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Ashish K. Jha, MD, MPH, K.T. Li Professor of international health in the department of health policy and management at the Harvard School of Public Health and director of the Harvard Global Health Institute in Boston, is both a practicing hospitalist and a widely published researcher in the middle of a teeming national debate about hospital readmissions policy.1 He’s seen his fledgling field of hospital-based internists grow from a few hundred two decades ago to nearly 50,000 hospitalists spanning every state. He’s also seen changes in the role hospitalists play in the inpatient setting.
“Now, when it’s time for my patient to get discharged, I ask a lot of questions like, ‘Who is with you at home? How will you get your medications or your groceries?’” says Dr. Jha, who practices hospital medicine at the VA Boston Healthcare System.
Hospitalist care went under Medicare’s microscope in October 2012, when the Hospital Readmissions Reduction Program (HRRP) began penalizing hospitals with higher-than-predicted rates of 30-day readmissions for certain common conditions (see “Optimal Discharge Checklist for Hospitalists”). HRRP places hospitalists under greater scrutiny for things that happen to their patients after discharge, whether to home or another healthcare facility. In one swoop, the program changed how the healthcare system views care transitions, continuity of care, teamwork, collaboration, and the post-discharge period.
Experts in improving transitions of care—which, it is hoped, would ameliorate the problems that lead to readmissions—emphasize the importance of teamwork across disciplines, specialties, and care settings; dialogue and collaboration between providers; and the formation of community coalitions and integrated systems of care.
Many of the factors that influence the likelihood of readmission are nonmedical, however: socioeconomic status, health literacy, home environment, adherence to prescribed medications, and the ability to make—and keep—follow-up appointments. So, while social variables are an essential part of the readmission conversation, a hospitalist often has no remedy to address—let alone prevent—them.
“The part we own is communication, and lack of communication is a problem. But if there is to be a handoff, at some point you have to cut the cord.”—David J. Yu, MD, MBA, SFHM, medical director, adult inpatient medicine service, Presbyterian Hospital, Albuquerque, N.M.
And therein lies the debate: At what point do hospitalists stop being responsible for discharged patients?
“The part we own is communication, and lack of communication is a problem. But if there is to be a handoff, at some point you have to cut the cord,” says David J. Yu, MD, MBA, FACP, SFHM, medical director of the adult inpatient medicine service at Presbyterian Hospital in Albuquerque, N.M.
Dr. Yu agrees that hospitalists are responsible for the quality of their discharges. Readmissions, he says, are a system issue. Although hospitalists have a responsibility to help drive quality improvement in the hospital, he says it makes little sense to hold the hospitalist responsible for what happens to the patient after discharge.
“I believe that when we talk about hospitalist-staffed post-discharge clinics and things like that, we’re asking the wrong questions,” he says. “We’re turning the hospitalist into a temporary PCP. Those things are only temporary solutions.”
Some hospitalists see this issue as black and white, arguing that their focus should be on caring for “inpatients,” working strictly according to the definition of a hospitalist. They ask a very simple question: How long can responsibility linger once the patient exits our facility?
Others, like Dr. Jha, choose to “own” care transitions into the post-discharge period.
“I tell my residents that I’m accountable for what happens to the patient after discharge. It’s now part of my job,” Dr. Jha says. “Some of that can be outsourced to social workers, but some only I can do. Some of my colleagues don’t like it, but I say no one comes off our service until at least two or three days after discharge. We follow up on pending lab results. The hospital makes a post-discharge phone call. We’re reachable by phone. We’re still taking care of the patient but in a different way.”