Evidence indicates that a small portion of hospitalized patients comprises a majority of hospitalizations through frequent readmission. “It’s frustrating for healthcare professionals, because we often feel that we are only temporarily improving the health of such patients,” explains Kevin J. O’Leary MD, MS. Despite considerable efforts to improve transitions of care in recent years, in part due to financial incentives, few high-quality studies have assessed interventions in the care of frequently hospitalized patients.
Dr. O’Leary and colleagues suspected patients could be experiencing similar frustrations as physicians with recurrent hospitalizations. Dr. O’Leary and colleagues developed the Complex High Admission Management Program (CHAMP) at Northwestern Memorial Hospital to address the needs of frequently hospitalized patients. In an effort to inform the design of CHAMP, Dr. O’Leary and his colleagues formally evaluated patients’ perspectives on recurrent hospitalization to identify factors that patients believed contributed to the frequent need for medical assistance and hospitalization. The researchers interviewed patients in a semi-structured format on their frequent hospitalizations and contributing factors. Participants had two unplanned 30-day readmissions within 12 months and one or more of the following: at least one readmission in the last 6 months, a referral from a clinician, or three or more observation visits.
Data from the interviews identified four key findings:
- Major medical problems were universal, while higher hospital use had varying onsets. “Some patients had medical problems throughout their entire life,” notes Dr. O’Leary, “whereas others had a major medical problem that did not require frequent hospital use until the patient developed another medical problem or complications of their medical problem.”
- Hospital use fluctuated, with patients reporting an increase of their hospital use during periods of psychological, social, and/or economic stress.
- Patients felt that there was no identifiable cause of onset and progression of episodes and felt uncontrollable.
- Patients preferred being at home versus the hospital. “It may surprise many healthcare professionals, but it’s really important to emphasize that patients would much rather be at home than in the hospital,” highlights Dr. O’Leary.
The recurrent hospitalization of patients with sickle cell disease was a common variable observed by the study team. Patients with sickle cell disease comprised one-third of the study group, which made it important for the researchers to compare their needs with those of other patients (Table). They note that patients with sickle cell disease can have frequent episodes of vasoocclusive crises that often require hospitalization.
“It was implied but not explicitly stated in the study that every patient has their own set of challenges,” notes Dr. O’Leary. “It seems important that we understand each patient as an individual and take the time to respect their unique circumstances so that we can help partner with them.”
The findings suggest that social work and a focus on mental health should be important aspects of programs for frequently hospitalized patients. Patients could also benefit from the support of peers and by providing support to others in similar situations. “We hope our findings can inform the design and adaptation of programs serving similar populations and other hospitals,” adds Dr. O’Leary.
Programs that are uniquely designed with patient perspective in mind are more likely to be better prepared to address patient needs and improve outcomes, when compared with those that are not, according to Dr. O’Leary. “More research should be conducted to analyze utilization of the health system, along with the patients’ quality of life, physical and cognitive function, and emotional wellbeing,” he says.