I would never ask an individual hospitalist to reduce readmissions. It requires a multidisciplinary, all-hands-on-deck approach by the hospital.
—Amy Boutwell, MD, MPP, hospitalist, Newton (Mass.) Wellesley Hospital, president, Collaborative Healthcare Strategies
Most of these “well-established, evidence-based interventions,” including BOOST, will be given preference in applications for grants from the federal Community-Based Care Transitions Program (CCTP). The program recently committed $500 million to support community-based coalitions that include hospitals that are working with community partners to create seamless care transitions. “It’s most important that hospitalists are integrally involved with these care-transition teams—if not leading them,” Rutherford says.
BOOST’s approach is built on a major change-management strategy to reconstruct hospitals’ care transitions and discharge processes from the ground up, says Tina Budnitz, MPH, the project’s director at SHM (see “Discharge Improvement,” p. 7.) “The first thing we do, we literally get out pens and paper and chart what happens before patients get into the hospital and what happens after they are discharged, all of the services that touch them—or should,” she says. “The planning process occurs on many levels, with all of the stakeholders in the community looking at the process map and seeing where people fall off and end up readmitted.”
—Jeff Critchfield, MD, division chief of hospital medicine, San Francisco General Hospital
SHM is planning to launch several new BOOST cohorts for participating hospitals this fall, along with a wider range of technical support, Budnitz says.
The Cross-Setting Team
Research on care transitions for uninsured or indigent patients “is not very robust,” observes Amy Boutwell, MD, MPP, a hospitalist at Newton Wellesley Hospital in Newton, Mass., former director of health policy at IHI and president of Collaborative Healthcare Strategies. “We don’t have the information we need, but there are great opportunities to improve our research base,” she explains.
Dr. Boutwell is a big fan of the “cross-setting team,” which brings together around a conference table professionals who work in different care settings, including the hospital, long-term care, and home-based care. She says it’s her job “to make sure patients are safe upon discharge, but if the community is under-resourced for primary-care physicians, if the patient is uninsured and we can’t find a PCP, the hospitalist and cross-setting team need to say, ‘We just can’t accept that.’ ”