Cover the Gray Zone
Hospitalists describe differing approaches to ensuring patients get the care they need when they leave the hospital.
In the case of the UWHC patient who wanted to leave the hospital, the hospitalist team arranged to stay in touch with the patient. They watched for the test results during the next 24 hours. When the test came back positive, they called the patient back to the hospital, and began treatment.
“Although tracking test results may be out of the hospitalist’s purview, I think we have a strong obligation to make sure we look at some of that data,” Dr. Wright says. “I think there has to be some redundancy, otherwise, the patient probably would not have seen the primary care physician in time and would have become more ill.”
Attention to detail before discharge can avoid problems in the post-discharge period. Partnering with the pharmacy to achieve medication reconciliation has been shown to reduce risk of readmission, notes Tom Bookwalter, PharmD, associate professor of health sciences at the University of California San Francisco School of Medicine and formerly clinical pharmacist there. Using standardized templates and electronic medical records (EMR), hospitalists at many academic centers can furnish real-time discharge summaries to patients’ primary care physicians.
Dr. Yu is especially proud of the EMR system at his institution, by which discharge summaries are faxed to the primary care physician (PCP) in real time. “A patient can call their primary care physician right after discharge, and that physician will know exactly what happened during the hospital course, and what the medications and the discharge plan are,” he explains.
In addition, computerized entry and transmission eliminates the risk of error introduced when handwritten instructions are given to patients. “We believe that communication is the ‘mother’s milk’ of the hospitalist,” Dr. Yu says. Accordingly, his hospitalist service also makes a courtesy call to the PCP following transmission of the EMR for the patient.
Attorney Patrick T. O’Rourke of the Office of University Counsel at Colorado University in Denver and legal columnist for The Hospitalist, advises how to avoid inviting unintended legal consequences. “It’s important for hospitalists to understand that they are the conduit of information about what happened during the hospitalization,” he notes. “Failing to define everyone’s job in the discharge process can expose people to liability.”
In that vein, he urges hospitalists not to delegate the process of giving discharge instructions to the patient. Patients should hear directly from the hospitalist about their condition, the recommended course of action, and how to respond in case of emergency post-discharge. When returning the patient to their regular physician, the hospitalist should also touch base with the patient’s physician via e-mail or telephone to prevent gaps in communication.
If budgets allow, some groups employ ancillary staff who call patients after discharge.
Hospitalist David Grace, MD, area medical officer for the Schumacher Group, Hospital Medicine Division, in Lafayette, La., reports that having a practice coordinator who calls patients within 48 hours of discharge “adds one more layer of safety to the process.” “Yes” answers to some questions (e.g., “Have your symptoms worsened? Do you have any new symptoms?”) trigger follow-up calls to the on-call hospitalist to take appropriate steps. However, O’Rourke cautions that midlevel providers should possess adequate training to be able to act appropriately upon patients’ information.
Hospitalist Randy Ferrance, DC, MD, medical director at Riverside Tappahannock Hospice in Tappahannock, Va., agrees follow-up calls to patients are a good idea. “I think more aggressive follow up in the short term, and then turning the patient over, for continuity reasons, to their primary care physician as quickly as possible is very important.” His hospitalist group, comprising only four staff, struggles with having the time to devote to such activities. However, with an average inpatient age of 72, their patients often transition to home healthcare. His group enjoys an “excellent relationship” with all the area home health agencies. Those agencies are asked to call the hospitalist group during their first visit with the patient, in addition to sending their usual report to the primary care physician. “At that first home health visit, we consider ourselves still responsible for the patient,” he says.