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Improving the transition from hospital to home

Adam Singer, MD, July 17, 2008

The period following a patient's discharge from a hospital to the time the patient re-enters the healthcare system via a physician office visit or other means can be treacherous for the patient. Nearly 12% of patients in a population of more than 15,000 had new or worsening symptoms within two to five days following discharge from the hospital, says a study in the March/April issue of the Journal of Hospital Medicine. If corrective steps are not taken to improve how transition management is handled in hospitals, the risk of errors and near misses in the post-hospital discharge time period is likely to rise.

Void in post-hospitalization patient care

After a patient is discharged, there is a gap of time before he or she re-enters the healthcare system-most often through a visit to a primary care physician or specialist or through a home health visit. This period of unsupervised recovery is fraught with potential dangers. Roughly one in five discharged patients, 21%, required assistance in at least one area that could impact their recovery, according to data from IPC The Hospitalist Company, for the 12 months ending June 2007. This finding parallels industry statistics on the number of patients having issues that could potentially jeopardize their recovery, from forgetting to pick up important prescriptions to having a bad reaction to a medication. Sometimes home health providers do not show up. Patients may have difficulty scheduling outpatient appointments for timely follow-up care. Ultimately, some patients get worse and wind up back in the hospital; starting the cycle over, ratcheting up both suffering and costs.

Using IT to improve the discharge process

Why does this bounceback cycle occur? What can be done to change the outcome? The standard of care in almost every community is to give patients discharge instructions and have them assume responsibility to fulfill the plan. Yet some patients do not receive adequate education about their discharge plans, and many are unable to understand or follow the plan. Family members and caregivers may be of help, or they may add confusion to the process. In the absence of discharge notes and an admission summary, the patient's own primary care physician is often in the dark during a post-hospitalization visit and is not able to act quickly. Additionally, time and money must be spent chasing down the patient's records. Without a defined process to catch problems and correct them, it seems many patients are just discharged into a black hole. And post-hospitalization outcomes measurements are being sucked down with them.

The healthcare industry can, and must, do better. Today, information technology systems can play an important role in improving patient transition management. Shipping companies track packages and provide delivery instructions along the way; yet the healthcare system has not yet found a way to successfully track patients.

At IPC The Hospitalist Company, we have embraced information technology as the critical component of a successful multi-stage patient transition management program. The system is helping our physicians and patients avoid the black hole.

In creating this system, we learned that effective transition management involves communicating with both the patient's primary care physician and with the patient. Not surprisingly, very different types of communication are required for these different audiences.

Enhancing physician-to-physician communication

First, let's look at the physician's point of view. In recent years, many primary care physicians have stopped making hospital rounds. As this change in practice pattern has occurred, communication breakdowns have increased. An ideal model- - and one that we use to prevent such breakdowns - - requires that hospitalists update all involved parties (primary care physician, insurance company, etc.) upon patient admission and within 30 minutes of the patient's discharge. Before we adopted a technology-based system, patients sometimes appeared at their primary care physician's office to find that neither they nor their doctors knew exactly what had happened during their hospital stay. After the system was implemented, that problem was fixed.

Bring patients into the loop

Better communication among physicians, however, is only part of the solution. We also discovered that discharged patients must be involved in a timely manner. Otherwise, they may fail to follow discharge instructions or fail to recognize a trend toward an acute event requiring immediate attention.

Again, we looked to technology to help drive a solution. We configured our system to automatically produce an individualized "smart survey" based on each patient's hospital experience. We then set up a nurse call center to ensure that patients were contacted by phone within 48 to 72 hours after discharge.

In addition to basic satisfaction and general outcome questions, the survey was developed to ask specific questions related to that patient's care as it is generated from notes available in the relational database. For example, if a patient was discharged on warfarin, the survey includes a question about the patient's knowledge of the need for Protime monitoring. For a patient with an order for a visiting nurse, he or she is asked whether the nurse has called or visited. If a patient reports an unexpected outcome, the nurse conducting the phone call is prompted to intervene right away. The case manager documents the intervention, and the entire survey is immediately faxed to the same healthcare partners who received the discharge notes. The loop gets closed, and those care providers who need to act are armed with information.

Continuity of care saves lives

This type of technology is critical to addressing the serious problem of transition management for today's hospitalized patients. It should be considered unacceptable to continue to allow preventable adverse events after hospitalization.

If proven technology systems are implemented on a national scale, post-hospitalization outcomes could be improved, lives could be saved each year, and millions of dollars of costs (including costs that are never reimbursed to hospitals or physicians) could be removed from the system. In the midst of heightened focus on healthcare issues at the national level, policymakers, elected officials and healthcare executives should promote systems that prevent needless suffering and expense.


Adam Singer, MD, is chairman and CEO of North Hollywood, CA–based IPC The Hospitalist Company, Inc.

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