Readmissions – the post-hospitalisation syndrome?

08 March 2013

Dr Simon Conroy is Head of Geriatric Medicine, University Hospitals of Leicester, Honorary Senior Lecturer, University of Leicester and an Associate Editor for Age and Ageing journal.

Harlan Krumholz recently used the New England Journal of Medicine as a platform to describe a biological approach to readmissions. He challenged us to develop technologies to identify and respond to “post-hospitalisation syndrome” - a sort of multifactorial vulnerability triggered by the exposures that patients face in modern acute hospitals.

Some have attempted to deal with exactly this sort of challenge by developing risk stratification or frailty scales to identify those at risk of readmission at the time of discharge.  The problem is that, when viewed through a cost-effectiveness prism, these interventions don’t make sense – see my recent piece from Age and Ageing for the maths.

So it’s worrying that current NHS policies are ‘crippling’ acute hospitals by penalising them financially for caring for patients readmitted within 30-days, yet there appears to be no evidence based approached that will help the hospitals address the problem. Hardly seems fair, does it?

Yet there may be a glimmer of hope.  There is a technology that reduces readmissions in frail older people. It is well evidenced. It is called Comprehensive Geriatric Assessment. You can learn more about it here.

So what is this magical treatment? Well, in essence, it is about multidisciplinary teams working together to focus on individual patient care. It involves the healthcare professions not just working in parallel but actually talking to each other, to develop a shared understanding of each others’ roles and responsibilities.

In a mature CGA team, the margins get blurred. You end up with physiotherapists covering occupational therapist roles, or nurses suggesting changes in medication to doctors. It is the breakdown of artificial hierarchies and meaningful reciprocal respect that allows holistic patient centred care to flourish. Geriatricians are usually pretty good at working within this sort of team, as it is the bulk of their training.

Can non-geriatricians do it? Yes.....but are there enough of non-geriatricians willing and able to engage in this work to serve the needs of the NHS? These issues are being discussed in multiple forums, not least the future hospital commission. Some interesting scenarios might emerge, ranging from a halt in the expansion of non-geriatrician training posts, through to changing Core Medical Training into Core Geriatric Training. Whatever the solution, we need more MDT working with a patient centred focus, otherwise the NHS will not survive. Time for geriatricians to lead the way!

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