Out of more than 2,600 discharges during 1997-1998, the first year that the follow-up service existed, only 47 patients were prescribed with follow-up visits. “It was never meant to be a highly utilized service,” says Dr. Pantilat, “but to be a highly expandable, flexible service that addresses the needs of specific patients.” Of those 47 patients, four were readmitted to the hospital—one directly from the follow-up visit—compared with a national readmission average of 14%.
“We see these patients in the ED,” says Dr. Pantilat. “It’s the only department that’s open 24/7, and the ED has some extra bed capacity.”
When the hospitalist feels a follow-up is necessary, he or she schedules a visit with the patient before discharge for midmorning one or two days after discharge. (Midmorning is typically a slow time in the emergency department.) He then faxes the appointment information to the emergency department, so that when the patient shows up, she is preregistered. The emergency department telephones the hospitalist when the patient arrives, and that doctor then comes down to see the patient. The emergency department physicians have nothing to do with these follow-ups, though the nursing staff might be asked to help. Also, follow-up visits are considered an outpatient service and charged as such. “The follow-up service was established and run at virtually no cost,” says Dr. Pantilat.
Even if every hospital doesn’t arrange in-person follow-ups, there will be some form of contact after discharge. “Hospitals providing care in transition will expand a lot,” he explains, “whether it’s phone calls from a nurse or other healthcare professional or some other contact during that gap until a patient can re-establish with their primary care physician. Not every patient needs this, but a lot would benefit.”
THE HOSPITALIST ROLE IN DISCHARGE
As we move toward creating a better discharge process, hospitalists will be at the center of that change and the process itself.
“The hospitalist is the keeper of information,” says Dr. Arora. “They know why certain care decisions were made. This movement depends on the flow of information to help design systems to help implement communication.”
There are some barriers to a smooth discharge process that only hospitalists can eliminate. “The increased use of hospitalists means that patients are not familiar with their doctor” in the hospital, says Dr. Arora. “When they leave the hospital, some information stays behind. They don’t know who to call for that follow-up lab work prescribed in the hospital. … The hospitalist needs to do a better job of telling patients who they are and how to reach them after discharge. A systems-based solution, or solutions, is needed.”
It is up to hospitalists to ensure that their discharge system works, that each patient leaves with an understanding of next steps in their care and knows who to call for which specific follow-up step, and with contact information if they (or their primary care physician) need to reach their hospitalist.
Dr. Halasyamani believes that hospitalists are well positioned to implement change in general within their systems. “The hospitalist is in the trenches, in a position to see what changes have to take place,” she says. “It’s their role to inform their management of better processes.
Each of us needs to be a waver of the banner for new standards—it’s not good enough to just scribble prescriptions”
CONCLUSION
The future is coming fast, for improved hospital discharge as well as other everyday processes. “We’re learning that discharge should be a more structured, formal process,” says Dr. Whelan. “We’d like to move to a safer, more complete and more efficient way of handling it.”