What Now?

Of the contributing factors cited by patients, one-third were due to unintentional nonadherence, followed by financial barriers, intentional nonadherence, and neglect in filling a prescription.8 At the system level, incomplete, inaccurate, or illegible discharge instructions (as a result of either poor handwriting or use of Latin abbreviations) were the most commonly identified contributing factors, followed by conflicting information from different informational sources and duplicate prescribing.

Partnering with Case Management

Variability in physicians’ rounding patterns and schedules and in nurses’ and case managers’ shifts and assignments can make it difficult to bring involved parties together. Yet hospitalists look to case managers to follow up on acute services, interact with the patient’s plan of care, communicate with families, arrange follow-up with the primary care physician, and track the patient’s condition for progress.

Cogent Healthcare (Irvine, Calif.), a leading hospitalist company, has devised a means to optimize communication between case managers and hospitalists. The effects of this partnership have been shown to shorten hospital stay and reduce costs with no adverse effect on patient outcomes or patient satisfaction.16, 17 Along with responsibilities during the hospitalization, Cogent’s clinical care coordinators (CCC) make sure the primary care physician gets correct and appropriate information as soon as possible. The CCC phones the patient at home to ensure that the discharge plan is in place, that the patient is compliant with the post–acute treatment plan, and that she or he has a plan to meet with the primary care physician.

Case managers face a good deal of daily frustration, working on the same problems for patient after patient and trying to be available to help hospitalists make clinical practice decisions at the point of care. One way to improve overall post-discharge communication would be to lobby hospitals to provide the resources to support the case managers’ workload and their accessibility to their hospitalist colleagues.16, 18

Conclusion

Effective post-discharge communication includes standardizing an institution’s protocol for handoffs, increasing training and practice in post-discharge communication, and keeping the lines of communication open among hospitalists, primary care physicians, patients, and families. Collecting reported feedback from patients and families shortly after patients have returned home can be used toward quality improvement. Although the effectiveness of post-discharge communication may vary from hospital to hospital and even from hospitalist to hospitalist as well as across each hospitalist-primary care physician pairing, “I think that the interest that’s been stimulated in this whole area is exciting,” says Dr. Frankel. “This is an area where everybody wins. Rather than one person or one hospital winning and another one losing, there’s a new collaborative spirit that is very heartening to see.” TH

Andrea Sattinger writes regularly for The Hospitalist.

References

1. Nelson JR, Whitcomb WF. Organizing a hospitalist program: an overview of fundamental concepts. Med Clin North Am. 2002 Jul 8;86(4):887-909.
2. Solet DJ, Norvell JM, Rutan GH, et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005 Dec;80(12):1094-1099.
3. Lurie JD, Merrens EJ, Lee J, et al. An approach to hospital quality improvement. Med Clin North Am. 2002 Jul;86(4):825-845.
4. Callahan EH, Thomas DC, Goldhirsch SL, et al. Geriatric hospital medicine. Med Clin North Am. 2002 Jul;86(4):707-729.
5. Delbanco T. Hospital medicine: understanding and drawing on the patient’s perspective. Am J Med. 2001;111(Suppl 9B):2S-4S. 6. Calkins DR, Davis RB, Reiley P, et al. Patient-physician communication at hospital discharge and patients’ understanding of the postdischarge treatment plan. Arch Intern Med. 1997 May 12;157(9):1026-1030.
6. Makaryus AN, Friedman EA. Patients’ understanding of their treatment plans and diagnosis at discharge. Mayo Clin Proc. 2005 Aug;80(8):991-994.
7. Coleman EA, Smith JD, Raha D, et al. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005 Sep;165(16):1842-1847.
8. Nelson JR. The importance of postdischarge telephone follow-up for hospitalists: a view from the trenches. Am J Med. 2001 Dec 21;111(9B):43S-44S.
9. Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005 Jul 19;143(2):121-128.
10. van Walraven C, Mamdani M, Fang J, et al. Continuity of care and patient outcomes after hospital discharge. J Gen Intern Med. 2004 Jun;19(6):624-631.
11. Wachter RM, Pantilat SZ. The “continuity visit” and the hospitalist model of care. Am J Med. 2001;111(Suppl 9B):40S-42S.
12. Goldman L, Pantilat SZ, Whitcomb WF. Passing the clinical baton: 6 principles to guide the hospitalist. Am J Med. 2001;111(Suppl 9B):36S-39S.
13. Pantilat SZ, Lindenauer PK, Katz PP, et al. Primary care physician attitudes regarding communication with hospitalists. Am J Med. 2001;111(Suppl 9B):15S-20S.
14. Forster AJ. Can you prevent adverse drug events after hospital discharge? CMAJ. 2006 Mar 28;174(7):921-922.
15. Ramey MM, Daniels S. Hospitalists and case managers: the perfect partnership. Lippincotts Case Manag. 2004 Nov-Dec;9(6):280-286.
16. Ettner SL, Kotlerman J, Afifi A, et al. An alternative approach to reducing the costs of patient care? A controlled trial of the multi-disciplinary doctor-nurse practitioner (MDNP) model. Med Decis Making. 2006 Jan-Feb;26(1):9-17.
17. Palmer HC, Armistead NS, Elnicki DM, et al. The effect of a hospitalist service with nurse discharge planner on patient care in an academic teaching hospital. Am J Med. 2001 Dec 1;111(8):627-632.