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Care Transitions

Sunil Kripalani, MD, MSc | December 1, 2007 
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Hospital discharge is often viewed as the end of an acute medical event. Goodbyes are said as patients pack their belongings and return home. Physicians scratch the patient's name off their rounding list, and hospital staff remove the patient from the census as they clean out the room.

Although there is a finality associated with discharge, many patients' illnesses actually have not fully resolved by the time they leave the hospital. During a period of convalescence that may last days, weeks, or even months, patients must manage new medications, adopt lifestyle changes, and perform appropriate outpatient follow-up. Increasingly, evidence shows that during the time after hospital discharge, the patient is prone to medical errors, adverse events (AEs), and rehospitalizations. Half of patients experience a medical error after discharge, usually one related to medication continuity, follow-up of test results, or completion of diagnostic work-ups.(1) Approximately 20% of patients suffer an AE within 3 weeks of discharge.(2) Studies have suggested that most errors and AEs could be prevented or ameliorated through better communication and coordination of care.(1,2)

What is so challenging about ensuring effective hospital discharge and post-hospital care? More importantly, what can be done to improve patient safety in this setting?

From the patient's perspective, hospital discharge may come as a surprise, with little or no advance warning.(3) The discharge itself is often a rushed event in which the physician, nurse, and other staff provide verbal and written instructions, which may or may not be consistent with one another. When this counseling occurs is more likely to be dictated by the physician's rounding schedule or the hospital's desire to clear the bed than by the availability of caregivers to participate in the discussion. Patients who leave the hospital with a new diagnosis or new medications are asked to change their established routine, which may also pose difficulties. Research shows that patients often have difficulty understanding their hospital diagnoses, medications, and other self-care instructions, and that medication nonadherence is common.(4,5)

For hospital-based physicians, the barriers to quality discharge care are numerous.(6) Preparing a patient for hospital discharge takes time, especially when it includes performing medication reconciliation, patient education, and discharge summary documentation. Although physicians may bill for a higher level of reimbursement if they spend more than 30 minutes on a discharge, complex patients may require an hour or more. Of course, these patients are the ones most likely to experience a medical error or adverse event after discharge, so their preparation is the most critical. Moreover, most physicians have not received specific training or feedback on how to best discharge a patient. Contrast this with the emphasis placed on the admitting history and physical examination throughout medical education. I would argue that a good hospital discharge transition is just as important as a thorough admission evaluation.

Hospitalist groups and other rotating services must also contend with physician discontinuity during hospitalization. It is more challenging for a physician to discharge a patient who was admitted and managed primarily by someone else, especially for a long hospitalization. For a variety of reasons (e.g., not wanting to interrupt the primary care physician [PCP], perceiving that it will take a long time, or simply not being accustomed to having this sort of communication at discharge), hospital-based physicians may be reluctant to contact the PCP to assist in coordinating postdischarge care. Even when they are committed to making contact, the PCP's contact information may be unavailable or the patient may not have an established PCP.

On the receiving end, PCPs often first learn of the hospitalization when the patient calls in with a question or arrives for a follow-up appointment. A systematic review of discharge communications, conducted by the joint Society of Hospital Medicine/Society of General Internal Medicine (SHM/SGIM) Continuity of Care Task Force (7), revealed that discharge summaries are usually unavailable at the time of the first follow-up contact, and this adversely affects care in about one-fourth of cases. Moreover, discharge summaries often lack information that would be essential for providing good follow-up care, such as discharge medications (absent from a median of 21% of discharge summaries), pending test results (65%), and follow-up arrangements that were made or need to be made (14%). When chronic outpatient medications are changed during the hospitalization, the rationale for such changes is also usually not provided.

Health care policies have not done much to improve this state of affairs. The Joint Commission considers discharge summaries to be part of the hospital record and requires that they be completed within 30 days of discharge.(8) This is far too permissive, considering that patients often contact their PCP within 7 to 14 days of discharge. The Joint Commission requires that certain content, such as treatment and hospital course, be included in discharge summaries. However, other domains crucial to patient safety and continuity of care—such as discharge medications, pending test results, and recommendations for follow-up—are not specifically addressed in the current regulations.

Other aspects of the health care system also present barriers to an effective transfer of care. These include formulary restrictions and automatic medication substitutions, both of which are interventions intended to reduce costs. However, they inadvertently may create confusion about the outpatient medication regimen, particularly if medication reconciliation is not performed adequately. More widespread availability of information technology is also needed to support medication reconciliation, flag pending test results, and facilitate communication among physicians and patients. Lack of reimbursement for postdischarge support is a major deterrent to the proliferation of such services.

So, what can be done? Fortunately, a number of tested interventions and expert recommendations are available to improve care transitions.

At the patient level, empowering individuals and families to participate in their discharge preparations is essential. The effectiveness of patient empowerment has been demonstrated in a variety of outpatient contexts, but efforts that target hospital discharge are rare. An important model is the Care Transitions Intervention, which involved providing elders and their caregivers with a "transition coach" and empowering them to facilitate communication and other aspects of the care transition. This intervention significantly reduced rehospitalization rates and costs.(9)

Hospital physicians will play a critical role in improving care transitions as they work in collaboration with nurses, pharmacists, discharge care coordinators, and other hospital personnel. One interesting approach is to set a discharge appointment so that the patient and family can anticipate the date and time of discharge, and so that hospital staff can work toward this goal.(10)

Project RED (Re-Engineering Discharge) is an example of a multidisciplinary effort to revamp the whole process. Through qualitative analysis, process mapping, root cause analysis, and other techniques, the Project RED team developed 11 components for effective hospital discharge transitions, including the following (11):

  • Educate the patient throughout the hospitalization.
  • Organize and schedule postdischarge appointments.
  • Give the patient a written discharge plan that includes the reasons for hospitalization, instructions for following the medication regimen, recommendations on what to do if the condition worsens, follow-up appointments, and pending items (e.g., test results that have not returned at the time of discharge).
  • Prepare a detailed discharge summary and deliver it promptly to the PCP.
  • Reinforce the discharge plan and provide troubleshooting by telephone 2 to 3 days after discharge.

The SHM/SGIM Continuity of Care Task Force recently provided complementary recommendations about the content, format, and delivery of discharge communications.(7) These include the following:

  • Some form of communication should occur between the hospital physician and PCP on the day of discharge. A detailed summary should be delivered within 1 week.
  • Discharge summaries should be structured with subheadings to organize and highlight the key information.
  • Discharge summaries should include diagnoses, pertinent history and physical findings, dates of hospitalization, hospital course, results of procedures and abnormal studies, consultant recommendations, information given to the patient and family, functional status, reconciled medication regimen (with reasons for any changes and indications for new medications), details of follow-up arrangements made, specific follow-up needs (including appointments or procedures that need to be scheduled, and tests pending at discharge), and name and contact information for the hospital physician.
  • Hospitals should use information technology to facilitate completion of discharge summaries by filling in information located elsewhere in the hospital record.
  • Patients should be given a copy of the summary when possible and should be asked to bring it to their follow-up visit.

The most powerful efforts to improve patient discharge and transitions of care will have the full support of hospitals and health systems. Hospitals may need to weigh competing demands, such as a desire to discharge patients early in the day, versus discharging patients at a time when family can be present for counseling. Additional personnel may also be required, not only to coordinate care in preparation for discharge, but also to follow up with patients after they return home. Although it is likely that an investment in discharge planning and postdischarge support will be cost-effective (as was Coleman's Care Transitions Intervention [9]), earlier research suggests that this may not always be the case.(12) One of the most challenging aspects of improving care transitions will be to change the system so that hospital staff may begin working on discharge early in the hospitalization, in an effort to avoid a frenzy of activity on the final hospital day.

Of course, regulations could also play an important role in improving transitions of care. If the Joint Commission mandated, for example, that discharge summaries be completed and delivered to the PCP on the day of discharge, the availability of information for follow-up care would improve dramatically. It is likely that the quality of care would also improve, though research would be required to confirm this. Other beneficial regulatory changes would include providing reimbursement for postdischarge support, such as follow-up telephone calls to patients. Better reporting of discharge processes and outcomes should also help improve care transitions. SHM is working with the American College of Physicians and other organizations to develop care transition measures that could be incorporated into the 2009 iteration of the Centers for Medicare and Medicaid Services (CMS) Physician Quality Reporting Initiative (PQRI).

In summary, there are a number of challenges facing patients, physicians, and health systems with regard to ensuring a high-quality discharge and care transition. But there are also a number of steps that each party can take to improve the current state of affairs. As hospitalists, health systems, and regulatory agencies become more invested in the care transition, we are sure to see new and innovative approaches, and hopefully broader use of strategies known to be successful.

Sunil Kripalani, MD, MScAssociate ProfessorDirector, Section of Hospital MedicineAssociate Director, Program for Effective Health CommunicationDivision of General Internal Medicine and Public HealthVanderbilt University


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This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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