Published in the February 2013 issue of Today’s Hospitalist
TO CUT UNNECESSARY READMISSIONS, hospitalists are chasing a host of interventions, from making follow-up patient phone calls to having nurse practitioners make home visits.
A handful of hospitalist programs have even gone the distance to launch a comprehensive readmission-fighting tool: a dedicated post-discharge clinic. While that kind of clinic would strain the finances of many hospitals, that’s not necessarily the case in California.
Because capitated payment is so common in California, hospitals, physician groups and independent physician associations (IPAs) often have an incentive to manage the transitional costs of patient care. Now, as accountable care organizations begin to spring up around the country, more doctors and hospitals outside of California may find that it makes sense to spend a little extra money at discharge to save money down the road on readmissions.
One large Southern California IPA, Greater Newport Physicians, has embraced that concept by creating a hospitalist-directed multidisciplinary center for certain older patients within 72 hours of discharge. The Special Care Center is a unit adjacent to Hoag Hospital in Newport Beach that’s staffed by hospitalists from Pacific Hospitalists Associates, which contracts with the IPA. The center also includes a clinical pharmacist, an RN, a social worker and two medical assistants.
What sets it apart from typical post-discharge clinics is its range and design of services. Patients spend two hours in a typical “session” and are seen by every member of the care team, starting with the medical assistant and followed by the hospitalist, the pharmacist, nurse and social worker, in that order.
Data bear out the effectiveness of the approach. In its first 10 months, the center saw 489 patients. The 30-day readmission rate for those patients was 7% “50% less than that of other senior patients covered by the IPA who chose not to attend the center.
How it works
While so many providers might sound like overkill, the clinic uncovers plenty of issues that need to be addressed.
Hospitalist Salina Wolf, MD, the center’s medical director, says that the patients are often unclear about new medications prescribed in the hospital. They also often do not know which drugs to continue to take from before their hospitalization.
In fact, patients may not know what happened during their hospital stay. “They are interested in hearing an interpretation of their hospital laboratory results and diagnostic imaging, which gives us an opportunity to follow up on any pending results,” Dr. Wolf notes. The clinic team also addresses social factors that may pose safety issues or prevent patients from being able to deal with a new diagnosis or a disease process. “Those kinds of issues are hard to get a sense of when patients are acutely ill.”
The hospitalist or other team member may discover that home health services are warranted but haven’t been ordered. Or the hospitalist may decide that a specialty consult is needed even before primary care follow-up. Hospitalists also adjust doses, switch antibiotics and even diagnose a new medical condition.
“We’ve had a number of ‘saves,’ ” says Dr. Wolf, citing the not unusual example of a patient discharged after an acute myocardial infarction who now has three new heart medications and is found at the clinic to be hypotensive and bradycardiac. “We can capture these patients before they become symptomatic and end up back in the ER, potentially readmitted.”
In some instances, the center’s pharmacist picks up potentially dangerous drug-drug interactions. (Patients are asked to bring all prescription and over-the-counter medications.)
The RN can help patients with wound care or by changing a Foley catheter. And an onsite case manager and social worker arrange home health and physical therapy, as well as address social and emotional issues.
The hospitalist allocates an hour with each patient. The pharmacist then creates a final medication list and gives a print-out of it to the patient. The medical assistant schedules primary care and any needed specialist appointments before patients leave.
Who to target
The hospitalists, who otherwise work a week-on/week-off shift at Hoag, staff the center Monday through Friday, 9 a.m. to 5 p.m. Five of the group’s 40-plus hospitalists rotate through the center, each working a week at a time.
Those hospitalists volunteered to work in the clinic. “It is a unique and fortunate opportunity to see the hospitalized patient in the immediate discharge setting,” Dr. Wolf explains. “It provides continuity that we often do not have.”
For the hospitalists, center visits are a big change from their normal rounding and admitting. “We spend more time listening and evaluating because we have a complete history and physical available to us from the patient’s hospital record,” Dr. Wolf notes.
“I start by recapping what happened in the hospital, because patients are often too ill to take it all in while they were there,” she says. The patients seen are all over 65 and members of Medicare Advantage plans covered by the IPA. But other criteria include health status and comorbidity profile. “Most patients we see have three or four comorbidities,” Dr. Wolf points out. “Many have been hospitalized for an exacerbation of heart failure or COPD, sepsis syndrome, or an elective cardiovascular or orthopedic procedure.”
The hospitalists treating the patients in the hospital introduce the concept of the center to them and their families and encourage patients to attend. Hospital case managers also explain the clinic’s role and set up center appointments before patients are discharged.
“Patients are sometimes confused about why they need to go the center and how their primary doctor fits into the picture.” Dr. Wolf admits. “We explain that we are a bridge that allows a safe transition from the hospital to home, and that we’re collaborating with their PCP.”
Countering the “no-shows”
Once patients make it to the center, they’re uniformly pleased. Since the center’s inception, patient satisfaction scores have averaged 4.85 on a five-point scale.
But getting the center off the ground presented some challenges. For one, some outpatient physicians “most of whom participate in the same IPA “weren’t thrilled with hospitalists seeing their discharged patients before they did.
“That’s not an issue anymore, now that the PCPs understand the program and see the benefits for patients,” says Dr. Wolf. The hospitalist sends a note soon after a patient’s center visit. And if a serious issue arises or a specialist consult is needed, the hospitalist calls the primary physician immediately.
Another obstacle was actually getting patients to the appointment. Because the center was new, patients didn’t understand the importance of the visit. “We had a lot of no-shows in the beginning,” Dr. Wolf recalls. In situations where patients may have a hard time getting to the center, case managers now make sure transportation has been arranged or help set it up before discharge.
Now that the center is running smoothly, the hospitalists are looking for ways to add services. The IPA has recently expanded the center to include patients discharged from skilled nursing facilities. It is also considering having patients who visit the ER without being admitted followed up at the clinic for complex conditions.
Bonnie Darves is a freelance health care writer based in Seattle.