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.
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.