Bridge the hospital-to-outpatient gap with PC docs
Calls from nurses result in improved intervention
No matter how positive their experiences during the discharge process, patients can feel that once they exit the hospital doors, they're in "no man's land" if issues arise later. But a process tested at Somerville (MA) Hospital showed success at bridging the gap between hospital and primary care.
"Patients are often uncertain who to call [if they develop complications after discharge] the doctor they saw in the hospital or their primary care physician," says Richard B. Balaban, MD, medical director of Somerville Primary Care, part of the Cambridge Health Alliance. "By trying to bridge that gap for the patient, we're improving the information transfer between the hospital and the primary care physician."
Balaban cites studies that have shown that half of discharged patients don't understand their discharge plans. The potential for problems is increasing because hospitals are sending patients home earlier in their recovery, which means they have more complex responsibilities to deal with on their own, he adds. With shorter hospitalizations, the post-discharge period is vital to a patient's full recovery.
"A key aspect of that is effectively transferring the patient's care to their regular physician," he says. The process put in place for a study at Somerville Hospital, a 100-bed hospital just outside Boston, reframed discharge as a "discharge-transfer," transferring care from inpatient to outpatient, rather than simply as an end to inpatient care.
Clear discharge instruction, follow-up key
Balaban launched a study to find out if a low-cost intervention could markedly change the hospital-to-primary-care transition in a study population of 122 patients in a six-month period. The four-step intervention involved:
- generation of a patient discharge form in the patient's primary language;
- electronic transfer of the patient discharge form to the nurse at the patient's primary care office;
- telephone contact by the primary care nurse after receipt of the discharge form;
- review and modification of the discharge plan by the primary care physician.
The patient discharge form is "user-friendly," Balaban says, and contains the basic information the primary care provider needs to know about the patient and his or her hospitalization, including demographics, discharge diagnosis, all physicians (including hospitalists, residents, and specialists) who saw the patient, vaccinations given, new allergies, diet and activity instructions, home services ordered, scheduled followup appointments, new medications, discontinued medications, and any pending tests.
The discharge form was gone over with the patient and his or her family members, and a hard copy was given to the patients to take home.
The same form was sent electronically to the primary care provider's office, to be placed in the patient's medical record. Receipt of the form signaled the primary care nurse that the patient had been discharged and was ready for follow up. The primary care nurse called the patient the following day, and by phone assessed how the patient was doing, whether any questions or issues had arisen, and to confirm that the patient understood instructions and follow-up appointments.
Based on that call, the patient discharge form and any notes made by the nurse were forwarded to the primary care physician, who reviewed and modified the discharge plan as needed.
Balaban says the process takes into account the fact that patients don't always retain the instruction they're given at discharge and the statistical likelihood that they will develop complications post-discharge.
"There's a lot of uncertainty when you're trying to define a standard of care, and to have a plan is absolutely essential," he says. "In many instances I think the standard has been to discharge the patient from the hospital without thinking about where they go next."
In the report Balaban and his colleagues published on their research in August,1 they cite studies that indicate most patients don't know their discharge diagnosis, misunderstand the use of new drugs, and importantly receive insufficient post-discharge care. The key, they write, is for the hospital to communicate directly with the primary care provider.
In more than two-thirds of patients, their regular doctors will not have received a written discharge summary by the time of the first post-discharge visit, and in one-fourth of patients, their doctor never receives a discharge summary, the authors report.
"Getting the relevant information to the patient's primary doctor lets the primary care provider make the phone call to follow up, and giving the patient a copy of the report lets the patient play an active role in ensuring appropriate follow-up is made," Balaban says.
Bridging gap to physician
While the size of the patient sample makes Balaban reluctant to make generalizations about the discharge process his team studied, the results suggest it's a plan worth further study.
The 122 patients were divided into two groups one control group whose discharge plans weren't followed up by their primary physician's offices right away, and the test group who did receive the phone calls.
"We found in our study that when nurses called patients, in about 25% of those calls there was some sort of intervention by the nurse either the nurse determined that there was an incorrect use of medications, or the patient didn't have the prescription he or she should have had, or even that the patient was in poor condition and needed help immediately," Balaban says. "That sort of active intervention with 25% of the patients they called shows this could have a significant effect."
Another measurement compared the rate of undesirable outcomes readmission or an emergency room visit within 31 days, no follow-up within 21 days, or failure by the primary care doctor to complete an outpatient workup between patients who received the intervention and patients who did not.
Of patients who received intervention, 25.5% had one or more undesirable outcomes, compared to 55% of the patients in the control group.
The study population was culturally and linguistically diverse, and in those patients, intervention significantly increased the rates of outpatient follow-up and the completion of recommended outpatient workups, Balaban notes.
"It's important we look at non-English-speaking patients, and equally important is the older population," he adds. "They have more active issues, so ensuring there's some very immediate communication with their primary care physician at discharge we see as a way of preventing problems from coming up."
Besides non-English-speaking patients and older patients, the intervention appeared to make a positive difference for patients discharged on weekends, and patients whose hospital stay was shorter (and therefore afforded less time for discharge preparation).
Reference
1. Balaban RB, Weissman JS, Samuel PA, Woolhandler S. Redefining and redesigning hospital discharge to enhance patient care: A randomized controlled study. J Gen Intern Med 2008;23:1228-1233.
Source
For more information:
- Richard B. Balaban, MD, Medical Director, Somerville Primary Care, Cambridge Health Alliance; Instructor in Medicine, Harvard University, Cambridge, MA. E-mail: [email protected].
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