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Cognitive State Impacts Chronic Disease Management, Readmissions

Chronic disease management and preventable readmissions are often complicated by unrecognized cognitive impairment in patients, says a new study.

By Jennifer Bresnick

- A patient’s cognitive impairment level is one of the key indicators that he or she may be headed for a preventable hospital readmission due to inadequate chronic disease management, says a new study published in the American Journal of Managed Care (AJMC).

Chronic disease management and preventable readmissions

Patients admitted to the hospital for congestive heart failure (CHF) experienced 30 percent fewer early readmissions when they received care from a health psychology liaison compared to those patients who did not have their potential cognitive impairments addressed.

Untreated cognitive impairment can make a serious impact on a patient’s wellbeing during and after a hospital admission, writes a team of authors from Henry Ford Health System in Detroit, yet few provider prioritize assessments of a patient’s mental health status during an admission for seemingly unrelated issues.

In addition to contributing to longer-term hospital stays and higher mortality rates, cognitive impairment may also lead to poor adherence to treatment plans, “particularly when the family and/or patient have not yet recognized and intervened for the evolving problem, or the patient is not in a setting (eg, nursing home) that supervises medication administration.”

To better understand the impact of patient cognitive state on chronic disease management and preventable readmissions, the research team designed an intervention for patients admitted for a new diagnosis of CHF or an exacerbation of their existing condition.  Patients were identified as being at risk for cognitive impairment if they exhibited symptoms of anxiety, depression, and panic disorders or unexplained physical symptoms such as chest pain and chronic fatigue.

READ MORE: Chronic Care Management Improves Pediatric Outcomes by 20%

These patients received a variety of tailored educational resources as well as referrals to outpatient psychiatric or substance abuse programs, prescriptions for trials of low-dose antidepressants, and specialist services like sleep assessments for those with symptoms of undiagnosed sleep apnea.

The researchers found that patients receiving the intervention experienced a readmission rate of 16 percent, while those in a control group were readmitted at a rate of 21.5 percent.  The average CMS 30-day hospital readmissions rate nationwide hovers around 23 percent, the study added.

In addition to lowering readmissions, enhanced education, discharge planning, and ongoing chronic disease management support could save significant revenue for the healthcare system. 

“If the intervention reduces readmissions on 100 patients from about 23% to 9% in the first month, we project savings of $151,200 in the first month alone,” the researchers said.  The net expenditure required to maintain the program is approximately $33,500, which leaves more than $117,000 in profit for payers.

“The professional time required for our proposal is currently reimbursable under all insurance programs, including Medicare and Medicaid,” the team points out.

READ MORE: CMS Picks Care Coordination Hubs for Accountable Health Program

“The net savings over longer periods can only be guessed at currently, but may prove substantial. Regardless of the net cost/savings, this intervention improves clinical outcomes for patients by decreasing potentially fatal medical crises. For the hospital, the cost of the system of care being provided is covered by billing for the psychological services rendered.”

While the study suffers from certain limitations – it was not a randomly assigned, controlled clinical trial – it does align with other research that promotes the importance of considering a patient’s mental health status along with his or her physical ailments as the best way to measure overall health.

A 2014 study published in the Journal of the American Medical Association found that elderly patients admitted to the hospital often lack the cognitive ability to make independent decisions.  Nearly half of seniors needed significant help from family or other caregivers when making major decisions about their care.  Close to sixty percent of those choices involved life-sustaining care.

A separate study from the same journal also highlighted the positive role of post-discharge care coordination in patient populations experiencing socioeconomic or behavioral health challenges.  Patients who received detailed care plan documentation while still in the hospital were 13 percent more likely to adhere to appropriate follow-up than those who were not able to access extra help.

Stakeholders across the care continuum have been urging healthcare providers to improve their management of patients with mental and behavioral healthcare issues, especially as chronic disease management needs increase with an aging population. 

READ MORE: Using Machine Learning to Target Behavioral Health Interventions

Poor health data integration and subpar communication between clinical and behavioral healthcare organizations has produced significant challenges for providers looking to proactively identify and address patient problems in a holistic manner, but growing recognition of the benefits of integrated, coordinated care may be smoothing the way.

Currently, providers only recognize and identify between ten and twenty percent of patients with enhanced cognitive care needs, the Henry Ford study says, and providers must make more of an effort to utilize caregiver resources and education to compensate for patients who do not have the ability to maintain good health on their own.

“If evidence-based care of CHF patients that maximizes effectiveness, safety, and efficiency is the goal,” the team concludes, “enhanced recognition of cognitive impairment and more proactive management of adherence is a necessity.”


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