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New Design for Discharge


 

With hospitalists playing key roles in improving transitions in care, a new study has tested a low-cost process that shows increases in outpatient follow-up and completed workups soon after hospital discharge.

The improvements potentially could lead to better patient outcomes and lower readmission rates, according to Richard B. Balaban, MD, who as the medical director of Cambridge Health Alliance’s (CHA) Somerville, Mass., primary-care center and a hospitalist at CHA’s Cambridge Hospital has a unique, dual perspective on the discharge process.

Dr. Balaban’s team’s discharge-transfer intervention process, tested in one of the few randomized controlled studies on the subject of transitions of care, is intended to improve communication between hospitalists and primary-care providers, as well as promptly connect inpatients to outpatient providers. It’s also designed to better equip patients to participate in their care and to improve accountability within the medical team.

The study, published in the August 2008 issue of the Journal of General Internal Medicine, garnered praise from Mark Williams, MD, FACP, professor and chief of the Division of Hospital Medicine at Northwestern University’s Feinberg School of Medicine in Chicago and principal investigator of SHM’s Project BOOST study (see “BOOST Sites Chosen,” August 2008, p. 1), which is examining ways to improve transitions of care.1 “This small but well-done study demonstrates how using interventions similar to components in the Project BOOST toolkit resulted in a significant improvement in outpatient follow-up, and a trend toward a reduction in hospitalizations and emergency room visits,” Dr. Williams says.

The four-part process calls for:

  • The patient to receive a comprehensive, “user-friendly” discharge instruction form;
  • Electronic transfer of the discharge instruction form to RNs at the patient’s primary-care site;
  • A primary-care RN to call the patient by the next business day to monitor his or her condition; and
  • The review and modification of the discharge plan by the primary-care provider as needed.

The research team, which included Joel S. Weissman, PhD, of Massachusetts General Hospital, Harvard Medical School, and the Harvard School of Public Health; Peter A. Samuel of Harvard Medical School; and Stephanie Woolhandler, MD, of CHA and Harvard Medical School, thinks the discharge process, a key task for hospitalists, should be treated as vital as the admissions process. “Hospitalists need to improve the level of detail in discharge plans; this form and process supports that,” Dr. Balaban says. By providing this quality information to outpatient providers, collaboration is improved, making hospitalists more effective, he says.

Better process equals better outcomes

The discharge-transfer intervention process studied by Dr. Balaban and his team showed:

  • 14.9% of the “new” process patients failed to follow up within 21 days, compared with 40.8% in the control group and 35% in the historical group;
  • 11.5% of the recommended outpatient workups were incomplete among the new process patients, compared with 31.3% in the control group and 31% in the historical group;
  • Among weekend discharges, 8.3% of the new process patients had undesirable outcomes, compared with 85.7% in the control group and 60% in the historical group; and
  • Among non-English-speaking patients, 21.1% of the new process patients had undesirable outcomes, compared with 55.6% in the control group and 51.6% in the historical group.

Additional Resources

  • Project RED (www.bu.edu/fammed/projectred) is a series of randomized controlled trials at Boston University Medical Center. It is aimed at re-engineering the workflow process to improve safety for patients from a network of community health centers discharged from a general medical service at an urban hospital serving a low-income, ethnically diverse population.
  • Project BOOST (Better Outcomes for Older adults through Safe Transitions) is an SHM initiative charged with improving the care of patients as they transition from hospital to home. For more info, visit www.hospitalmedicine.org/BOOST.
  • The U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality supported two studies that are summarized by “Acute Care/Hospitalization: Studies suggest ways to improve the hospital discharge process to reduce postdischarge adverse events and rehospitalizations.” Visit www.ahrq.gov/research/dec07/1207RA12.htm.

Proof in the Pudding

The process was tested at Somerville Hospital, a 100-bed community hospital and teaching facility affiliated with Harvard Medical School. Approx-imately 25% of Somerville’s patients are non-English-speakers; the process was designed to serve a culturally diverse population.

All patients in the study, conducted between June 2006 and January 2007, had received care from hospitalist-led teams and received outpatient care at CHA facilities. Ninety-six patients were studied; 47 took part in the new discharge process and the rest were discharged according to existing procedures. Outcomes were compared with those of 100 patients who previously had been discharged from the hospital.

The team measured four undesirable outcomes after discharge:

  • No outpatient follow-up within 21 days;
  • Readmission within 31 days;
  • Emergency department visit within 31 days; and
  • Failure by the primary-care provider to complete an outpatient workup recommended by hospital doctors.

The study found just 25.5% of the patients who completed the new process had one or more undesirable outcomes, compared with 55.1% of the control group patients and 55% in the historical group. The most significant improvements were in the rates of outpatient follow-up and completed workups (see “Better Process Equals Better Outcomes”).

The process was especially effective among patients discharged on weekends, and had a greater effect on patients who did not speak English, were hospitalized one or two days, and were age 60 and older. The effect of the new process also was evident in outpatient treatment, Dr. Balaban says. At least seven of the 47 patients discharged through the new process had their treatment plan changed by the RNs who made the follow-up phone call. “They weren’t big changes, things like calling in prescriptions and making urgent appointments,” he says, “but they made a difference: for example, providing a pneumonia patient with a thermometer to monitor possible infections, and a scale so that a patient with congestive heart failure could monitor weight gain possibly caused by harmful retention of fluid.”

Dr. Balaban’s team plans to conduct a larger study, though not randomized, at Cambridge Hospital to test the new process on all discharges. “There usually is little collaboration on discharges,” Dr. Balaban says. “This process provides detail, a record of critical information, and creates interchange between care teams. Discharge should be looked at as a continuing, key part of care.” TH

Karla Feuer is a freelance writer based in North Carolina.

Reference

1. Balaban RB, Weissmann JS, Samuel PA, Woolhandler S. Redefining and redesigning hospital discharge to enhance patient care: a randomized controlled study. J Gen Intern Med. 2008;8:1228-1233.

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