Ashish K. Jha, MD, MPH, K.T. Li Professor of international health in the department of health policy and management at the Harvard School of Public Health and director of the Harvard Global Health Institute in Boston, is both a practicing hospitalist and a widely published researcher in the middle of a teeming national debate about hospital readmissions policy.1 He’s seen his fledgling field of hospital-based internists grow from a few hundred two decades ago to nearly 50,000 hospitalists spanning every state. He’s also seen changes in the role hospitalists play in the inpatient setting.
“Now, when it’s time for my patient to get discharged, I ask a lot of questions like, ‘Who is with you at home? How will you get your medications or your groceries?’” says Dr. Jha, who practices hospital medicine at the VA Boston Healthcare System.
Hospitalist care went under Medicare’s microscope in October 2012, when the Hospital Readmissions Reduction Program (HRRP) began penalizing hospitals with higher-than-predicted rates of 30-day readmissions for certain common conditions (see “Optimal Discharge Checklist for Hospitalists”). HRRP places hospitalists under greater scrutiny for things that happen to their patients after discharge, whether to home or another healthcare facility. In one swoop, the program changed how the healthcare system views care transitions, continuity of care, teamwork, collaboration, and the post-discharge period.
Experts in improving transitions of care—which, it is hoped, would ameliorate the problems that lead to readmissions—emphasize the importance of teamwork across disciplines, specialties, and care settings; dialogue and collaboration between providers; and the formation of community coalitions and integrated systems of care.
Many of the factors that influence the likelihood of readmission are nonmedical, however: socioeconomic status, health literacy, home environment, adherence to prescribed medications, and the ability to make—and keep—follow-up appointments. So, while social variables are an essential part of the readmission conversation, a hospitalist often has no remedy to address—let alone prevent—them.
And therein lies the debate: At what point do hospitalists stop being responsible for discharged patients?
“The part we own is communication, and lack of communication is a problem. But if there is to be a handoff, at some point you have to cut the cord,” says David J. Yu, MD, MBA, FACP, SFHM, medical director of the adult inpatient medicine service at Presbyterian Hospital in Albuquerque, N.M.
Dr. Yu agrees that hospitalists are responsible for the quality of their discharges. Readmissions, he says, are a system issue. Although hospitalists have a responsibility to help drive quality improvement in the hospital, he says it makes little sense to hold the hospitalist responsible for what happens to the patient after discharge.
“I believe that when we talk about hospitalist-staffed post-discharge clinics and things like that, we’re asking the wrong questions,” he says. “We’re turning the hospitalist into a temporary PCP. Those things are only temporary solutions.”
Some hospitalists see this issue as black and white, arguing that their focus should be on caring for “inpatients,” working strictly according to the definition of a hospitalist. They ask a very simple question: How long can responsibility linger once the patient exits our facility?
Others, like Dr. Jha, choose to “own” care transitions into the post-discharge period.
“I tell my residents that I’m accountable for what happens to the patient after discharge. It’s now part of my job,” Dr. Jha says. “Some of that can be outsourced to social workers, but some only I can do. Some of my colleagues don’t like it, but I say no one comes off our service until at least two or three days after discharge. We follow up on pending lab results. The hospital makes a post-discharge phone call. We’re reachable by phone. We’re still taking care of the patient but in a different way.”
Dr. Jha agrees it’s not reasonable to expect hospitalists to take responsibility for what happens to their patients 30 days after discharge, the standard of such performance models as HRRP.
“But I believe you can push me and my team to step up for a few more days,” he says. “I’ve had patients come back to the hospital the next day. Hey, that means I dropped the ball.”
Yet, the middle ground, from a few days after discharge to 30 days, can seem like an eternity.
“If we think our role completely ends at the time of discharge, what tends to happen is we take our foot off the gas,” says Win Whitcomb, MD, MHM, co-founder of SHM, practicing hospitalist, and CMO of Remedy Partners, a firm specializing in bundled payment programs. “We back off from the patient being discharged and start focusing on the next acutely ill patient who just got admitted.”
At a minimum, Dr. Whitcomb says he believes that hospitalists should place a direct phone call to the PCP, preferably before the patient leaves the hospital, although he acknowledges that this is the exception rather than the rule for most hospitalists today.
“You learn things about the patients and their history,” he says, that might be important to the next provider.
Pending lab tests at the time of discharge are another big issue, most experts on readmissions agree. If the hospital doesn’t have a system for ensuring that these results are properly passed on to the next provider of care, the hospitalist group should be spearheading a quality improvement (QI) process to make it happen. Even so, Dr. Whitcomb says hospitalists should not be trying to fix these problems in a vacuum. For example, they should partner with others in the hospital working on readmissions issues and coordinate their post-discharge phone calls to patients with other groups that may be placing similar calls.
“The individual hospitalist is responsible for working with the hospital team to ensure that the patient understands the post-discharge plan of care, that medications are reconciled, and that there is a system for transmitting information to the PCP,” he says.
What Is a Satisfactory Discharge/Handoff?
Experts can agree on one thing: A successful discharge (or handoff) is paramount to preventing what are considered “avoidable” readmissions (see “What We Already Know about Hospital Readmissions”). Exactly what a successful discharge looks like, however, is not as easily defined.
Most agree hospitalists are responsible for making sure that patients understand their condition, treatment plan, what to watch for, and where to go or who to call in a crisis. This means short, digestible, actionable, tailored advice utilizing “teach-back” and other techniques that clarify for the physician whether patients truly understand what they need to know. Some hospitalist groups task a member of the group to be available for the questions that can arise in the first few days after discharge. Some argue hospitalists should provide contact information, even a pager number, to patients going home from the hospital.
Hospitalists should communicate critical information about patient care to the outpatient provider via faxed or e-mailed discharge summaries, phone calls, or other prearranged forms of contact. Breakdowns in this communication have been well documented, as in the 2007 JAMA study that found that only 12% to 34% of discharge summaries had reached the PCP by the time of the first post-discharge medical visit.2 Other studies have found that PCPs were not aware of important test results for recently discharged patients roughly 60% of the time, and one in three adult patients discharged from hospital to community didn’t even see a physician within 30 days.3.4
Seriously or chronically ill hospitalized patients need help making an appointment for their first post-discharge medical visit; staff should also work with the patient and/or caregiver to make sure they have transportation and can keep that appointment. Patients who don’t have a relationship with a PCP or can’t get an appointment soon enough to forestall potential bounce-backs face an additional challenge.
Some hospitals have developed relationships with community clinics, specialty groups, and other providers who might be able to see the patient more quickly. Others have developed post-discharge clinics on the hospital campus, where the patient can come back for a first follow-up visit with a hospitalist. A medication reconciliation process, drawing upon a best possible medication history conducted within the hospital, is important.
Although it makes sense to try to figure out who needs the most attention, Dr. Maynard says there is no national consensus about the optimal tool for assessing the patient’s risk of rehospitalization. A number of factors considered likely indicators can help focus the team’s attention on those at higher risk, such as patients who are very elderly, have certain diseases like heart failure, take problem-prone medications like warfarin or insulin, have complex medical needs or social circumstances, suffer a lack of financial resources, and have behavioral health overlays.
SHM’s quality improvement toolkit, Project BOOST, offers expert mentored implementation and a variety of other resources to help hospitals get a handle on their care transitions. BOOST now features a readmissions risk assessment tool called the “8Ps”.
SHM has been on record since November 10, 2010, saying that “reducing unnecessary readmissions through improvements in the hospital discharge process is a high priority” for the society and its members, because readmissions are a cost for both the system and the patient—and are often preventable.5 Project BOOST is the society’s major contribution to improving care transitions, but SHM also offers other readmissions resources for hospitalists through its Leadership Academy, Quality and Safety Educators Academy, and other QI tools, says Eric Howell, MD, SFHM, chief of hospital medicine at Johns Hopkins Bayview Hospital in Baltimore and a former SHM president.
Dr. Howell agrees a hospitalist’s responsibility doesn’t end at the hospital door but acknowledges that it is “difficult to say exactly where it ends.”
“I’m not sure we ever end our relationship with our patients, whether they come back to the hospital or not,” he says. “In our practice, we are available to the patient by telephone, with no formal end point.
“I feel more comfortable as a hospitalist with my responsibility ending when I have completed a good handoff to the next provider,” he says, adding that “good handoff” means that the receiving provider acknowledges receiving it and has a chance to ask questions. “There may be information I can provide to the outpatient provider or, if the patient is readmitted, to whomever cares for them next in the hospital.”
Hospitalists have played a key role in highlighting the problems of a fragmented healthcare system, with its inadequate care transitions and follow-up, problems that long preceded the emergence of hospital medicine, Dr. Howell says.
“As a hospitalist, I want my service to try to make the world a better place and to fix the broken incentives that are now in place,” he says. “Whether or not you believe that hospital medicine has introduced its own dyssynchronies on transfers of care, it’s still our responsibility to try to improve the processes.”
Healthcare is moving toward integration of services, a process that muddies the waters somewhat when it comes to determining who is accountable for readmissions, says Nancy Foster, the American Hospital Association’s vice president of quality and patient safety policy.
“Every one of our members who is actively engaged in integration tells us that not all of those readmissions we might have thought preventable are,” she says, “but they were also surprised at how many we could prevent with better education and communication.”
The new penalties for readmissions are encouraging hospitals do a better job with their care transitions, Foster says. That pressure has helped hospitals to deliver better care, and hospitalists are a “critical piece of the puzzle.”
“When you get patients coming back, analyze what went wrong and reach outside your four walls to other providers,” Foster says. “Those are important opportunities for improvement.”
Rachel George, MD, MBA, SFHM, CPE, now system vice president for Presence Health in Chicago but formerly central business unit president for Brentwood, Tenn.-based Cogent Healthcare, says that when she was at Cogent, the company developed a readmissions playbook for its physicians. Cogent, which was acquired by Seattle’s Sound Physicians late last year, included readmissions in the quality conversations it had with its contracting hospitals, she says, although those conversations varied widely in terms of the resources dedicated to improving care transitions.
“How do you make sure the necessary communication happens?” Dr. George poses. “We believe everybody has a role, but in the hospital, the hospitalist is definitely the captain of the ship.
“It’s not as clear who is the captain of the ship when the patient goes home. Do we need to send someone out to the patient’s house to see what they have in their medicine cabinet?”
Ultimately, she says, it is up to the individual provider to use resources and implement processes that have been developed.
“Cogent always believed in quality as a business strategy, putting part of its payment at risk, but it was not clear that it could use incentives for readmissions rates for individual hospitalists. Hospitals’ incentives are undergoing evolution and are very different than physicians.’”
Randy Ferrance, DC, MD, FAAP, SFHM, medical director of the hospitalist service at Riverside Tappahannock Hospital in rural Virginia, says his hospital recently incorporated readmissions rates into the quality metrics that factor into the five-member hospitalist group’s collective bonus pay.
“The problem with readmissions incentives is who gets assigned the ‘blame,’” he says.
Incorporating readmissions into bonuses and penalties for hospitalist groups is likely to become an increasing trend, says Leslie Flores, MHA, SFHM, of Nelson Flores Hospital Medicine Consultants. She and partner John Nelson MD, MHM, are seeing that trend “as a bonus component in our clients’ incentive plans, whereas five years ago it was uncommon.”
SHM practice data support this observation, Flores says, with 46.1% of adult medicine hospitalist groups in 2013 reporting the use of readmissions rates as part of performance incentives.6
Dr. Nelson, a co-founder of SHM and a longtime practice management columnist for The Hospitalist, says a bonus based on readmissions rates might be reasonable, although it’s important not to create incentives that deny the patient a needed return to the hospital in order to ensure that the hospitalist gets the bonus. Competing pressures on performance for both shorter lengths of stay in the hospital and fewer readmissions complicate incentives for hospitalists. “Compensation incentives [bonuses] based on both length of stay and readmissions are problematic, because they could potentially be construed as incentives to deny needed care, so [they] are best avoided,” Dr. Nelson says.
The Wrong Target?
HRRP has generated a huge amount of commentary in the health policy media. Some charge that it unfairly penalizes teaching hospitals and large institutions, as well as those serving a greater proportion of patients with lower socioeconomic status or those with fewer social supports.7
In a New England Journal of Medicine editorial, Dr. Jha and co-author Karen Joynt, MD, MPH, ask “whether the hospital is the appropriate entity to be held accountable for readmissions, given that the events and circumstances that predict readmissions largely take place outside the hospital’s walls.”7 Dr. Jha doesn’t consider readmissions rates a true measure of a hospital’s quality.
“I think the real goal should be improving transitions of care—with better quality measures for assessing good transitions,” he says. “You can improve transitions of care without improving readmissions rates.”
A serious disconnect exists between readmissions penalties and evidence for strategies that might be expected to prevent them, says Bradley Flansbaum, DO, MPH, MHM, a hospitalist at Lenox Hill Hospital in New York City and blogger for The Hospital Leader.
“As much as we might be held accountable for certain outcomes like readmissions, the reality is we can’t control them,” he says. “There are so many other factors out there that we don’t know about. Is the readmissions rate a good proxy for quality? We’ve seen evidence that it doesn’t relate very well to mortality rates.”8
Assessing blame can be a slippery slope, some experts say.
“My first message to my hospitalist colleagues—myself included—is to try to stop reacting as if this were about individual blame for the discharging hospitalist,” says Amy Boutwell, MD, MPP, founder of Collaborative Healthcare Strategies, who practices HM at Newton-Wellesley Hospital in Newton, Mass. “Certainly, that’s not how CMS views it. They are incentivizing hospitals and providers to improve systems of care and provide new and better types of continuing care.”
Dr. Boutwell, who is also an attending physician at Massachusetts General Hospital in Boston, sees the good in programs such as HRRP.
“[The program] has done a good job of mobilizing resources where previously very little attention had been given,” she says. “It aimed to catalyze investments in readmissions reduction, and that has occurred.”
Often, when hospitalists don’t do an “adequate job” of preparing their patients for discharges, including failures in communicating with outpatient providers, patients are in a catch-22.
“In many cases the PCP may tell the patient, ‘I don’t know enough about your case. I need you to go back to the hospital,’” Dr. Boutwell says. “That’s a big part of what we’re trying to avoid.”
Larry Beresford is a freelance writer in Alameda, Calif.
- Joynt KE, Jha AK. A path forward on Medicare readmissions. N Engl J Med. 2013;368(13):1175-1177.
- Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297(8):831-841.
- Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005;143(2):121-128.
- Sommers A, Cunningham PJ. Physician visits after hospital discharge: implications for reducing readmissions. National Institute for Health Care Reform Research Brief No. 6. December 2011. Available at: http://www.nihcr.org/Reducing_Readmissions.html. Accessed March 12, 2015.
- Society of Hospital Medicine. Reducing readmissions and improving care transitions. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Where_We_Stand&Template=/CM/HTMLDisplay.cfm&ContentID=27513. Accessed March 12, 2015.
- Society of Hospital Medicine. 2014 State of Hospital Medicine Report. September 5, 2014. Philadelphia: Society of Hospital Medicine; 2014:84.
- Abelson R. Hospitals question Medicare rules on readmissions. The New York Times. March 29, 2013. Available at: http://www.nytimes.com/2013/03/30/business/hospitals-question-fairness-of-new-medicare-rules.html. Accessed March 12, 2015.
- Krumholz HM, Lin Z, Keenan PS, et al. Relationship between hospital readmission and mortality rates for patients hospitalized with acute myocardial infarction, heart failure, or pneumonia. JAMA. 2013;309(6):587-593.