It Takes a Village

Gregory Misky, MD, has been a hospitalist for 12 years, first at a community hospital and for the past seven years at the University of Colorado Denver. In recent years, his frustration has grown over the challenges of discharge planning, care transitions, and preventing readmissions for vulnerable, disadvantaged patients, including the uninsured, underinsured, and medically indigent.

“There’s a big elephant in the room that we’re not talking about, and that elephant is having babies,” he says. “Access is such a big problem for these patients and, as a hospitalist, it’s just not OK to me anymore. I need to be proactive about finding solutions.”

Dr. Misky’s concerns led him to do research with mentor Eric Coleman, MD, the university’s creator of the Care Transitions Program (, studying patients who lacked primary-care physicians (PCPs) or timely PCP follow-up, and their resulting higher rates of readmissions.1 Dr. Misky also helped develop care pathways, including post-discharge care, for VTE patients, a “common, costly, and dangerous” condition. He is working with a hospitalist colleague to explore how electronic health records (EHR) might be used to help trigger post-discharge follow-up for at-risk patients.

University of Colorado Hospital (UCH), a 425-bed urban academic tertiary-care center, is not the designated safety net hospital for metro Denver, yet 28% to 32% of patients discharged from its medical services are uninsured, Dr. Misky says. He finds that academic physicians at UCH are not always able to take on large numbers of uninsured patients in their clinics, given the productivity demands they face, while the hospital has not been able to participate in systemwide, comprehensive national models for improving care transitions, such as SHM’s Project BOOST ( or Boston Medical Center’s Project RED (

Dr. Misky is in discussions with local community services, such as the Metro Community Provider Network (MCPN) of clinics for underserved patients, and exploring the development of a collaborative model for integrating post-hospital care between UCH and MCPN. “A lot of our ideas are still very exploratory—trying to get the key providers to the table to talk about what these approaches might look like,” Dr. Misky explains. “I’ve been part of ongoing meetings, and I think similar kinds of conversations are happening at many levels at UCH, but there’s not a unified, consensus approach to care transitions—and that’s a problem. But I’m in the midst of it all, trying to highlight the issues and explore solutions.”

This is not a hospital problem—it’s a communitywide problem. So there’s not just a hospital solution; it will take the whole village.
—Patricia Rutherford, RN, MS, vice president, Institute for Healthcare Improvement

Dr. Misky says every hospital-based provider—hospitalist, nurses, social workers—feels the same frustration and worry about the level of care when indigent patients are discharged to the community. Uninsured patients can run into problems post-hospitalization and return to the ED for their primary care because they lack other options, he says. “Without established liaisons to the community clinics,” he notes, “it can take three or four months for a new indigent patient to get seen at one.”

Disproportional Issues of the Uninsured

Hospitalists at San Francisco General Hospital, which is the safety-net provider for the Bay Area, are looking at similar issues, says Jeff Critchfield, MD, division chief of hospital medicine. “What we know about the uninsured is that they have a wealth of other challenges and barriers that they bring to the table,” he says. “First of all, un- and underinsured patients are more likely to have chronic illnesses, to be hospitalized for those illnesses, and then to be rehospitalized after discharge.”

Figure 1. Proactive Steps You Can Take to Improve Care Transitions

Recommendations for hospitalists to improve care transitions for indigent patients, gathered from sources for this article, include:

  • If the hospital doesn’t have a team talking about care transitions, start one.
  • Explore the possibility of a quality improvement project, such as Project BOOST or Project RED. The next deadline for BOOST applications is Aug. 1 (
  • Create a multidisciplinary task force to forge partnerships with primary-care physicians. Find ways to involve them in providing access to indigent patients without placing undue burdens on a few doctors. Find the doctors who are providing pro bono medical care in free clinics or church basements.
  • Screen for eligibility for all appropriate entitlement programs, and get the applications rolling while the patient is still in the hospital.
  • Always ask (respectfully) about housing status as part of the patient’s social history. In addition to patients in shelters or on the street, others may be living in cars or “couch-surfing” with friends and families.
  • Connect with homeless resources, such as medical respite programs, now in 60 communities with 15 more under development, according to the National Health Care for the Homeless Council of Nashville, Tenn. ( Programs rotating medical residents through homeless healthcare services have also been shown to change doctors’ attitudes toward homeless patients.11
  • Avoid generic counseling about exercise or nutrition without first assessing the patient’s living situation and access to needed resources.
  • Know the costs of medications and their accessibility or barriers for a given patient. Learn how to connect patients with indigent drug programs, or have the hospital provide a supply of needed medications to prevent relapse and readmission.
  • Partner in more integrated ways with community health clinics and explore cross-referral relationships that work for both parties.
  • Some hospitals have successfully targeted care transitions for patients with specific conditions, such as heart failure, diabetes or pneumonia. Quantify and stratify the need at your hospital.
  • Home health agencies can be invaluable sources of support for hospitals willing to meet with them to establish working relationships and protocols for indigent patients.
  • Floor nurses often know more about readmission risks and patients’ stories than administrators give them credit for. Find ways to regularly tap into that expertise.
  • Listen to your patients and find ways to include their input in quality initiatives.

Other issues disproportionally impacting uninsured or indigent patients include low literacy, low healthcare literacy, language barriers, cross-cultural barriers, substance abuse and mental health issues, homelessness or marginal housing, transportation barriers, and “social isolation, which also plagues our population and, I believe, places patients at risk, as does depression,” says Dr. Critchfield’s colleague Michelle Schneidermann, MD.

Leave a Reply

Your email address will not be published. Required fields are marked *