Published in the August 2004 issue of Today’s Hospitalist
In an ideal world, hospitalists would send patients home armed with all the information they need to manage their condition, the medicines they need to prevent recurrences, a follow-up appointment with their primary care physician, and some understanding of what constitutes an emergent complication and who to call if one occurs.
In the real world, however, too many patients fail to follow through with even basic steps like obtaining their medications. Follow-up appointments are never made, the home health nurse never shows up, and the order for durable medical equipment is never placed.
In fact, one of the few studies to focus specifically on post-discharge medical issues found that a significant number of patients experience some problems after discharge. The study, which appeared in the Feb. 4, 2003, Annals of Internal Medicine, reported that 19 percent of patients experience an adverse event problem that requires either medical attention or physician intervention.
And a recent study undertaken by IPC-The Hospitalist Company found that nearly 40 percent of patients had one or more issues post-discharge. Of those, more than 10 percent were related to new signs or symptoms, and nearly 9 percent were related to medication problems.
“To think that one-fifth of patients have some new problem after they leave the hospital is staggering,” says Sunil Kripalani, MD, assistant director for research at Emory University’s hospitalist program at Grady Memorial Hospital. He is examining the issue as part of a continuity of care task force created by the Society of Hospital Medicine and the Society of General Internal Medicine.
The prevalence of post-discharge issues, combined with the reality that patients are being discharged “sicker and quicker,” help underscore the pressing need for improving discharge planning and better managing the handoff from hospitalist to primary care physician.
The most important under-addressed aspect of that handoff is the timely transfer of knowledge, suggests Christopher Phillips, MD, MPH, a hospital medicine researcher who is currently involved in a study looking at that deficit, along with interventions to help bridge the gap. “There aren’t good data on this deficit in information transfer,” he says, “but we know that we need to increase the turnaround time of the arrival of the discharge summary to the primary physician. A lot of patients are seen by an outpatient physician before the summary shows up.”
To combat these problems, hospitalist groups are developing strategies to improve interphysician communication and continuity of care during the vulnerable period in the first week after discharge. They know that it’s during that time that issues such as new signs or symptoms and medication problems can prove not only dangerous, but potentially lethal.
Those interventions include low-tech activities like placing a detail-focused telephone call to the primary physician at the time of discharge. They also include more sophisticated systems that automatically generate and send discharge summaries to referring physicians within hours of the patient’s departure from the hospital.
Discharge navigator: University of Michigan
At the University of Michigan Health System in Ann Arbor, a newly developed Web-based tool called the “discharge navigator” is helping to bridge the transfer of information from hospitalists to outpatient physicians. The tool allows physicians and nurses to extract and compile key patient information in a simple document that is created before the formal discharge summary.
The objective of the discharge navigator, according to its chief architect, Michael Kramer, MD, was to compile and send the basic details a referring physician might need before or during the first follow-up appointment.
“We know that referring physicians don’t care to have a long document,” says Dr. Kramer, an informatician and board-certifi ed internist and pediatrician who serves as physician lead for clinical systems integration at the University of Michigan. “They want the basics.”
To that end, the tool, which is part of the University of Michigan’s computerized medical record system, tracks discharge diagnosis and medications; date and time of follow-up appointment; outstanding and pending labs and studies; and outstanding issues the referring physician needs to address.
Physicians who enter information in the application can add clinical narrative, but the emphasis is on brevity. Nurses also use the tool to generate discharge medication information and education.
The tool automatically produces documents that bypass the traditional dictation process. Physicians can produce either a preliminary discharge summary or a final discharge summary. Both versions are incorporated into the medical record, and one is provided to the patient at discharge.
The reports are very similar and include the chief diagnosis, medication list, and details on follow-up appointments that have been scheduled or are recommended. The final document may contain more clinical narrative than the patient document.
It’s too soon to tell how the tool will affect patient outcomes. The discharge navigator was launched last September on two general medicine wards, and it was rolled out to the University of Michigan’s hospitalist practice only last month.
Early results, however, are promising. A four-month randomized study of the tool found that its condensed summary made its way into the medical record a full week earlier than dictated summaries. Referring physicians were generally satis- fied with its content.
In addition, patient satisfaction scores on discharge education and preparedness indicators improved markedly on the patient units where the discharge navigator was used. In addition, the tool helped the University of Michigan cut its discharge-related transcription costs by approximately two-thirds.
Dr. Kramer says that during the research phase, half of all physicians received a traditional discharge summary and half received a discharge summary created by the discharge navigator. Researchers found no significant differences in the feedback they received from both groups, which he takes as a positive sign. “If clinicians didn’t like it,” he explains, “we probably would have seen a negative response.”
He adds that his group is continuing to monitor the response of referring physicians to the tool, which will eventually be implemented throughout the medical center.
Dictation and phone follow-up: Cogent Healthcare Inc.
Cogent Healthcare Inc., an Irvine, Calif., company that operates hospitalist programs in 12 states, has tackled post-discharge issues through a sophisticated discharge dictation system and follow-up phone calls.
When patients are discharged, Cogent’s hospitalists dictate the important details “primary and secondary diagnoses, procedures performed, discharge medications, pertinent labs and discharge plans “into the company’s patient information system. A summary is then generated and faxed to the referring physician or primary provider in 24 to 48 hours. During that same time, the patient receives a phone call at home.
Cogent developed its system to make sure that outpatient physicians were getting the information they needed in a timely fashion. “The issue was that hospitals just aren’t set up to provide discharge information in a timely manner to primary care physicians,” says Navneet Kathuria, MD, MPH, Cogent’s national medical director.
Even if a Cogent hospitalist has talked to the referring physician during the patient’s hospitalization and has updated the doctor on major developments, Dr. Kathuria says, the outpatient physician may not remember the gist of that telephone exchange a week to 10 days later.
“When you’re a busy practitioner, how many things will you remember?” he asks. “If you have this piece of paper and it gets filed correctly, when you open the chart, it’s right there.”
And while the discharge summary’s format and contents are standardized, Dr. Kathuria says, those elements are updated based on input from primary care physicians.
“When we survey primary care physicians,” he explains, “we specifically ask whether the information they receive is valuable and whether they want something added or deleted. This is not a static thing. We are constantly looking at survey results to ensure that we maximize the effort we put into compiling these data.”
The phone calls, which occur when a discharge note “pops up” in Cogent’s information system, are made by trained interviewers who are supervised by a nurse and follow a strict protocol. One of the biggest challenges is helping patients navigate and understand all of the information and paperwork they’ve received in the hospital.
“Patients often need a bit of reassurance, some confirmation of the information they’ve received,” Dr. Kathuria says. “Patients receive a stack of papers at discharge. When people are sick, they’re not really focusing on those papers. The patient who has had a heart attack is focusing on how to deal with things when they get back home.”
In some instances, patients simply want to review their medications. In other cases, Cogent’s interviewers learn that patients never filled a certain prescription.
In Cogent’s experience, the least common post-discharge problem “at 24 to 48 hours postdischarge, at any rate “is the emergence of new signs or symptoms, Dr. Kathuria says.
To help improve the handoff, Cogent is also developing a discharge checklist. That list, Dr. Kathuria says, will have two “points of view” and will provide both a patient version and a hospitalist version.
The physician checklist will include reminders of all the items and issues that need to be addressed before discharge. It will list chief diagnosis, medications, follow-up appointments that have been made or need to be made and other items, depending on the documentation the contracted hospital is already providing.
“It will be unique to each hospital,” Dr. Kathuria says, “because some already have a version of this kind of checklist in place.”
Call-center strategies: IPC
With 300-plus physicians working in 150 U.S. hospitals, California- based IPC-The Hospitalist Company takes a similar systems approach to smooth the transition from hospital medicine to primary care.
Since IPC started in the mid-1990s, its physicians have transmitted patient information to the company’s IPC-Link system. But even IPC has found that when it comes to post-discharge transition planning and information transfer, the devil is indeed in the details.
“Like everybody else, we started out with nothing,” says Mary Jo Gorman, MD, MBA, the company’s chief medical officer. She explains that early in its history, the group began developing systems to manage the transition from the hospital to home.
Today, IPC uses nurses in its centralized call center to call patients between 48 and 72 hours after discharge to ask about their health status. Those nurses also check on other post-discharge issues such as medications and home health services.
While IPC initially used only nurses to make those calls, the company has begun using trained interviewers who have some health care experience. They use a strict algorithm, and situations that call for medical advice or possible physician intervention are still handled by nurses.
IPC instructs its callers to obtain only relevant and potentially “actionable” information on topics like health status decline, new symptoms, medication issues and follow-up appointment scheduling.
“Our study showed that about 40 percent of patients needed nurse intervention and 60 percent didn’t, so we started changing our mix of staff,” Dr. Gorman says. Today, the IPC call center is staffed by an RN supervisor, three LPNs and seven patient care representatives.
Despite its follow-up efforts, IPC finds that issues still fall through the cracks from time to time. “We were finding interesting problems, like patients who weren’t getting their durable medical equipment, that the home health nurse hadn’t shown up, or that patients weren’t able to schedule an appointment with the referring physicians,” Dr. Gorman recalls. “We didn’t have a way to report that information back to the physicians, the hospitals, the health plans or the home health agencies.”
IPC now uses a variety of methods, including monthly meetings with contracted health plans and regular meetings with medical practices that use its services. The goal is to share details and concerns about problems hospitalists and their patients are encountering post-discharge.
For example, Dr. Gorman says, IPC might discover after several months that every time its hospitalists care for a patient of Dr. Smith, that patient is told no appointment is available for at least six weeks after being discharged from the hospital. “When we figure that out,” she explains, “we take that information to the medical group.”
Smaller scale approaches
Dr. Gorman acknowledges that IPC’s system is too expensive and technology-dependent to be adopted by small groups. But she thinks its principles can be embraced even by groups with limited infrastructure and modest resources.
“Hospitalists need to make sure patients reach the next step,” Dr. Gorman says. Sometimes, she adds, that may mean advocating for the patient by picking up the phone on behalf of your patient.
“A lot of older patients are not aggressive,” she explains.” When they call the doctor’s office and they are told that no appointment is available for six weeks, they don’t know they can push. In those cases, the hospitalist may need to step in.”
And while Grady Memorial Hospital in Atlanta doesn’t yet have an integrated electronic medical record or centralized call center to conduct follow-up calls, it nonetheless places a high priority on continuity of care.
Patients who leave the large public hospital receive a written sheet that lists their diagnoses, medications and follow-up appointments. Attending physicians encourage medical students and residents to call patients a few days after discharge to make sure patients have in fact filled their prescriptions. Residents also use that contact to check for new problems and clarify any questions.
And the outpatient clinic’s computers are linked to the hospital’s network, so physicians there can electronically tap into inpatient laboratory and radiology results. They can also view transcriptions of patients’ discharge summaries.
“The patient discharge form is fairly basic, but it helps remind patients about their appointments and medication changes, which increases compliance,” Dr. Kripalani says. “Physicians can also make a copy of the form and use it as a reference during the follow-up phone call. The point is that we need both low-tech and high-tech solutions, and there are lowtech but very important ways to bridge that vulnerable time period after hospitalization.”
Bonnie Darves is a freelance writer specializing in health care. She is based in Lake Oswego, Ore.