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Improve patient discharge with low-cost strategies for hospitalist-PCP communication

Hospitalist Management Advisor, August 1, 2008

Even a clear and concise discharge plan can have holes when it comes to patient care.

As the medical director at Somerville (MA) Primary Care and a hospitalist at Cambridge (MA) Hospital, Richard Balaban, MD, understands both sides of hospitalist-primary care physician (PCP) miscommunications that can arise during patient discharges.

Far too often, patients leave the hospital confused about their diagnosis, medication, or the next step in their care, according to a recent study, Redefining and Redesigning Hospital Discharge to Enhance Patient Care: A Randomized Controlled Study, coauthored by Balaban. In another study on discharged patients, Balaban found that half of discharged patients didn’t know their diagnosis, and the other half didn’t fill their prescription for new medications during the two weeks after discharge.

Balaban’s study showed that a concentrated team effort among medical staff members can enhance patient follow-up in relatively low-cost ways. The study calls for the:

Hospitalist to electronically notify the PCP office about the discharge plan with an effective discharge form

Nurse in the PCP office to then follow up with the patient by phone

This effectively minimizes the likelihood of a poor outcome. “There’s certainly some coordination that needs to occur,” Balaban says. “But acting proactively and not reactively is best.”

The root of the problem

Problems with discharge planning have as much to do with systemic problems as the condition of the patients. There are challenges to each side of the equation, says Balaban.

“It’s a very vulnerable time for patients, and on the hospital side, there’s a tremendous rush to get people out,” he says. “The process is sometimes rushed or incomplete. You’re trying to transfer information in one fell swoop, but it’s hard for a patient to absorb it all.”

From the standpoint of a PCP, the emergence of the hospitalist movement may have created an information gap between the two groups of healthcare professionals. Balaban says PCPs complain that hospitalists don’t give enough information (e.g., recommendations for future tests and medication changes) in a timely manner.

Because the PCP decides on the course of action in care of his or her patients, the study evaluated methods of how to incorporate the PCP into the discharge process at the exact time of discharge.

Step 1: Redesigning the discharge form

Discharge instructions are often too clinical for patients to fully understand. Further, if patients require instructions in another language, translations are frequently unavailable.

Step one in Balaban’s study was to develop a user-friendly format for the discharge form, translated into several languages.

A discharge planning nurse prepared the form with help from a discharging physician. The redesign of the form aimed to address patients’ inability to state their diagnosis or recall changes to their medication list. It also addressed PCPs’ failure to act on abnormal test results or to complete recommended outpatient workups.

  • The redesigned discharge form included the following information:
  • Patient demographics
  • Discharge diagnosis
  • Names of hospital physicians who attended to the patient (including residents, hospitalists, and specialists)
  • Vaccinations given
  • New allergies
  • Dietary and activity instructions
  • Home services ordered
  • Scheduled upcoming appointments with a PCP, with a specialist, or for diagnostic studies
  • Pending medical test results
  • Recommended outpatient workups
  • Discharge medications, list of continued drugs with dose changes highlighted, new medications, and discontinued medications
  • Nursing comments (optional)
  • Reminder to patients to bring the form to their next PCP appointment

“We tried to use as little text as possible,” Balaban says. “It also encouraged us not to send too much information; a lot of times, less is more.”

The floor nurse reviewed the information with the patient, aided by an interpreter when necessary. And the nurse reminded the patient, in writing, to bring the discharge form with him or her to follow-up appointments.

Step 2: Sending the discharge form to the PCP office

During the study, the nurse electronically sent the discharge form (via e-mail or fax) to the RNs at the PCP site on the same day the patient left the hospital. That form then became part of the patient’s permanent medical record.

“In our initial model, there had to be some sort of electronic communication, so this works best in an integrated system where they share an electronic record,” says Balaban.

But an integrated system isn’t essential for this exchange to work. “There really just has to be a commitment from both sides,” he says.

Step 3: Reaching out from hospital to home

When the PCP office received the discharge form, it signaled the nurse to call the patient on the next business day.

“One of the ideas is getting the nurses to make this initial outreach,” says Balaban. “The PCPs are too busy.”

During this outpatient follow-up call, the nurse used a telephone script to ask questions about the patient’s medical status, review the discharge form with the patient, explore any patient questions or concerns, and confirm any scheduled follow-up appointments.

“A lot of times, discharged patients are in limbo and they don’t know who to call if they have a problem or a question,” Balaban says.

This conversation makes it clear to patients that they can contact the RN at the PCP’s office.

In the study, the nurse then forwarded the call notes electronically to the PCP, who either signed off on the hospitalist’s recommendations or modified them if needed.

This outreach process not only satisfied the PCP and the patient, but the nurses felt fulfilled too, Balaban says.

The inpatient nurses also felt the redesigned process provided an avenue of communication with PCPs and an avenue to explain what they’d learned about the patients.

“A lot of times, [nurses] have concerns but no one to share [them] with,” Balaban says.

For example, a nurse may worry about the possible onset of early dementia and wonder how a patient could manage at home. “This way, they could send their concern in the electronic transmission,” says Balaban.

Assessing the study results

The study measured four undesirable outcomes following hospital discharge to see how the new process affected patient care. The studied outcomes are:

  • No outpatient follow-up within 21 days
  • Readmission within 31 days
  • Emergency department visit within 31 days
  • Failure by the PCP to complete an outpatient workup recommended by the hospitalist

Only a quarter of the intervention patients had one or more undesirable outcomes, compared to more than half of the concurrent cases not included in the study and 55% of historical controls. The study indicated that the redesigned discharge plan reduced negative outcomes.

Only 15% of the intervention patients failed to follow up within 21 days, compared to 40.8% of the concurrent and 35% of the historical controls. Only 11.5% of recommended outpatient workups in the intervention group were incomplete, as compared with 31.3% in the concurrent and 31% in the historical controls.

Balaban says patients in the study were more likely to follow up with the PCP within a few weeks of discharge, and the PCP was more likely to initiate and complete the hospitalist’s recommendations.

This indicates that the PCP took the recommendation into account and decided whether to follow it, says Balaban.

“We counted the PCP not following the recommendation as completing the recommendation,” he adds. “Presumably, he had a reason. He responded and there was ongoing care.” The PCP reviewed the discharge form on the day of or the day following discharge—an improvement in patient care, Balaban says.

The study also found that during one-quarter of outreach calls, the nurses made some form of assistance intervention. In some calls, the patient didn’t have his or her medication, and the nurse assisted by reminding the patient what medication he or she needed and called the pharmacy for fulfillment. In other calls, the patient didn’t realize he or she had scheduled an appointment with the PCP.

Inexpensive tactics

Balaban is often asked why a physician would discharge a patient out of the hospital without following up with the PCP right away. In response, he quotes a colleague who asserts that discharging patients should be done with the same intensity as admitting them.

“People are so focused on working in their site that their purview doesn’t extend beyond that,” Balaban says.

“Part of this is built on redundancy; you’re often just reviewing the material that was given the day before,” he says. “But we have to acknowledge that no matter how good a job we do, there will always be holes, and the patient is going to walk away with certain misunderstandings. That’s why it’s important.”

It’s important—and inexpensive. The low-tech fix doesn’t require any additional personnel; it only requires using existing nurses to make the outreach calls and the will to make a change.