A Multidisciplinary Example

Improving discharge processes calls for hospitalists to be the voice of change within their facilities, Michelle Mourad, MD, hospitalist and director of quality at the University of California at San Francisco Medical Center, said at UCSF’s 19th annual Management of the Hospitalized Patient conference in San Francisco.

"Be the role model. Be the one who always does discharges right," she said in a breakout session focused on discharge improvement.

Dr. Mourad and co-presenter Ryan Greyson, MD, MHS, MA, both sit on UCSF’s multidisciplinary Discharge Improvement Team, an approach they recommend to other hospitals. They also say fixing hospital discharges won’t be easy, and it requires an individualized approach tailored to each facility and its unique culture.

"Think about the little things you can do. Figure out which steps are needed for safe discharges," she added.

UCSF has implemented a post-discharge hotline for patients to call with follow-up medical problems, and also makes outgoing follow-up calls. A discharge pharmacist performs medication reconciliation for patients with high-risk medications or multiple prescriptions.

A folder called "Your Discharge Information," which encapsulates the patient’s medications, discharge plans, follow-up appointments, and the like, goes home with each patient. Unless the patient is known to be reliable, hospital staff also schedule the initial post-discharge medical appointment.

UCSF has developed relationships with local home health agencies, encouraging them to qualify patients with complex needs, including multiple prescriptions, for home health coverage. The home-care nurse then revisits medication reconciliation once the patient is settled back into the home setting. The medical center is developing an agreement with the pharmacy across the street to share the costs of uncovered prescriptions for patients who can’t afford to buy them, and often sends patients home with prescription supplies ranging from seven to 30 days, depending on diagnosis.

UCSF’s discharge improvements have made an impact on internal-medicine readmission rates. The rate of readmission for patients under age 65 was 16.5% in calendar year 2008, 15.5% in 2009, and 13.2% in 2010.

"Discharge has to be an institutional priority," Dr. Mourad concluded. It requires support from the top down and from the bottom up. It will be hard to succeed, "unless the whole institution believes that it is important."

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