READMISSIONS
on their medications. For example, they
continue to take a brand-name drug while
they’re also taking the same thing in ge-
neric form because they didn’t understand
or weren’t told they were supposed to stop
taking the brand name.”
Another medication issue that’s an un-
derlying source for many readmissions
is over- and under-medicating patients,
he says. “You’d be surprised how often a
prescription doesn’t take into account the
patient’s weight—it doesn’t make clinical
sense to give the same amount of a drug to
a 120-pound person than to a 250-pound
person, but that’s what we’ve found drives
a lot of readmissions.”
Shocking results
Getting chronically ill and recently discharged patients to take their medication
and follow diet and exercise recommendations has always been a seemingly intractable problem with elusive solutions. But
at the root of the problem is a simple question: Why don’t patients take the advice of
their doctors?
The reasons might shock even a grizzled veterans, says Scott Rusk, M.D., chief
medical officer at Mercy Hospital in Portland, Maine. Rusk has been the physician
champion of a pilot project in the cardiac
department that uses analytics tools to understand the personal circumstances and
personality traits that might put patients at
risk for readmission.
Patients are asked dozens of questions,
the answers to which are run though an
analytics engine developed by the Patient
Performance Institute and embedded in
the cardiology group’s electronic health
record.
The analysis found the biggest barrier to
medication and treatment compliance was
fundamental—the patients didn’t believe
what their physicians were saying.
“I was absolutely floored by this—a significant percentage of our patients simply
didn’t believe what we were saying is true,”
Rusk explains. “They thought we were deceiving them when we said they needed to
“The medical
model is to let
the patient lie to
the physician.”
—Scott Rusk, M.D.
avoid salty foods, or take certain medica-
tions—it’s almost like they think there was
a conspiracy among cardiologists to keep
them away from things they want to eat.”
The Patient Performance Enhancement
Test, as it’s called, scores patients in 10 dif-
ferent domains such as emotional control,
respect for authority, optimism levels and
financial situation. Rusk, like his peers try-
ing to unravel root causes of readmissions,
knows there’s something going on behind
the scenes that’s causing patients to be-
have badly, but has had problems putting
a finger on it or understanding how to ad-
dress those issues. “I don’t know any car-
diology groups that have psychiatrists or
psychologists associated with their group,
so we’ve had to rely on intuition and our
own attempts to understand these psycho-
social dynamics.
“Let’s face it, the medical model is to let
the patient lie to the physician. If obese
patients gain three pounds in a month
and you ask them if they followed the di-
etary plan, they’re likely to tell you they
did, even though you know and they know
it’s a lie. This data helps us get the under-
lying reasons why they didn’t follow the
treatment and felt compelled to lie, and
that helps us address those issues. It gets
you to the real roadblocks.”
Saint Barnabas also struggles with
medication adherence and recalcitrant
patients, Larkin Carney says. But like
Mercy, Saint Barnabas is working new
angles in its readmissions efforts, in this
case re-thinking how the hospital prepare
patients for discharge. “We’ve focused a
lot on optimizing our discharge processes
and focusing on a specific diagnosis when
they leave the hospital. But we’re starting
to think, did we do the best for that patient
in terms of their overall health? Did we
optimize them to go home and be able to
take care of themselves?”
The reason those questions are so im-
portant, she says, is that most readmitted
patients are there for reasons other than
complications with their initial diagnosis.
