Q&A: Helping patients learn about their health to reduce readmission

Q: Sometimes a patient doesn’t understand his or her conditions enough to do what he or she can to prevent readmission. Any tips on what a case manager can do to empower patients to learn about their health?

A: The case manager must commit to the patient-centric goal. However, the patient must also commit to a goal and demonstrate a desire to pursue this goal.

Here is an example: A patient is in a neurological intensive care unit suffering from a new stroke. The stroke was not on his radar, although his primary care physician had told him of his high cholesterol levels and his high blood sugars. The patient could not make the connection between these long-term abnormal biometric values and his stroke. The case manager had the patient participate in a project at the hospital designed to measure his patient activation levels. Over time, the patient learned more about his health and began to understand the connection between his values and his stroke. Upon discharge, he had a better knowledgebase about the etiology of stroke and what elements of his behaviors may have contributed to the stroke.

The ability for this patient to make a significant change in his healthcare plan and the case manager’s ability to transition him safely home without an unnecessary readmission was possible because of the relationship-based care the case manager provided. The case manager believed in the patient. Through the use of specific tools, the case manager engaged the patient in his own healthcare plan. The reduction in unnecessary readmissions through relationship-based care and patient activation tools is significant to the success of the population health model. Often, it does not require additional staff, but a realignment of workflow and the use of new tools to engage the patient.

For more information, see Case Management Guide to Population Health.

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