Published in the July 2008 issue of Today’s Hospitalist
When the hospitalists with the John Muir Medical Group divided up their 2007 quality incentive pool, most of them received a bonus for calling select patients after discharge.
It was the first time that the physicians, who serve hospitals in both Walnut Creek and Concord, Calif., were rewarded for picking up the phone and checking on patients. It used to be that all patients were called post-discharge by care coordinators.
But when many of those calls repeatedly produced questions that the hospitalists needed to answer, the group made the decision to have hospitalists place calls to sicker, more acute patients. That move wasn’t embraced by all the physicians, who worried that the calls would take too much time
To address those concerns, the group took a go-slow approach, letting doctors choose whether to call 30, 40 or 50 patients over the course of that first year. In addition, the measure accounted for only one-fifth of their overall incentive bonus.
Despite early resistance, the new measure was a success, reports hospitalist Viviane Alfandary, MD, who was associate medical director of the group while the initiative was being rolled out. For their quality incentive for 2008, the physicians decided to increase the number of post-discharge phone calls that they’ll make.
"Patients feel more watched over when we make the phone calls," Dr. Alfandary says. Most patients, she adds, end up having a lot of questions within the first few days post-discharge. "We feel we’re in the best position to answer those because most questions are directly related to medicine changes or events that transpired in the hospital."
Heading off dual prescriptions
The hospitalists at John Muir are far from alone in deciding to call patients themselves. With hospitals paying more attention to patient satisfaction scores, hospitalist groups are deciding that it’s worth the time to call patients instead of sending them out into the void. While the service takes time, hospitalists report big rewards in terms of improved patient safety, hospital marketing and feedback about physician performance.
For more than a decade, John Nelson, MD, the Bellevue, Wash., hospitalist who is a co-founder and past president of the Society of Hospital Medicine, has made a practice of calling almost all of his discharged patients.
"You think you are communicating effectively, but there’s often some important issue that patients don’t understand “and there are all kinds of things they don’t bother to do," says Dr. Nelson, who directs the hospitalist program at Overlake Hospital Medical Center and acts as a consultant to hospitalist programs nationwide.
Take patients discharged on coumadin. "You tell your patients a dozen times that they have to get their blood monitored, even if they feel fine," says Dr. Nelson. "Then when you start calling, you realize that about half the time they didn’t bother to get their blood drawn." While the rise in coumadin clinics has improved blood monitoring, he says, lack of compliance is still an issue.
In other cases, he’s discovered that the antihypertensive medicine he prescribed is, according to the patient’s pharmacist, "almost the same as the other one the patient is already taking" “a fact not uncovered during medication reconciliation. That’s the point in the conversation when, Dr. Nelson adds, patients usually ask, "Do you really want me to be on both?"
Dr. Nelson makes the calls himself, within a week of discharge and with the chart in hand. Typically, he spends between one and three minutes on each call. "I keep it simple. I ask how the patient is doing, and for the most part I don’t document the call," he explains, unless he makes a significant medication change or instructs the patient to seek medical attention.
On occasion, Dr. Nelson ends up spending 15 minutes on the phone with a patient who is fine but wants to chat. "That’s rare," he says. "Most of the time, the patient or the family member says, ‘It’s so nice of you to call, thanks.’ "
Heading off complaints
Other hospitalist groups have staff make initial calls, then bring in hospitalists depending on a patient’s question or situation. The Hospitalists of Franklin County in Chambersburg, Pa., for instance, uses its clinical care coordinators, usually RNs, to initiate calls two to three days after discharge.
According to medical director David Hoffmann, DO, the 10-hospitalist group credits those calls with helping keep the group’s 30-day readmissions at about 8%, low considering that 65% of their patients are on Medicare. It helps that the care coordinators have access to patients’ discharge summary and typically work on the same floor from which patients were discharged.
"The coordinators know the medication and the discharge plan," says Dr. Hoffmann. Even when hospitalists don’t need to get involved, he points out, the calls help head off complaints, including ones not related to hospitalists’ care.
"Sometimes it’s a nursing issue," says Dr. Hoffmann. "Other times, patients complain about the ER wait, but they calm down after you tell them that it generally takes three hours for a CT scan." The fact that someone has called, he thinks, often prevents the complaint from reaching the hospital or primary physician.
Reducing readmissions “or not
The physicians with Community Hospitalists in Cleveland, Ohio, have a similar arrangement, with secretaries “not care coordinators “placing the initial calls.
The program’s 45 hospitalists collectively discharge about 70 patients a day, and the group agrees in its contracts with local primary care physicians to call patients post-discharge. Office-based physicians appreciate that service, says Stephen Shaw, MD, the group’s regional medical director, because it saves them the headache of dealing with issues that arise from the hospitalization.
Callers use a formal script, asking about medications, symptoms and follow-up appointments. According to Dr. Shaw, hospitalists have to get involved in a potentially serious problem or worsening symptom about 5% of the time.
Callers also ask patients if they feel that their hospitalist spent enough time with them explaining their diagnosis and treatment plan. Those questions, Dr. Shaw admits, generate some interesting information.
One patient who was generally pleased with her inpatient experience complained that Dr. Shaw "had a Cheshire cat’s grin," he says. "Once in a while, you’ll get negative feedback based on what appear to be personality clashes." Other patients, he notes, complain that they felt they didn’t receive enough information or that communication wasn’t optimal. For patients who say they need more information, their hospitalist is asked to call.
"Negative feedback is rare," says Dr. Shaw, "but when it happens, it’s the director’s job to see if there’s a pattern emerging." Most patient comments, he says, are positive, which has led the physicians in his group to embrace the calls, despite the time and effort they take.
"I don’t have data," Dr. Shaw says, "but I have the sense that the few times you end up intervening because some piece of information hasn’t been perfectly conveyed to the patient, you’re saving a readmission."
As for Dr. Alfandary in Walnut Creek, where physicians place post-discharge calls to high-risk, high-acuity patients, she has the opposite impression.
"I doubt we’ve avoided any readmissions," says Dr. Alfandary, noting that the group’s coordinator calls discharged patients who aren’t as sick. "On the contrary, we have gotten several patients back into the hospital earlier than they would have come otherwise."
Bonnie Darves is a freelance health care writer based in Lake Oswego, Ore.
Tips for structuring post-discharge calls
HOSPITALISTS WHO ARE VETERANS of calling patients post-discharge offer the following tips to maximize benefits and minimize time spent:
● When making calls, always have patients’ records in front of you. "They’re invariably going to ask you about something you can’t remember, like whether the Lyme disease serology came back OK," says John Nelson, MD, director of the hospitalist program at Overlake Hospital Medical Center in Bellevue, Wash.
● Try calling in the early evening. "We’ve found that about 60% of our patients are home then, so it’s easier to connect," according to Viviane Alfandary, MD, who’s with the John Muir Medical Group hospitalist program in Walnut Creek, Calif.
● If you have to leave a message on voicemail or an answering machine, give your name, phone number (if you want to leave one) and general reason for the call. But to avoid potential HIPAA violations, don’t leaving details of diagnosis or test results.
● Act on any information generated through post-discharge calls, especially if that information uncovers communication lapses or poorly structured follow-through.
A look at high-tech follow-up and data
TWO LARGE NATIONAL GROUPS, IPC The Hospitalist Company and Cogent Healthcare, have long made it a practice to use structured, technology-driven systems to place calls to all patients post-discharge, initially by nonhospitalists. Both also collect data on what those calls uncover in terms of problems and hospitalist interventions.
At IPC, which is based in North Hollywood, Calif., calls are initiated within 48 hours of discharge through a national call center that is staffed by patient representatives and nurses, according to Felix Aguirre, MD, IPC’s vice president of medical affairs. "Data show that 16% of patients within three days of discharge experience issues that require attention," Dr. Aguirre says. "We’re able to resolve 90% of identified issues by making these calls."
Nashville-based Cogent has likewise implemented a system in which non-clinical staff make the first contact. Callers are provided a hospitalist-generated "transfer of care" dictation to guide their inquiries. The stand-alone sheet covers all of the basics: discharge date; primary and secondary diagnoses; procedures; medications; consults; pending tests; and the discharge plan.
According to Eric Siegal, MD, one of Cogent’s regional medical directors, the transfer of care dictation is designed to take no more than five minutes for hospitalists to complete, and it goes to patients’ primary physician in advance of the full discharge summary. If a patient reports possibly serious issues or symptoms, the call is escalated via e-mail to a clinical care coordinator or the hospitalist (or, occasionally, to 911).
Based on an analysis of Cogent’s 100,000-plus annual discharges, callers catch "something on the tail end" that requires intervention about 22% of the time, Dr. Siegal notes. "In 42% of those cases, the issue is medication related," he adds, "while in 35%, it’s appointment related. About 15% of the time, it’s a symptom issue."
Discharge summary "to go"
TO GIVE CONTINUITY OF CARE a final boost, one hospitalist now makes a practice of giving most of his patients a copy of their discharge summary as they leave the hospital.
Initially, hospitalist John Nelson, MD, co-founder of the Society of Hospital Medicine who practices in Bellevue, Wash., provided a copy only to patients who were from out of town or whose homeless status made a follow-up appointment unlikely.
But several years ago, he says he realized a copy would be a boon for everyone. "Research shows that many patients forget most of what they have been told by the time they get home," Dr. Nelson says. "My hope is that the discharge summary will serve as a reminder."
He notes that the summaries have proved invaluable when a patient goes to a subspecialist before seeing a primary care physician or when a visiting nurse shows up with only sketchy details of a patient’s hospitalization. And in at least one instance, a homeless patient who landed in another hospital’s emergency department was able to produce the crumpled document, avoiding unnecessary tests and work-up.
Dr. Nelson admits that the idea may not be "quite ready for prime time." Many physicians, he points out, are worried that issues raised in a discharge summary could confuse or anger patients. And slow transcription time is another hurdle at some hospitals.
But he maintains that concerns about patients getting too much information or becoming unduly worried about a diagnosis haven’t been much of an issue. He is careful not to use labels like "drug seeker" in a summary; instead, he notes that a patient has "complex pain management issues."
And he doesn’t balk at including that a patient is obese, for instance. "I think we shouldn’t hide the reason behind the person’s health."
He also says that concerns about patients having to struggle with "medicalese" haven’t been a problem. In fact, Dr. Nelson adds, he thinks it’s the patients with low health literacy who most benefit from having the summary. That’s because they’ll use it as a basis to ask caregivers or other providers to help them understand what’s going on with their health and why they were in the hospital.