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The patient is a 72-year-old man with a past medical history significant for congestive heart failure with an ejection fraction of 25%. Your inpatient team is called by the emergency room to admit the patient who has presented with decompensated congestive heart failure. Review of his records reveals 6 admissions in the past 4 months. Each time he is admitted he rapidly improves, and your team wonders why the patient requires so many hospitalizations.

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1. What social issues may be contributing to the patient's frequent hospitalizations?

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Answer

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  1. Readmissions often signal a failure to address aspects of a patient's social situation that might limit the patient's ability to comply with a complex medical regimen and thus hinder a successful recovery. Numerous social issues may exist for any patient.

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With this case, you further discover that while the patient's condition, medication regimen, and dietary restrictions seem standard to you, he doesn't understand it. His wife previously took care of him—she ensured that he took his medications correctly and prepared nutritious low-sodium meals for him; however, she passed away 8 months ago. In addition, the patient doesn't read very well and finds the small print on the bottles difficult to decipher. Even if he can read them, he doesn't always understand the directions. His meals consist mostly of frozen dinners and cans of soup, both of which tend to have a high sodium content. In general, the patient is very frustrated and beginning to feel hopeless about his medical condition, and he misses his wife terribly.

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Transitions of Care: Patients with Social Issues

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Discharge is a complex transition of care that leaves a patient highly vulnerable to adverse events. The key to a successful transition from the inpatient to the outpatient setting begins at the time of admission. Numerous social issues might exist that can complicate patients' hospital stays and compromise their success during this critical transition of care.

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The literature cites that up to 20% of US hospitalizations result in readmission within 30 days. The Medicare Payment Advisory Committee found that up to 76% of 30-day readmissions in Medicare beneficiaries are potentially avoidable. Similar literature states that unplanned rehospitalizations may signal a failure in hospital discharge processes, patients' ability to manage self-care, and/or the quality of care in the next community setting. Patients' ability to manage self-care is, in part, closely related to their social context.

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Eliciting these social issues in the setting of medical illness requires the physician to think broadly—to move beyond symptoms, diagnosis, and treatment to inquire about aspects of the patient's life that may be quite personal. The physician may also need to obtain collateral information from family or other persons close to the patient.

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Important factors to consider include:

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  1. Living situation:

    • Where does the patient live?
    • ...

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