Hospitalists at the "Management of the Hospitalized Patient" conference, Oct. 14-16 in San Francisco, expressed frustrations during an interactive presentation on how to reduce preventable rehospitalizations.
Participants described the challenges of high-risk patients who lack insurance coverage and a relationship with a primary care physician (PCP), which can negate streamlined outreach to PCPs at the time of discharge. “The people who least need follow-up, I'm able to call their physician. But it seems like the ones who most need follow-up care are the hardest to reach a PCP," one hospitalist observed ruefully. Participants also acknowledged steep learning curves for electronic medical records, even though they hope these could facilitate better discharge processes in the long run.
And careful patient education might not help with cases like the 75-year-old heart failure patient described in the July 28, 2009, issue of The Wall Street Journal, cited by the presenters as a typical example of readmission risk. Despite targeted education on the need to reduce her sodium intake, the patient insisted on eating a hot dog at a Fourth of July picnic and was readmitted to the hospital the following day.
Presenter Michelle Mourad, MD, medical director of CHF and Oncology Hospitalist Services at the University of California at San Francisco, which sponsors the annual conference, challenged hospitalists to identify readmission risk factors for their patients, including diagnoses of heart failure, pneumonia and COPD, high-risk medications and polypharmacy, poor health literacy, poor social support, and advanced age. Patients at risk could then become the focus of strategies designed to minimize rehospitalizations, including follow-up phone calls post-discharge and scheduling a visit to a PCP before the patient leaves the hospital.
Hospitalists have an important role in improving the quality of discharges at their hospitals, Dr. Mourad said. They can start by convening a multidisciplinary team of stakeholders that assesses current practice and designs process improvements.
“At UCSF, our discharge process was broken,” she says. A new QI process led to implementing patient teachback strategies, a hotline phone number discharged patients could call, and "core measures" of discharge quality, as well as designing new discharge folders with a user-friendly yellow medication card for patients to bring home.