Published in the February 2005 issue of Today’s Hospitalist
While hospitalists talk about “handoffs,” Eric A. Coleman, MD, MPH, talks about “care transitions,” the key distinction being that transitions include both a sending and a receiving component. Despite the difference in nomenclature, both take aim at the ill effects that seeing new health care providers can have on the people who need the most help.
Dr. Coleman, a geriatrician and associate professor at the University of Colorado Health Sciences Center in Denver, and one of the nation’s experts in the field of posthospital care transitions for older patients, focuses specifically on the transition or handoff that occurs at discharge. He has written numerous articles on the difficulties fragile patients and their caregivers face in the weeks immediately following a hospitalization, many of which result in readmission.
Although he was initially concerned about how the hospital medicine movement might contribute to the fragmentation of care, Dr. Coleman says he has come to view hospitalists as an important ally in the mission to improve the transition from hospital to outpatient setting. Because handoffs are here to stay, he says, the challenge is to design processes that bridge the gaps and catch dropped balls.
In an interview with Today’s Hospitalist, Dr. Coleman said that physicians and nurses who work in the hospital usually think their treatments and discharge plans were successful ” even when it turns out they weren’t. In large part, he explains, this ignorance of the end result of the hospital-to-outpatient handoff comes because practitioners in the hospital typically don’t learn about what came after.
In health services research lingo, there is a “silo” mentality in most of American health care.
“Hospitalists can say they did a great job,” Dr. Coleman explains. “But the plan may have failed, and they never know that because once the patient leaves the building, they rarely receive any feedback.”
He points out that on the other side of the equation are hospitalists and nurses who share in the frustration. The problem? They realize that while they may have done a stellar job of caring for the patient in the hospital, “all that good work may unravel as soon as the person leaves the door.”
Dr. Coleman’s research has found that for as many as one in four seniors, the 30 days following a hospital discharge are “complicated.” That term refers to multiple transfers back and forth to nursing homes, home, emergency rooms and even readmissions into the hospital.
Still other research by Dr. Coleman shows a correlation between how well the discharge process worked (as reported by patients and caregivers) and hospital readmission.
“It’s not that the practitioners in the hospital didn’t do a good job,” he says, “but that the time when patients leave the hospital is such a vulnerable one, especially for older people. Hospitalists cannot overcome this vulnerability alone.”
While Dr. Coleman praises the hospitalist movement for recognizing problems inherent in the post-hospitalization handoff, a trend he says has already led to new levels of awareness about the problem, he says that the specialty can do more.
And he has further cause for concern. While the initial pioneers of the hospitalist movement tended to be very forward- thinking, experienced clinicians, Dr. Coleman describes the “the next wave of hospitalists” as physicians who are often “right out of training programs.” They are often very well-trained and competent in hospital care, he says, but most haven’t had the benefit of practicing in other settings beyond residency.
As a result, he explains, some young hospitalists may have unrealistic expectations about what the next caregiver will be willing and able to do. For example, they may not realize that getting a colonoscopy as an outpatient means a three-month wait, and they may not realize that Mr. Smith’s wife will not be able to give him the heparin shots ordered on discharge because she has crippling arthritis of her hands.
Patients are not the only weak link, Dr. Coleman says. Swamped primary care physicians will rarely be able to wade through a three-page, single-spaced discharge summary they receive days after the patient’s hospitalization. And as a result, they may not find the one nugget of information that may make the difference between a smooth transition and a complicated one that results in a hospital readmission.
The above scenario assumes that the discharge summary even made it into the hands of the primary care physician. As Dr. Coleman points out, “some research suggests that piece of paper never makes it to its destination 30 percent of the time.”
“You would like a section that says, ‘Hey, if you only pay attention to one or two things, then look here. You better check this lab test and ask how they are tolerating the new medication.’ But all too often that critical information is not highlighted well in discharge summaries,” Dr. Coleman says. “The goal is to create a discharge summary that is meaningful to the next person.”
While some attention has been paid to discharge planning and summaries, Dr. Coleman notes that hospitalists can also help make sure that the patient is ready for self-care in the next setting through the decisions they make while the patient is still in the hospital. While the rallying cry of hospitalists may say that discharge planning begins on the day of admission, Dr. Coleman argues that reality rarely matches that presumption.
“If we are really going to think about discharge at the time of admission, then we need to avoid keeping older patients in bed,” he says. “We know that when we leave them in bed for a couple of days, it takes them at least that long to regain their strength.”
“And this means we don’t put catheters and IVs in people unless we absolutely have to, because that tethers them to the bed,” Dr. Coleman adds. “And we don’t give them medicines that make them confused, because it is bad to send people out who are a little bit delirious.”
Furthermore, when doctors and nurses talk to their older patients, he says that they need to remember that “this is a group where there is a relatively high prevalence of cognitive impairment or memory disorders. On top of that, they are sleep-deprived and sick.”
All this means that elderly patients are unlikely to remember any verbal information you give them. “We have to write things down,” Dr. Coleman says. “We have to write it down in large enough print for them to read it, and we need to not use Latin abbreviations, among other things, when we communicate with people.”
The good news is that hospitalists can play an important role in this arena through their positions on hospital quality improvement teams and other committees. They need to convince their colleagues that this is an area deserving attention.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has already announced that medication reconciliation “an important component of an improved discharge process “is one of its patient safety goals. Dr. Coleman says that it would be natural for a hospital to pick another aspect of the discharge handoff to work on.
(He and his colleagues have developed and tested a set of performance measures hospitals can use to identify problems in their systems. They are available online.)
In addition to JCAHO, Medicare may also be looking more closely at transition problems in the near future. When Congress asked the Institute of Medicine (IOM) to study pay-for-performance approaches Medicare might adopt, the group selected transitional care as one potential topic.
“Hospitalists should realize that coming downstream, they might be paid a differential for performance on transitional care,” Dr. Coleman says. “It behooves them to be thinking about this today.”
One project Dr. Coleman’s team has worked on has used a “transition coach” to help patients and their caregivers negotiate discharge handoffs. (A paper detailing the work was published in the November 2004 issue of the Journal of the American Geriatrics Society.)
The project’s experience shows that having a person “a case manager or a discharge planner who is familiar with all the settings the patient may encounter post-hospitalization “work with the family during this period pays for itself in a few months simply because of the number of hospital readmissions it prevents.
“Coaches aren’t there to be health care providers per se, although their background is such,” Dr. Coleman says. “Coaches are there to provide continuity across settings. The coach goes where the patient goes and helps people reach their individual goals, and also keeps them out of the hospital.”
While many health care leaders believe that electronic medical records will make these transition problems go away, Dr. Coleman is not so optimistic. While he believes that this technology is necessary, he adds that it is not sufficient to remedy these problems. Electronic medical records may help with the transfer of information, he explains, but information transfer between caregivers is only one part of the handoff problem.
More important, he says, are interventions that would help improve the other problems that patients and their caregivers identify as setting them up for failure. These include paying attention to patient and caregiver preferences and developing plans that are feasible, giving patients and caregivers the skills and backup to make plans work, and educating them about what to expect.
Many of his patient empowerment-proposed solutions, Dr. Coleman says, come out of his own frustrations practicing as a geriatrician interested in frail populations and working in outpatient, inpatient and nursing home settings. All too often, he found he had to depend on patients and their caregivers to fill him in on details of what happened during hospitalizations that he may have been ignorant of altogether.
He explains that he came to realize that the term ‘health care system’ is truly a misnomer. Although he and his team are exploring system-level approaches to better coordinate care across different settings, he says that in practice, he often felt forced to “totally rely on patients who went through hell and who now have another responsibility: to debrief me on their hospital stay. What’s wrong with that picture?”
As a result, Dr. Coleman says he came to think that the way to improve patient care in this area was to empower patients more so they can succeed at the difficult job that, by default, has fallen to them “all the while not letting the doctors, nurses and system off the hook.
“Each individual physician or nurse doesn’t necessarily feel accountable for things that go wrong,” he says, “but they are all bummed out when the person is back in the hospital again because there really wasn’t good preparation. If doctors are going to propose a care plan and expect family members to do it, they need to reality-check their plan.”
Deborah Gesensway is a freelance writer in Toronto, Canada.
More information on “care transitions”
For more information on performance measures and other tools for physicians, hospitals and patients, the work of Eric A. Coleman, MD, MPH, to improve posthospital care transitions is found on his Web site.
Dr. Coleman has also written numerous papers on the topic. The following three were published this past fall:
“¢ “Lost in Transition: Challenges and Opportunities for Improving the Quality of Transitional Care.” Annals of Internal Medicine, Oct. 5, 2004.
“¢ “Preparing Patients and Caregivers to Participate in Care Delivered Across Settings: The Care Transitions Intervention.” Journal of the American Geriatrics Society, November 2004.
“¢ “Posthospital Care Transitions: Patterns, Complications, and Risk Identification.” Health Services Research, October 2004.
Finally, Dr. Coleman notes that the Society of Hospital Medicine has been identifying strategies to improve geriatric hospital care with support from the John A. Hartford Foundation of New York.