Many improvement leaders want to target the patients who need care transitions to work well. Of course, every person moving around in the care system needs the processes to work reliably, but some either have few needs or can handle their needs on their own. So – who is it who gets caught in snafus and errors? The folks who either have very complicated needs or who really can’t handle much on their own. And who is that? First are the elderly folks with many medicines, multiple chronic conditions, poor hearing and vision, and so forth. This is not your tennis-playing 80 year-old uncle – but his 86 year old sister living alone in fragile circumstances in a second floor walk-up. Yes – living arrangements and availability of help really matter.
And who else? Those with serious chronic mental health problems – depression, delusions, addictions. A person who has trouble “keeping it together” on a normal day is going to have challenges coping with the complexity of the health care system, and even more trouble on a day when he or she is not feeling well.
Any others? Those are the two major groups, perhaps supplemented by any others who have proven their ability to keep recycling back into the system. Anyone who has been in the hospital twice in six months, or in the ER a few times, is someone who is at high risk of keeping on with that pattern.
We don’t yet have good evidence-based tools that a provider could use. But there is so much interest that there’s a contest to find algorithms that can predict rehospitalization – with $3million in prizes! http://www.heritagehealthprize.com/c/hhp If you know of any high-functioning, low-cost screening tools, let us know in comments to this blog or send it to [email protected].