10 steps to the ideal transition
No one does it all, but everyone should try
Everyone has a great idea for reducing read-missions and improving transitions of care. The literature is full of it. But just what would the dream discharge look like? How could you get a patient from the hospital to the next phase of care in the best way possible? Robert Burke, MD, a hospitalist at Denver VA Medical Center, and a group of his peers looked at the literature to see what the best possible transition would look like. They published their results in the February 2013 issue of the Journal of Hospital Medicine1.
There are 10 domains that they found were part of the “bridge” between places of care. They are:
- discharge planning;
- complete communication of information;
- availability, timeliness, clarity and organization of information;
- medication safety;
- educating patients to promote self-management;
- enlisting the help of social and community supports;
- advance care planning;
- coordinating care among team members;
- monitoring and managing symptoms after discharge;
- outpatient follow up.
Most of these steps should take place while the patient is still in the hospital, and in places where they have, there is evidence they work. In his article, Burke has recommendations of where to start — such as with the Project RED program of re-engineered discharges that came out of Boston University Medical Center. His hope, though, is that someone will get a grant to do a trial of all of these things together.
“Everything here came from things that have worked in some way for others,” he says. “But a lot of what has been written about hasn’t worked to reduce readmissions in a meaningful way. I guess we really don’t know why they are happening in many cases. I would hope that this would move the field forward.”
No hospital has implemented more than seven of the domains — three hospitals reached that level — and they are the most effective at reducing readmissions, says Burke. But there are issues which are unique to every hospital, and Burke wonders if there is really something called an ideal discharge that would work for every facility. “Some hospitals have more issues with primary care access — something that isn’t an issue with the VA, where more than 80% of our patients have primary care providers. So one size won’t fit all.”
That said, this is a place to start, and each of these domains has proved effective — and cost effective — in a real world situation. “You can use this as a diagnostic tool and see which of these categories cause you the most trouble. Then you can work on them.”
The best programs provide others with tools, information, and even training, Burke says. Project RED has a toolkit available (http://www.ahrq.gov/professionals/systems/hospital/red/toolkit/index.html), and Eric Coleman’s Care Transitions Intervention provides a wealth of information on its website (http://www.caretransitions.org/), including free webinars.
Burke thinks that hospitalists in particular will play a big role in improving care transitions and discharges, possibly by working more outside the hospital in the post-discharge world. “Hospitalists often think their responsibility ends at discharge, but I think there is value in extending it a week or two beyond that,” he says. “It’s very valuable to have someone who knows about the inpatient experience be part of the outpatient care. It’s better for continuity of care, and also for patient education. The hospital isn’t a conducive environment to learning for a sick patient.” Having hospitalists attend a post-discharge clinic and/or be at the first appointment with the primary care physician could be valuable, he says. “Patients can be confused about who their doctor is after they get out of the hospital. That joint appointment could help.”
Granted, there are issues of payment and even the desire of inpatient specialists to move into the outpatient world, even temporarily. In a survey of hospitalists that Burke did on the topic, about half were willing to participate in an out-patient appointment, and most said they wanted to be paid for participation. But nearly all think that it would be a good thing for patients and have faith it would improve outcomes.
Beth Israel Deaconess in Boston has a program like this, Burke says. It’s a money loser for the hospital, but it could be that when you take reduced readmissions into account, it has a positive financial impact. It will help that this fall the Centers for Medicare & Medicaid Services will start providing augmented reimbursement for the first post-discharge doctor visit. That might encourage more hospitals to create some sort of bridge program for patients.
None of the 10 domains is a panacea, particularly not individually. But Burke says they offer organizations a place to start.
Reference
- Burke RE, Kripalani S, Vasilevskis EE, Schnipper JL. Moving beyond readmission penalties: Creating an ideal process to improve transitional care. J Hosp Med. 2013 Feb;8(2):102-9. doi: 10.1002/jhm.1990. Epub 2012 Nov 26.
For more information, contact: Robert E. Burke, MD, Hospitalist, Denver VA Medical Center, Assistant Professor of Medicine, University of Colorado. Telephone: (303) 399-8020, ext. 5830.
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