Of all the care decisions we make during a hospital stay, perhaps the one with the biggest implications for cost and quality is the one determining the location to which we send the patient after discharge.
Yet ironically, we haven’t typically participated in this decision, but instead have left it up to case managers and others to work with patients to determine discharge location. This is a missed opportunity, as patients first look to their doctor for guidance on this decision. Absent such guidance, they turn to other care team members for the conversation. With a principal focus on hospital length of stay, we have prioritized when patients are ready to leave over where they go after they leave.
Discharge location has a large impact on quality and cost. The hazards of going to a postacute facility are similar to the hazards of hospitalization – delirium, falls, infection, and deconditioning are well-documented adverse effects. We may invoke the argument that, all things being equal, a facility is safer than home. Yet, there is scant evidence supporting this assertion. At the same time, when contemplating a home discharge, a capable caregiver is often in short supply, and patients requiring assistance may have few options but to go to a facility.
In terms of cost during hospitalization and for the 30 days after discharge, for common conditions such as pneumonia, heart failure, COPD, or major joint replacement, Medicare spends nearly as much on postacute care – home health, skilled nursing facilities, inpatient rehabilitation, long-term acute care hospitals – as for hospital care.1 Further, an Institute of Medicine analysis showed that geographic variation in postacute care spending is responsible for three-quarters of all variation in Medicare spending.2 Such variation raises questions about the rigor with which postacute care decisions are made by hospital teams.
Perhaps most striking of all, hospitalist care (versus that of traditional primary care providers) has been associated with excess discharge rates to skilled nursing facilities, and savings that accrue under hospitalists during hospitalization are more than outweighed by spending on care during the postacute period.3
All of this leads me to my point: Hospitalists and inpatient teams need a defined process for selecting the most appropriate discharge location. Such a location should ideally be the least restrictive location suitable for a patient’s needs. In the box below, I propose a framework for the process. The domains listed in the box should be evaluated and discussed by the team, with early input and final approval by the patient and caregiver(s). The domains listed are not intended to be an exhaustive list, but rather to serve as the basis for discussion during discharge team rounds.
Identifying patient factors informing an optimal discharge location may represent a new skill set for many hospitalists and underscores the value of collaboration with team members who can provide needed information. In April, the Society of Hospital Medicine published the Revised Core Competencies in Hospital Medicine. In the Care of the Older Patient section, the authors state that hospitalists should be able to “describe postacute care options that can enable older patients to regain functional capacity.”4 Inherent in this competency is an understanding of not only patient factors in postacute care location decisions, but also the differing capabilities of home health agencies, skilled nursing facilities, inpatient rehabilitation facilities, and long-term acute care hospitals.
Dr. Whitcomb is chief medical officer at Remedy Partners in Darien, Conn., and cofounder and past president of the Society of Hospital Medicine. Contact him at [email protected].
1. Mechanic R. Post-acute care – the next frontier for controlling Medicare spending. N Engl J Med. 2014;370:692-4.
2. Newhouse JP, et al. Geographic variation in Medicare services. N Engl J Med. 2013;368:1465-8.
3. Kuo YF, et al. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med. 2011;155(3):152-9.
4. Nichani S, et al. Core Competencies in Hospital Medicine 2017 Revision. Section 3: Healthcare Systems. J Hosp Med. 2017 April;12(1):S55-S82.
Framework for Selecting Appropriate Discharge Location
- Can the patient perform activities of daily living?
- Can the patient ambulate?
- Is there cognitive impairment?
- If the patient needs it, is a caregiver who is capable and reliable available? If so, to what extent is s/he available?
- Does the patient require PT, OT, and/or ST?
- How much and for how long?