Dr. Jha agrees it’s not reasonable to expect hospitalists to take responsibility for what happens to their patients 30 days after discharge, the standard of such performance models as HRRP.
“But I believe you can push me and my team to step up for a few more days,” he says. “I’ve had patients come back to the hospital the next day. Hey, that means I dropped the ball.”
Yet, the middle ground, from a few days after discharge to 30 days, can seem like an eternity.
“If we think our role completely ends at the time of discharge, what tends to happen is we take our foot off the gas,” says Win Whitcomb, MD, MHM, co-founder of SHM, practicing hospitalist, and CMO of Remedy Partners, a firm specializing in bundled payment programs. “We back off from the patient being discharged and start focusing on the next acutely ill patient who just got admitted.”
“I tell my residents that I’m accountable for what happens to the patient after discharge. It’s now part of my job. 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.”—Ashish K. Jha, MD, MPH, K.T. Li Professor of international health, Harvard School of Public Health, director, Harvard Global Health Institute, hospitalist, VA Boston Healthcare System
At a minimum, Dr. Whitcomb says he believes that hospitalists should place a direct phone call to the PCP, preferably before the patient leaves the hospital, although he acknowledges that this is the exception rather than the rule for most hospitalists today.
“You learn things about the patients and their history,” he says, that might be important to the next provider.
Pending lab tests at the time of discharge are another big issue, most experts on readmissions agree. If the hospital doesn’t have a system for ensuring that these results are properly passed on to the next provider of care, the hospitalist group should be spearheading a quality improvement (QI) process to make it happen. Even so, Dr. Whitcomb says hospitalists should not be trying to fix these problems in a vacuum. For example, they should partner with others in the hospital working on readmissions issues and coordinate their post-discharge phone calls to patients with other groups that may be placing similar calls.
“The individual hospitalist is responsible for working with the hospital team to ensure that the patient understands the post-discharge plan of care, that medications are reconciled, and that there is a system for transmitting information to the PCP,” he says.
What Is a Satisfactory Discharge/Handoff?
Experts can agree on one thing: A successful discharge (or handoff) is paramount to preventing what are considered “avoidable” readmissions (see “What We Already Know about Hospital Readmissions”). Exactly what a successful discharge looks like, however, is not as easily defined.
Most agree hospitalists are responsible for making sure that patients understand their condition, treatment plan, what to watch for, and where to go or who to call in a crisis. This means short, digestible, actionable, tailored advice utilizing “teach-back” and other techniques that clarify for the physician whether patients truly understand what they need to know. Some hospitalist groups task a member of the group to be available for the questions that can arise in the first few days after discharge. Some argue hospitalists should provide contact information, even a pager number, to patients going home from the hospital.