Published in the March 2014 issue of Today’s Hospitalist
WITH ALL THE PRESSURE ON HOSPITALISTS to do a better job at discharge, one big piece of the transitional equation often goes missing: what primary care physicians can or should be doing to help prevent readmissions.
“We always think about the ‘pitchers’ discharging patients, but not about the ‘catchers’ who receive them,” says Lee Lindquist, MD, associate division chief of geriatrics at Chicago’s Northwestern University Feinberg School of Medicine. “We can do everything perfectly in the hospital, but if we’re not convincing people to take their medications, it’s not going to work.”
To test that theory, Dr. Lindquist and her colleagues enrolled 75 patients, all of whom left the hospital on five or more medications. Primary care physicians were instructed to contact patients “either in person just before they left the hospital or by phone within 24 hours of discharge “to briefly review their diagnosis. They were also asked to discuss which medications had been added or dropped during their hospital stay and which prescriptions were to be continued.
Researchers then followed up with patients within 48 hours to see if they had spoken to their outpatient physician and to find out if patients still had medication discrepancies or problems with discharge instructions. Discrepancies included not taking drugs prescribed at discharge, adding drugs that hadn’t been prescribed, taking duplicate medications, or taking drugs at the wrong dosages or frequency.
What researchers found was that primary care phone calls pay off: Patients contacted by their outpatient physician were 70% less likely to have a discrepancy than those who weren’t contacted. Result were published in the December issue of the Journal of Hospital Medicine.
“The study points out that relationships are important,” Dr. Lindquist says. “We’ve looked so much at the relationship between the hospitalist and the patient, but it’s in building on the relationship between the primary care doctor and the patient where you get real strength.”
Too many strangers
Another point the study revealed: “The medication list is completely fluid once people leave the hospital,” Dr. Lindquist adds. “Hospitalists may assume that once they write meds in discharge instructions, patients just follow that list. But that’s not the case.”
Dr. Lindquist and her team unearthed the causes behind each discrepancy, dividing those into system-associated and patient-associated factors. The biggest system-associated factor was incomplete or inaccurate discharge instructions, accounting for 14% of the discrepancies found. But an even bigger culprit was intentional nonadherence, which accounted for more than 59% of discrepancies. Patients either didn’t fill their prescriptions or weren’t taking them as instructed.
Why? Patients may not be convinced they need a medication, or they may be confused about how to work a new drug into their existing regimen. That’s where, Dr. Lindquist says, talking to a primary care physician has an impact.
“Patients still trust their PCPs and often want to check in with them before making any medication changes,” she explains. “Considering how much information they’re given by strangers in the hospital, the only staying force patients have is the primary care physician who they know.”
That brings up a potential flaw in many new transitional-care strategies. “Hospitals may believe that it will be effective to send a new nurse, social worker or discharge planner to patients’ homes after discharge,” she points out. “But these are all new people who patients don’t always trust because they’re meeting them for the first time.”
Instead, says Dr. Lindquist, patients may need validation from their primary care physician, either through approving a new medication list or clearly stating which prescriptions must be filled and which are not critical.
Meds in the real world
Even with primary care involvement, the study pointed to a lot of room for improvement.
Among patients not contacted by their primary care physician, 59% experienced some kind of medication discrepancy. Men were four times more likely to have a discrepancy than women, but variables like age, ethnicity and living alone weren’t significant.
But even among those contacted by outpatient doctors, a whopping 41% were still experiencing some medication discrepancy 48 hours after discharge. For Dr. Lindquist, that underscores the need for more interventions.
Primary care physicians who speak to patients and unearth discrepancies, for instance, could make sure they fit those patients in with appointments as soon as possible. But clinicians in the hospital can also try to tamp down high discrepancy rates.
For one, says Dr. Lindquist, hospitalists should cull out drugs at discharge that patients may not absolutely need. More importantly, she adds, “When we write discharge instructions, we don’t incorporate patients’ lives into those instructions. So patients at home have no idea how to integrate a new drug into their other eight medicines.”
Instead of just handing patients a list of prescriptions, Dr. Lindquist urges hospitalists to have patients walk them through how they take medications at home. Hospitalists can then help patients decide how to fit in new medications, such as whether to take them in the morning or afternoon or with meals or without.
Incentives already in place
So how hard is it convincing primary care physicians to step up? For the study, Dr. Lindquist’s team worked with outpatient doctors enrolled in Northwestern’s practice-based research network. Those physicians have access to inpatient electronic records for medication lists.
Being a part of that type of network certainly made it easier for primary care physicians to make post-discharge calls. But Dr. Lindquist maintains that such a system is feasible even in nonintegrated networks.
For one, nurses in outpatient practices can make the calls. “A lot of patients know those nurses very well,” she says.
And hospitalists should already be making sure that primary care physicians are contacted both on admission and while discharge is taking place, contacts that are key to putting post-discharge calls in place.
“People rely on texts and faxes, with medication lists and discharge summaries,” Dr. Lindquist points out. “Contacts can also be standardized with an automatic page, giving a primary care physician a contact number for the hospitalist.”
Hospitalists who can incorporate a phone call with primary care physicians before discharge, as the doctors in the study were able to do, would glean a lot of information, she points out. Outpatient physicians can, for instance, give hospitalists insights into patients’ health literacy or level of compliance, which could inform discharge planning.
And a recent development should persuade more primary care physicians to get involved. As of Jan. 1, 2013, Medicare now allows outpatient clinicians to bill transitional care codes for work they do post-discharge. While outpatient providers must have at least one face-to-face encounter with patients to bill one of the codes, they can factor in non-face-to-face services that outpatient doctors, midlevels and some nurses provide when determining the level of code to bill.
“Medicare is already paying for this, and transitional care codes are much higher billing than just a regular visit,” says Dr. Lindquist. “So there’s already an incentive.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.