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
“Most of this is common sense and courtesy but hard to deliver reliably.”—Gregory Maynard, MD, MSc, SFHM, clinical professor, chief quality officer, University of California Davis Medical Center, Sacramento
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.”