Standardizing Readmissions and Improving Post-Discharge Care

Episode Contents

• 0:00 NovaNav Introduction
• 0:54 Guest Introduction: Dr. Albert Hakaim
• 2:26 Decisions with the biggest positive impact on outcomes
• 3:28 Automating triage to reduce communication delays and readmissions
• 4:24 Streamlining post-operative care coordination support
• 7:25 Patterns in post-discharge struggles that traditional metrics miss
• 10:21 Cross-team alignment: creating uniform readmission criteria
• 12:02 CABG readmissions and post-discharge variability in care
• 16:02 Longer length of stay vs readmission risk under CMS TEAM
• 16:59 Managing accountability, data, and outliers across divisions
• 22:50 Episode wrap-up

Key Takeaways

The conversation explores why aligning surgeons on consistent readmission criteria is harder than most people realize, and why patient experience is often shaped by one simple factor: how quickly questions get answered after discharge.

Transcript

Welcome to The Surgical Journey, a podcast about putting patients at the center of surgical care. From preoperative readiness to recovery at home, we talk about the real processes and data that shape outcomes. Each episode features conversations with health system leaders, surgical teams, and technology experts who are changing how patients move through surgery and recovery. At NovaNav, we focus on making surgery easier for patients and their care teams.

That means clearer communication, reducing administrative burden, and smarter use of data. In this series, you'll hear how that work plays out in real clinical environments. Let's get into the conversation with our host, Lisa Miller. Welcome to The Surgical Journey podcast.

Today, we have Dr. Hakim with us, and we're very excited to speak with you, Dr. Hakim. Thank you for being here.

Thank you for the opportunity. I'm looking forward to it. So I want to give everyone a little bit of background on you. So you, Dr.

Hakim, are MD, a pioneering vascular, endovascular surgeon, and one of the foundational surgical leaders at Mayo Clinic in Florida. You've spent three decades, you've helped shape modern vascular surgery through both technical innovation and institutional leadership. You've trained general surgery and vascular surgery at the Cleveland Clinic, completed advanced endovascular training in Sweden, and pursued transplant surgery training in Boston. So you've got this amazing background with complexity and invasive techniques.

At the Mayo Clinic, you served at the Department of Charitable Armoury Surgery and Division Chair of Vascular Endovascular Surgery. You were directly involved in constructing and placing the first stent graft for endovascular aneurysm repair within the Mayo Foundation that really contributed to a shift towards invasive vascular interventions. Across your career, 15,000 surgical procedures, and you played a really big part in building multidisciplinary surgical programs and mentoring surgeons. So we really welcome you today, your Distinguished Fellow of the Society of Vascular Surgery, where you remain active in advancing the profession.

So thank you. Thank you. Thank you for the kind introduction. So I want to jump in, really want to talk with you about, from your leadership perspective, right?

So what actions and decisions have you seen make the biggest positive difference in patient outcomes once care moves behind the hospital walls? And as you know, we have got teams, we've got all these bundle payments, but through your experience, you've seen a shift. So what do you really think, you know, in that? Yeah, really good question.

I think as time has evolved and the practices have evolved, the impetus has always been to not keep patients in the hospital any longer than necessary. So there's kind of a balance between when a patient can go home safely and not be readmitted versus when they go home maybe too soon or don't understand the process and then need to be readmitted. So I think one of the things that we instituted a few years ago was to have a dedicated nurse call the patient within 48 hours of discharge after surgical procedures. And then that nurse would triage whatever issues the patient had to the appropriate provider in the division.

Each division is a little bit different, but, you know, that's kind of the overall scheme that seemed to work. The patients seem to be more willing to say things or bring problems to our attention versus relying on the patient to call us. Yes. I've often said this, and I might've shared this on another podcast where recently I've had calls.

My mom is in the ER and we've gotten that call. And it really, it's great because it really allows you to, you know, if you do have anything on your mind, you know, sometimes patients don't know where to call. So getting an incoming call, I think is very, very helpful. And then like you said, you can then be triaged or, you know, through the system.

So that sounds like it worked well. Yes. I'm going to stay on that question for a minute. I mean, you know, as we have so much, you know, we have workforce issues.

Do you think that that becomes challenging? You know, as you know, at NovoNav, we provide a technology and platform to streamline that support, you know, care navigators. Did you start seeing the shift in kind of some of those issues with those, maybe those navigators having a lot of responsibility, making the calls, or how do you think technology could be used? Yeah, I think it requires some training and practice to know for the mid-level or the nurse to know, you know, what to triage, when to triage, that sort of thing.

But I think a lot of those issues are, some of them are very straightforward. You know, if somebody has a fever, that's, that's pretty objective. If a nurse says the patient just doesn't feel right, then you're kind of, you know, you're kind of stuck because you don't know, you know, exactly what that means. And that's probably going to end up being having the patient be seen just to make sure that, you know, something isn't amiss that we should have known about.

I think in terms of technology and automation, maybe adding a video call instead of a voice call to the post-op patient, you know, maybe better having the ability for patients to have, to give you their vital signs if there was a, you know, either send a nurse to their house or, you know, some technology, maybe a wearable that they could wear, you know, for two weeks post-op that could give us some objective data. Because, you know, there's a spectrum, people either blow everything off and, and they say, well, you know, I didn't call you on Monday about this redness on my incision because I knew I was going to see you on Friday. And it's like, I wish you would have called me on Monday. So.

I was talking to somebody that their specialty is really, it's not in this, you know, not in your area, but I'm sure you could speak to it, but particularly in cancer care where in between appointments, a lot happens. And so, either really looking at focusing on having more opportunities to speak to patients because it's exactly what you just said. If I only would have known that I would have done something. I think that's a really good point.

Yeah. I think, you know, especially with, you know, I've had relatives and friends go through, you know, cancer treatments and there are multiple, multiple side effects from the chemotherapy and the radiation. And if the patient reads that in a pamphlet, they don't really understand until they actually experience it. Especially, you know, if they start vomiting and have really bad side effects, you know, they, that really can lead to dehydration and renal problems.

And so, you know, those things really need to be addressed quickly and not just, you know, Oh, I just think it's something I ate or something like that. Right. I just wanted to work through it a little bit. Yeah.

You made the point about something in a pamphlet versus something that happens, you know, like in a specific situation, probably with other environmental or other issues too. So thank you for that. The second question I have, from your vantage point, overseeing surgical service at the Mayo Clinic Florida, what patterns did you notice in patients who struggled after discharge that were not visible in traditional quality metrics? So, yeah, I think that's really depends on a little bit on, you know, what kind of surgery and what kind of recovery.

But I think a lot of patients, especially older patients may say, Oh yeah, I have a caregiver, you know, I have somebody at home, you know, we kind of believe them. We don't think they're lying about it, but you know, some of them don't have a caregiver at home or some of them, you know, have a neighbor that they could call or, and then, you know, there's a lot of variability in the caregiver's understanding of what needs to be brought to our attention or what the patient should be doing or should not be doing. Because, you know, patients try to get away with everything they can, you know, if you tell them don't drive for two weeks, I don't know, they drive, you know, I mean, they drive to their appointment. So, I mean, you know, it's, I think we rely a lot on the patient and their caregiver for the quality of, you know, the post-op recovery.

And again, one of the other issues, you know, not knowing when to call. So, the caregiver doesn't know when to call because they only know what the patient told them. So, it's kind of, you know, you leave a lot up to assumption, which is never a good thing. Right.

I think that's what technology affords us to do, is to be able to have a connection, you know, that maybe, that allows some real-time interaction, right? Yes, yes. That says, you know, here's some issues where I'm seeing, and now the office, the PA, the physician can say, wait a minute, this is now hit a standard or some kind of state where I need to have an intervention or have a phone call. But I think that's where technology allows us to be.

And to your point, wearables, devices that really give us some advanced warning, you know, allows us to rescue and recover, even if it's something small, maybe that can be done at home, maybe that would take two days, you know, otherwise now becomes an issue. So, I think we're seeing some big advantages in how technology is really going to support home care. Yes. Yeah, definitely.

So, as a senior leader, what was your most challenging outcome issue to improve? Not because it was clinically complex, but because it required alignment across multiple teams. I'm sure that's probably how a lot of your days were spent, right? Like just teams together and...

Yeah, you could say it's herding cats, I guess. But yeah, I think as you get more senior in leadership, you have direct reports who, you know, in the surgical specialties, the individual surgeons report to their division chair and the division chair reports to me. And each division has different issues, you know, coronary artery bypass surgery recovery is a lot different than hernia recovery. But the thing they all have in common, which is not very complex, but does require some standardization is the readmission criteria.

So, you know, within a division, there really has to be some uniformity and when patients are readmitted, you know, one surgeon can have different criteria than another surgeon. Otherwise, you know, people won't really understand why is it different for one surgeon or the other surgeon. So, that makes it hard to standardize. And if patients come to the emergency room, the emergency physicians have various backgrounds in surgery.

So, they usually call the surgeon on call. And so, if the surgeon on call has, if each surgeon on call has different criteria, then you're going to end up with, you know, a variety of different reasons people are readmitted. So, to try to standardize that as much as possible, I think is one of the challenges that we, you know, we still face, but I think it's better now. You know, I've never heard that and that's really great insight.

So, especially every surgical procedure has to standardize what readmissions or what that criteria looks like. So, that would be a big challenge, right? Just, you know, in that across physicians and just really drawing that down and then having that in place, you know, systematized, that's very interesting. And that's the first time I've heard that, that's difficult.

Yeah. Well, everybody's an expert. So, it's hard to tell people what to do, but if they can compromise and agree, it makes it a lot smoother. And it's better to have a uniform policy than to have, you know, 10 different policies.

So, I'm going to throw a little bit of a curveball, I think. I'm sure you can handle it. You mentioned CABG before, it's for obvious reasons, pre-intensive surgery, and I understand that, but just generally speaking, maybe from a clinical perspective and maybe, maybe patient perspective and maybe transition to care, CABG procedures has the highest readmission rates. Yes.

Can you just speak to that? Like, I'm curious as, you know, I'm learning more about that area and like from your perspective, why that would be? I think it's because it's so invasive. So, you know, the chest is opened, the recovery can be pretty rough, you know, it hurts when you breathe, it hurts when you cough.

And I think if it's, you know, most of the time, I think most of the time coronary bypass is not an elective procedure. It's usually because somebody either had an MI, a heart attack or, you know, flunked the stress test. So, I think the patients are already pretty hyped up going into surgery. So, when they come home, if something, you know, if they think something is wrong or something changed, those patients usually don't wait.

They usually call or come to the ER pretty quickly. So, I think once they get to the ER, then I think, again, what as we were talking about, you know, there's variability in what the ER physicians know, there's variability in who's going to see the patient from the cardiac service. It could be a PA, you know, the cardiac surgeons usually aren't in-house on call or anything like that. So, it may be a cardiologist that's covering, but, you know, I think a lot of those readmissions are for kind of peace of mind of the patient because you don't want them at home worrying their blood pressure goes up, then they may really have a problem.

That's such an interesting perspective. Again, I hadn't thought about that because you're right, they've already been in a state, you know, they have an emergency state, it is an elective. So, now they've gone through this. So, now they're really very much worried about any little thing.

And so, that just becomes something more challenging, right? And part of it, because they're going to maybe react more as they might need to, to certain symptoms. I was reading in a Medicare cost report or digging into some readmissions, some reasons, and there's a reason that it's signs and symptoms is actually a reason. It's not even so just so much I didn't know, which is so interesting to your point earlier, like it could be just so nonspecific.

Yeah. And I think it's another area where, you know, if somebody had it, you know, is wearing a device, you can say, well, your blood pressure's normal, your pulse is normal, you don't have a fever, you know, kind of reassure them not to prevent them from coming to the emergency room, but just to give them some peace of mind. And then I think, you know, over time, we used to keep patients in the hospital for a week after coronary bypass, now they're in for about two or three days. So.

Is there an argument to be made to just keep them in the hospital for a few more days and let them, and then send them home? Isn't that a better, wouldn't that be a better use of, I don't want to say resources, but maybe just a better care plan to keep them in a few days longer? Yeah, I think, you know, it's a lot of that's driven by insurance. And, you know, we've all had patients who say, you know, I'm not going home.

And I, you know, I don't feel like I can go home. And you tell them, well, you know, insurance may not cover, you know, another day. They're like, I don't care, just send me the bill. I mean, they just don't want to go.

And then there's other patients who they'd go home in a heartbeat if you'd love them. So it just kind of depends on the patient. But I mean, I think that's a good point. Insurance companies have kind of whittled down the reimbursement for post-op care.

But, you know, readmissions are not cheap. It requires usually, you know, some stat testing in the ER, some time in the ER. And I think you just kind of trade paying for an extra day versus paying for an emergency workup. Right.

I mean, if you think about Medicare, I mean, the payers, you're right. Usually there is a length of stay. There's some sort of payment attached to days and so on. But if you talk about Medicare and you talk about teams where you have bundled payment, I wonder if there are some specific cases where it makes sense to hold the patient a little bit longer versus sending them home and the potential that 20% rate of being readmitted.

And then now that, like you said, the stat, all those other costs then increase. It's a hard study to do. You couldn't really prospectively send some patients home at two days and three days and five days, you know. And I think, I don't know, you know, in terms of the teams bundling, I think their stick is going to be if you're outside the norm in how long you keep a patient, then you'll get a reduction in the reimbursement.

I don't think they're going to give you more money if you say, well, I have to keep this patient another two days. Over time, how did your definition of accountability for patient outcomes evolve as your responsibility expanded from individual patients to the full organization? I think the accountability ends with me or with whoever the leader is of the department. And, you know, as we've kind of talked about, each division is different.

Each division's criteria for like post-op progress in the post-op period is different. You know, if somebody has a hip replacement, they may go home the next day. And as we're talking about coronary artery bypass surgery, you know, they're usually in for probably, I think, a minimum of two or three days. So those assessments of recovery from a particular procedure, those assessments are done by the division.

And so that's by the division chair. And so they have to have some criteria that everyone in the division agreed upon. But, you know, if there's an issue, I mean, if somebody, the hard part for me or for the department chair is to monitor those things and to make sure that, you know, if there's an outlier, that it's being addressed. Right.

Yeah, absolutely. And just to drill into that a little bit, because yes, you did answer that earlier. I think for you to have, is it data? Is it lagging data?

Like, I think data is so key, right? For you also, I mean, right, you get the report out through your leaders and then it's those scorecards or those, you know, those outliers. And so I would imagine that that data, how that rolls up to you or was probably so key for you then to have those discussions. Yes.

Yeah. And, you know, a lot of that depends, you know, I can't, I depend on the division chairs to report, you know, the issues to me. What always happens, I think in any organization is somebody, one of their direct reports isn't happy with them. So they come directly to me and then it kind of works in reverse.

I have to, I have to discuss it with the division chair and, you know, that kind of loses the credibility of the process. Right. And that makes sense. It's a big responsibility to really try to, you know, understand where I guess the biggest priorities are, you know, when you're managing such a large organization and particularly so many specialties, just as, you know, we wrap up here.

Yeah. What do you think are the challenges that leaders now, right? So physician leaders or even surgeons need to give more attention to, right? So, so much is changing, but what do you think needs to be focused on?

Like what are the challenges and where do you think the areas now that need to be looked at from your perspective? Well, I can tell you as a, as a provider and as a patient, one of the issues that really goes kind of so far has been unaddressed is, you know, if a patient has an issue and the patient calls, you know, we discussed, you know, triaging and having a nurse provider conversation, those sorts of things. But if there's a delay in returning a patient's phone call or, you know, electronic message, portal message, I think the patient really is not happy with the service. And we see that in our, you know, everybody does patient surveys to see patient satisfaction scores and all those.

And, and the two things that usually come up on those that are not that easy, some of them are kind of funny, but you know, I don't want to pay for parking when I come to see you, you know, that's, that's kind of entertaining. But, you know, the usual one, the more important one, it took three days to get my phone call returned, or no one responded to my question in a way that I could understand. So either, I really think the whole outside of the financial aspects of, of healthcare, I think the communication has to be one of the areas that we really focus on, because it can either make or break a patient's experience. I love that you brought this up.

And I'm going to, I'm going to dig in here about communication. So I agree, the portal, the phone call, three days, the understanding, I think that's why with the teams, they have the problems, the questions, right? They're going to literally right away. And I think a couple of months later, and I think they specifically address what you said, right at the heart of the matter.

I think in fact, teams does even say that they really want to promote the communication and understanding for the patient. I think that's really the focus if you read what Medicare speaks about. And I think from a financial perspective, you know, you can't just say, well, we'll hire more, more nurses to take more phone calls. I mean, that's not, that's not going to really fly.

So I think as much as you can automate as possible, and again, that gets kind of back to wearables and objective data that can go along with the call. And, you know, if, you know, somebody says, well, I have chest pain after a cabbage, you know, obviously that, you know, all the literature and most people know to call 9-1-1. And so they're not, they're not going to, you know, wonder why should I call or should I wait for a phone call? You know, they're not going to do that.

But, you know, the more subacute things like there's some puffiness on my incision or my incisions draining, those things have to be addressed pretty quickly. And so if a nurse gets that call, if they were able to, you know, get the vital signs or do a, you know, telemedicine thing, that would be a big advantage because then you could triage a patient correctly. Right. Absolutely.

And what we're able to do, you know, with our multimodal platform is the patient really is able to put that information in and answer some questions. And then the providers, whether it's a navigator or a PA gets to see that. And I think that's going to make a big, big difference. You had mentioned about being a patient.

So can you, do you mind sharing a little bit about being a patient? Oh, yeah. I have a kidney transplant. So I, you know, I was operating one day and the next day I couldn't breathe and I got kind of rushed to the my wife who drives fast all the time drove even faster.

So I credit her with keeping me alive. But yeah, so I was in acute renal failure. Didn't really know it had dialysis and I was in the ICU for three weeks. So I got the perspective from a patient that I never had before because I'd never been sick before.

So that was kind of eye opening. And then the post-op recovery, you know, takes, Mayo was instituting the home health, home hospital, or I think it's called home hospital. I went home two days after my transplant. I went home on post-op day two.

Wow. How bad were you? I was fine. I mean, I kind of knew, you know, one thing about being a doctor who's a patient is, you know, too much.

Right. Those are the times when, you know, ignorance is bliss. So I had an iPad that I could call the home health team and they would, you know, I could see them. They could see me.

They got my vital signs, I think, three times a day. So, you know, I mean, it was a little bit of work on my part, but, you know, I was fine with it. And I think I really liked it because I went home fast because, you know, I'm not saying this specifically for Mayo, but any hospital mistakes happen in the hospital. So if you're not in the hospital, you're not going to be a mistake and anything's possible.

But I think, you know, being at home, you know, you're in familiar surroundings and if it's just taking vital signs, that's pretty easy to do. So I think it was a good experience, I think. But, you know, getting back to what we're talking about about portal messages, you know, I would, the minute I sent in a portal message, it was like, they're on the clock. How long is this going to take?

What did you take away? You saw it in real time. What were your thoughts? Oh, yeah.

Well, I was, you know, I mean, I didn't get treated any differently than any other patient and, you know, they didn't know who it was, you know, they just said, oh, here's a call from this guy, you know, like, I mean, they saw who the message was coming from. But, you know, I think it's frustrating. I think the more you have to wait for an answer is very frustrating. And I think at the time, I mean, I worked through when I was on dialysis and after my transplant, I was still working.

So, but I think if I was retired, I would really freak out because the only thing I would think about is, you know, me. And, you know, time goes really slow for people that are retired and not on a routine. And so they just stare at the phone, you know, when are they going to call? And it's frustrating.

I love your perspective. Did anything change for you then going back? Because you said you worked. Was there anything that you, your conversations changed?

Obviously, your perspective changed. Did anything change for you then going back into leadership? Yeah, I mean, you know, one of the best resurgent procedures, pretty common procedure is an AV fistula for dialysis. So that's connecting an artery and a vein in the arm so they can put needles in it and connect you to a machine.

I didn't have that. I had peritoneal dialysis where they put a catheter in your abdomen and you put solution in overnight at dialysis. So, you know, one of the questions was, well, you know, you're a vascular surgeon. Why didn't you just have a fistula?

And I was like, that's why I didn't have a fistula because I know what can go wrong. But so when I'd see patients, you know, that were sent from nephrology for fistulas, I would tell them, you know, well, there's two different ways of dialysis, all that stuff. And I would tell them, you know, I have a transplant and they would just stare at you like that's amazing. You know, it's like, yeah, you know, you can live after it and you can work and all those things.

So I think I was able to give them a little more of a perspective on what it's like because, you know, people don't know. I think probably the biggest, you may have data on this, but I think the patients who miss the most appointments are patients who are being evaluated for dialysis, renal failure patients. They don't want it. They really, you know, don't want to be on dialysis.

They don't want to talk about it. Our cancellation rate for renal failure patient, I mean, we would have to, there were times actually that I went to the dialysis unit, which is near, is on the campus with the hospital, but I actually have to go to the dialysis unit to see the patient because they just were like, they would not come to the office. And, you know, it's just because they don't really feel that bad. You know, I mean, I felt, I was like, I was really bad when I, I mean, you know, I went had emergency dialysis, all that stuff.

But if you're, if your fate, you know, your kidneys are failing, but you're not to that point yet, the whole point of it is to stick, to make the fistula so it can heal. So in time didn't be used for dialysis or to put in the peritoneal catheter. So it's healed. So you need probably about at least a month before you actually need it.

But patients, I mean, they're, they just, they're just basically denying. I think, well, I don't care. You know, eventually they come, eventually you get it done. But I think having gone through it, I can give them a little different perspective.

I think you said two really important things. I love that you became aspirational, inspirational, right. And really giving people hope, right. What a great story to have their physician be, you know, understand them, right.

I think that's amazing. And, and I wasn't aware of that high cancel. Actually, I wasn't aware of that now, but I have to do some research. So thank you for sharing.

I wasn't aware of that, but it makes sense. So Dr. Hakim, I really love this conversation. Thank you for, you know, the mixture of just your clinical leadership expertise and discussion, but you're just being the patient and putting the real world conversation here, I think is really valuable.

I've learned a lot, and I think there's just a lot of great information you've shared. So thank you for being here. Sure. Thank you.

Thanks for the opportunity. And we would love to continue to have the discussion, Dr. Hakim. So we will, we will continue it.

Thank you. Sounds good. Thanks for listening to The Surgical Journey. Join us next time as we continue examining smarter, more connected approaches to perioperative care.