Lynne Ruff, MD, have been West Windsor residents since 1982. Their daughters, Becky and Lisa, both went through the West Windsor-Plainsboro schools and graduated from High School South.
