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Moving Out


 

This article is the second in a series on the hospital of the future, designed to get our readers thinking and planning ahead for their own facilities.

Hospitals across the country wrestle with improving their discharge process, whether the goal is gaining a more time- and cost-effective outcome for the facility, or improving quality measures for patients upon departure, or both.

“A lot of people are attacking discharge problems from a lot of different angles,” says Vineet Arora, MD, academic hospitalist and researcher, University of Chicago Pritzker School of Medicine.

What will hospital discharge look like in the future? Based on current research, trials, and trends, it seems there are few surprises down the road in this area. The changes will come in the form of fine-tuning critical areas in the process rather than implementing new technology to radically change the way we release patients. Positive changes seem to be people-based rather than computer-based.

“Everybody’s on the technology bandwagon, but we have to understand the processes first,” says Lakshmi Halasyamani, MD, associate chair for the Department of Internal Medicine, St. Joseph Mercy Hospital, Ann Arbor, Mich. “Better technology won’t make care safer or more efficient. We have to examine how we organize care delivery, then look at technology. Otherwise it replicates the inefficiencies we have now.”

Here are some predictions for how the discharge process will be improved in the hospital of the future.

Our series continues with a look at discharge planning

THE DISCHARGE PROCESS WILL BE SMOOTHER AND SAFER

Most hospital-based professionals agree that discharge is an area of care that needs more attention.

“Every day that you’re [in the hospital], we spend a little less time with you,” says Dr. Halasyamani. “We undervalue the risk of discharging patients; we need to focus on [the patients] more. The nurse calls us, and we get the discharge done as quickly as possible.”

In the hospital of the future, the discharge process will be driven by specific structured guidelines that ensure patients safety when they leave the hospital. Every discharge will involve a multidisciplinary team, with members signing off that the patient is not only ready to leave the hospital, but informed about their condition and any next steps, and has necessary medications or prescriptions in hand.

As for improving efficiency, minor changes can make a big difference. Chad Whelan, MD, assistant professor of medicine, University of Chicago Hospitals, is part of a task force working on how to move hospital discharges earlier in the day.

“An earlier discharge is better for everyone, including the patient—especially if they’re being transferred to another facility,” he points out. “One thing we’re looking at is the way diagnostic tests are categorized. Everything falls into two categories now: emergency diagnostics and everything else.”

Dr. Whelan and the taskforce have asked departments, including radiology and other labs, to create a third category: for patients waiting for a test before they can be discharged. All it takes is one question on the part of the service provider: “Is this patient waiting for these results before she can go home?” to move that patient to the front of the line.

Another recommendation Dr. Whelan’s task force will make involves staffing up. “Like we ramp nursing staff up and down depending on the census, we are looking at doing that with case managers and ward clerks to handle heavy discharge times,” he says.

David J. Rosenman, MD, senior associate consultant, Hospital Internal Medicine, Mayo Clinic in Rochester, Minn., suggests that paperwork might also be changed. “The discharge summary of the future will be more visual,” he predicts. “There are ways of displaying information that are more sophisticated and probably more helpful than static lists and linear prose alone.”

SHM to Provide Discharge Guidelines

SHM received a grant from the John A. Hartford Foundation to examine and improve the geriatric discharge process. A group of volunteer researchers are compiling information from three demo sites to create quality indicators around care transitions. In 2006, their findings will be available to benefit other SHM members in the form of a toolkit for discharge planning. This toolkit will include a process guideline, or checklist, for hospitalists to apply in their own organizations.

“A process guideline is unusual in healthcare,” admits Dr. Halasyamani, who is involved in the grant project. “Guidelines are usually clinical. SHM is working on several other initiatives that will also become process guidelines for key issues.”

SHM will hold a workshop on “Transition of Care” at its 2006 Annual Meeting, May 4-5, Washington, D.C. Visit www.hospitalmedicine.org for more details.—JJ

EMPOWERED PATIENTS

One change we are likely to see is patients taking on the responsibility of their own medical information. Ideally, the patients themselves will make caring for—and discharging—them easier and more efficient by sharing complete information on their current medications and other healthcare details that are often forgotten or overlooked by a provider or caregiver.

“The future of discharge lies with our ability to arm patients with their own information,” says Dr. Arora. “The more empowered the patient is, the better the outcome.” Personal health records (PHRs) are one solution. MyPHR is one online product, offered free by the American Health Information Management Association (AHIMA). Roughly 30 companies currently offer paid subscription PHR services to consumers. Peoplechart Corporation (San Francisco) is one of them and provides a single source of information controlled by the patient.

“We’re a pioneer of the PHR idea,” says Megan Mok, president and founder, Peoplechart Corporation. “There are not that many out there.”

Healthcare consumers can subscribe to a variety of Peoplechart tools and services (including initial collection of their records) that allow them to gain access to their comprehensive medical records via the Internet—or phone, if they choose—and to grant any given healthcare provider access to part or all of their records.

“Everything is patient-initiated and patient-controlled,” explains Mok. “There’s a big difference from systems controlled by providers, which may allow patients access, but not ownership.”

PHRs typically offer a comprehensive, integrated overview of an individual’s health data, including information that individuals add themselves on their symptoms and prescriptions, along with information such as diagnoses and lab results. Once a discharged patient updates her PHR, she can share her complete hospital records with her primary care physician, physical therapist, rehab facility, or whatever caregiver requires the information. This will save time and effort for all healthcare providers, and, more importantly, ensures that essential information is available.

Regardless of whether a patient has a PHR, physicians and other staff must ensure that the individual leaves the hospital with complete information on their care and medications.

“Discharge is a quality measure,” says Dr. Arora. “We need a multidisciplinary approach to address what each patient needs to go home.”

In the hospital of the future, the discharge process will involve a multidisciplinary team, which will ensure that the patient is ready to leave the hospital, informed about their condition and any next steps, and has necessary medications or prescriptions in hand.

DEMYSTIFIED MEDICATIONS

In the very near future, the 2006 JCAHO standard for medication reconciliation will eliminate many problems with medications after discharge.

“This standard is extremely important,” says Dr. Rosenman. “Almost half of medication errors occur at transition points in a patient’s care. Reconciling medication lists—especially at these points—is critical to ensuring patient safety.”

The medication reconciliation form could conceivably morph into something broader in the future. “It would be nice for the medical record to be a living document that evolved with each encounter over the course of a patient’s life,” says Dr. Rosenman. “People may someday carry replaceable, updatable, credit-card-like medical cards or chips. In the meantime, we need to do our very best to keep medication lists and related data accurate and complete.”

While the patient will own his or her medical information, “the burden for ensuring the med list is accurate falls entirely on the healthcare organization,” insists Dr. Halasyamani. “This is a ripe opportunity to partner with the patients themselves. They and their families own the information. We have to help patients be stakeholders and give them the tools to manage their ever-changing medications and their healthcare.”

Many paper-based and computerized tools exist now, but there is no obvious standout product or method physicians can provide to patients that will ensure they take their prescriptions correctly on an ongoing basis.

“Health systems will have to develop a standard” for helping patients manage their medications, says Dr. Halasyamani. “Strategies must be low-tech but get the job done. They must resonate with things that patients already do, like paying bills.”

COMMUNICATION STILL CRITICAL

One step in the discharge process that ensures a smooth transition for inpatient to outpatient is communication with the professionals, facilities, or caregivers who will take over the patient’s care.

“The gap in care after discharge puts patients at risk for adverse events,” warns Dr. Arora. “One reason for this vulnerable gap is the flow of information between settings and teams of providers.” In the future, hospitals will better manage this essential transfer of information.

Typically, the patient’s primary care physician wants information from the hospital at admission and at discharge, and, if the primary care physician wishes, in between.

“We need to improve communications with primary care physicians in a way that respects their wishes for communication,” says Dr. Arora. The UCSF Hospitalist Group is already working on this.

“Until recently, we provided fax copies of our notes to primary care physicians. Now we have a new dictation system,” says Steven Pantilat, MD, FACP, SHM president. “We did a survey that found that most physicians want telephone contact at admission and at discharge, plus any major occurrences in between. The ability to exchange information in real time is important—and e-mail is not realtime.”

How does a hospitalist keep track of everyone’s communication preferences? “The hospitalist simply has to figure out what each primary care physician wants,” stresses Dr. Pantilat. “My sense is that in any hospital, there is a limited number of doctors or practices to deal with. How do you keep them all straight? Well, the same way a hospitalist keeps all the various nurses straight—you just do. It’s your business.”

PLANNED FOLLOW-UP

In the future, nearly every discharged patient will be contacted within two or three days by the hospitalist or another hospital medical staff. This may come in the form of a phone call to the patient to check on their overall health, symptoms, and medications. Or it may be a more hands-on approach.

The UCSF Medical Center has established a follow-up service to provide care to patients during the transition period immediately following discharge.

“This service was designed for patients who couldn’t otherwise be followed up on or those who would benefit from seeing the doctor who treated them in the hospital,” explains Dr. Pantilat, who initiated the idea for the service. “For example, if a patient with DVT was discharged, is the swelling smaller? The primary care physician can’t say—he didn’t see it.”

Out of more than 2,600 discharges during 1997-1998, the first year that the follow-up service existed, only 47 patients were prescribed with follow-up visits. “It was never meant to be a highly utilized service,” says Dr. Pantilat, “but to be a highly expandable, flexible service that addresses the needs of specific patients.” Of those 47 patients, four were readmitted to the hospital—one directly from the follow-up visit—compared with a national readmission average of 14%.

“We see these patients in the ED,” says Dr. Pantilat. “It’s the only department that’s open 24/7, and the ED has some extra bed capacity.”

When the hospitalist feels a follow-up is necessary, he or she schedules a visit with the patient before discharge for midmorning one or two days after discharge. (Midmorning is typically a slow time in the emergency department.) He then faxes the appointment information to the emergency department, so that when the patient shows up, she is preregistered. The emergency department telephones the hospitalist when the patient arrives, and that doctor then comes down to see the patient. The emergency department physicians have nothing to do with these follow-ups, though the nursing staff might be asked to help. Also, follow-up visits are considered an outpatient service and charged as such. “The follow-up service was established and run at virtually no cost,” says Dr. Pantilat.

Even if every hospital doesn’t arrange in-person follow-ups, there will be some form of contact after discharge. “Hospitals providing care in transition will expand a lot,” he explains, “whether it’s phone calls from a nurse or other healthcare professional or some other contact during that gap until a patient can re-establish with their primary care physician. Not every patient needs this, but a lot would benefit.”

THE HOSPITALIST ROLE IN DISCHARGE

As we move toward creating a better discharge process, hospitalists will be at the center of that change and the process itself.

“The hospitalist is the keeper of information,” says Dr. Arora. “They know why certain care decisions were made. This movement depends on the flow of information to help design systems to help implement communication.”

There are some barriers to a smooth discharge process that only hospitalists can eliminate. “The increased use of hospitalists means that patients are not familiar with their doctor” in the hospital, says Dr. Arora. “When they leave the hospital, some information stays behind. They don’t know who to call for that follow-up lab work prescribed in the hospital. … The hospitalist needs to do a better job of telling patients who they are and how to reach them after discharge. A systems-based solution, or solutions, is needed.”

It is up to hospitalists to ensure that their discharge system works, that each patient leaves with an understanding of next steps in their care and knows who to call for which specific follow-up step, and with contact information if they (or their primary care physician) need to reach their hospitalist.

Dr. Halasyamani believes that hospitalists are well positioned to implement change in general within their systems. “The hospitalist is in the trenches, in a position to see what changes have to take place,” she says. “It’s their role to inform their management of better processes.

Each of us needs to be a waver of the banner for new standards—it’s not good enough to just scribble prescriptions”

CONCLUSION

The future is coming fast, for improved hospital discharge as well as other everyday processes. “We’re learning that discharge should be a more structured, formal process,” says Dr. Whelan. “We’d like to move to a safer, more complete and more efficient way of handling it.”

Consider what your own facility is doing regarding discharging patients. If there is room for improvement, can you envision a way to bring that process into the future? TH

Jane Jerrard will continue writing the “Hospital of the Future” series this fall.

Flashback:

Colonial Hospitalists

250 years of admissions and discharge

The hospital-based physician must deal with many arcane and Byzantine criteria for admission, care, and discharge of patients. There are regulations for record-keeping and concerns about length of stay. Becoming a staff member may involve physician credentialing, and practitioners from other states or countries have to meet more rigorous standards.

This previous paragraph was not written about modern-day America. These issues are lifted from the “Rules and Regulations of the Pennsylvania Hospital” approved by the Board of Managers in 1752.1 The Pennsylvania Hospital was founded that year under the guidance of Benjamin Franklin. The facility was dedicated to care for the sick and poor. Among the biggest obstacles to its creation was fundraising. Franklin’s accounts of the early years of this institution included a final page with a useful form for donating money.

Hospitalists today face many of the same issues, including admission and discharge criteria, concerns about funding, and practice regulation, as their peers in 1752.

ADMISSION AND DISCHARGE CRITERIA

In 1752 there were 15 rules for admission and discharge of patients, as well as regulations for patients’ behavior while hospitalized. Among the most interesting:

  1. No patients can be admitted if deemed incurable, lunaticks [sic] excepted, nor any case not requiring special services of a hospital.
  2. No admits for smallpox, itch, or other infectious distempers unless proper apartments [isolation] available. Admits found to have the above will be discharged.
  3. No admits of women with small children. Hospital will not maintain childcare facilities.
  4. Persons admitted as above must provide funds for their own burial in case of their own demise.
  5. 5. One bed to be held for a trauma case.
  6. Patients will be discharged when cured or judged incurable
  7. All cured patients must sign a release stating their cure and the benefit received from the hospital for use by the hospital managers.
  8. No patient may leave the facility without a physician release. They may not swear or curse, get drunk, behave rudely or indecently, on pain of expulsion at first admonition.
  9. No patient may gamble or beg.
  10. Patients will aide in nursing other patients when able. This will include washing and ironing the linen and cleaning the rooms.

The Hospital Management Board was responsible for choosing a staff of six practitioners to manage these patients. There were guidelines for who could fill this job.

RULES FOR CHOICE OF PHYSICIANS AND SURGEONS

There were the rules in place in 1752 for choosing physicians and surgeons who could work in the hospital; the most interesting was that applying practitioners must be 27 years old, have served an apprenticeship in Philadelphia, have studied “physick” or surgery for seven years or more, and have undergone an exam by six hospital practitioners. Visiting practitioners had to reside in the city for three years before applying and then had to qualify under the same criteria.

LENGTH OF STAY

There was a significant interest in abstracting the admit diagnosis, length of stay, and outcome. The disposition of patients admitted during the first two years of the hospital’s existence, ending in April 1754 was presented in a modern format.

There were 117 admissions, with 60 cures. Eleven patients were relieved, though not cured. Seven were deemed incurable, 10 were taken away by friends, and 10 died. Three were discharged for irregular behavior, and 16 remained hospitalized.

The most common admission diagnosis was ulcers, representing almost a third of all admits, followed by lunacy. Other frequent diagnoses were dropsy (congestive heart disease), scrophulous and scorbutic diseases (extrapulmonary tuberculosis and scurvy) and rheumatism.

The highest mortality was for consumption, at 100%. The two patients admitted with flux (diarrhea) and prolapsus ani also died. Dropsy carried a 33% mortality rate, without the benefit of the latest medical innovation, foxglove (digitalis), which would be described a few decades later.2 Also notable is death from scurvy, the cure for which was described in 1753 by James Lind.3

The managers were pleased with the performance of the facility. They believed that their efforts had resulted in “good” for the 60 persons afflicted with “various distempers” who were cured and that many had received considerable relief. This was accomplished despite the limited amount of funds available, thanks to careful attendance afforded to the sick and poor, as well as proper diet and availability of medicines. Based on these favorable reports, the Board of Managers requested further funding.

Two hundred and fifty years later, physicians face many of the same issues, including admission and discharge criteria, concerns about funding, and practice regulation. Their actions continue to be monitored, and it is likely that the same will be true in the future. Hospital administrators remain frugal, and we are admonished, in the words of Benjamin Franklin, writing in Poor Richard’s Almanac, “A penny saved is a penny earned.”

—Jamie Newman, MD, FACP

REFERENCES

  1. Franklin B. Some Account of the Pennsylvania Hospital 1754. (Facsimile Edition.) Baltimore: The Johns Hopkins Press; 1954.
  2. Withering W. An Account of the Foxglove and Some of Its Medical Uses. Birmingham, England: M. Swinney; 1785.
  3. Lind J. A Treatise of the Scurvy. Edinburgh, Scotland: Sands, Murray and Cochran; 1753.

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