How do your transitions of care rate?
A look from the other side
In the brave new world of healthcare, what goes right and wrong in patient care can't be blamed on someone else along the continuum of care. Rather, with the advent of Accountable Care Organizations, everyone has a part to play, and learning to play it well may make the difference not just in the quality of care provided to patients, but in whether an organization survives financially.
It was with that background that Ning Tang, MD, an internist at the University of California, San Francisco, wrote a piece in the August issue of the Journal of Hospital Medicine1 outlining what she, as a primary care physician, sees as imperatives for hospitals in creating an ideal transition of care.
She outlines seven things that need to happen during the hospitalization: communicating with the primary care physician on admission, involving that doctor in discharge planning early, letting the doctor know when his or her patient is discharged, completing discharge summary at discharge, scheduling follow-up appointments by the time the patient is discharged, making sure the patient has or can get needed medications at the pharmacy, and educating the patient about managing his or her condition.
Tang outlines another seven items that are the purview of the primary care physician and his or her clinic staff within the first three days after discharge: ensure follow up appointments with the primary care physician are made, coordinate care, get the patient to medical stability, make sure patients with new symptoms have access to the physician, track readmission rates, and track and review frequent flyers.
What she notes in her article are all things seconded by other primary care physicians. What they say could be the inspiration of quality improvement projects that could transform transitions of care and make them better for everyone on the continuum. Below are five that could bring their wish list to fruition.
Ulfat Shaikh, MD, MPH, MS, associate professor of pediatrics and director of healthcare quality at UC Davis School of Medicine, is working on a project with clinicians and residents in pediatrics to improve transitions of care by getting the parties involved to communicate better.
Among the communication elements they are working on in her project are improving the timeliness and quality of discharge communications. "The Joint Commission has mandated what a discharge summary should include, and while most have the essential elements, they don't come in a form that the outpatient provider can make easy use of."
For example, Shaikh notes that if medications were changed while the patient was in the hospital, there needs to be a way to flag that in the summary, and include an explanation about why the medications were changed and how long they should be continued, or continued at that particular dose. "You rarely see something where the medications piece is completely missing, but you'll often get this long list of meds and no indication of why they were changed. I want to see that reason and for how long the change should last."
1. Consider a chart audit that looks at unplanned readmissions and how many of them had changes in medications or dosages during the first hospitalization with notations on the rationale for the changes.
Shaikh agrees with Tang that timely delivery of discharge summaries is vital for a good transition. "Most outpatients who are readmitted go back to the hospital in the first few days or first week. If the discharge summary isn't sent to the primary care physician immediately on discharge, then I have to recreate the hospitalization from the patient's perspective alone, which is hard and may not be completely accurate." Those missing pieces are often enough to tilt a patient into a situation where a return to the inpatient setting is required. If you can't get it to the primary care doc the day of discharge, then make sure it's there within 24 hours. That gives the doctor time to look through it before the patient comes in, usually on day three or four.
And make that summary succinct — about a page is usually enough. It needs to include all the pertinent information, but it shouldn't go on for pages. "I need to be able to absorb the information in a short patient encounter," Shaikh notes.
2. Educate physicians on ideal length of discharge summaries. What is the existing average length? Keep track of that number and post a trend chart. Reward those who have the best succinct summaries.
The way discharges are communicated is crying out for some standardization, Shaikh says. "If there is a discharge coordinator who can bring order to that process — make sure that there is a one-page discharge summary faxed or emailed within 24 hours, that it includes a list of pending labs, that everyone uses the same templates and language — that would go a long way to improving things." Shaikh is clear that a bunch of lone wolves doing things their own way won't play in the new healthcare world order. Everyone will have to quickly come to an agreement on the information included and the way to present it.
One thing she thinks would help make up for any lapses: Make sure a discharge summary leaves with the patient, too. That way, if something goes wrong in the process of faxing or emailing a copy to the primary care physician, the patient has one she can bring with her to the follow-up appointment, says Shaikh.
3. Consider a QI project that tracks readmission rates for patients who get a copy of their discharge summary compared to patients who don't.
One of Tang's colleagues at UC San Francisco, Molly Cooke, MD, says that what happens in transitions can range from the ideal described in literature to nothing. "Getting nothing still happens," she says. "Can you believe it?" Cooke, who is president of the American College of Physicians and the director of education for Global Health Services at UC San Francisco, has a fairly sick patient panel — she has specialized in the care of patients with HIV, among others — and they are often in the ED. "The most common thing I get is an electronic communication that my patient has discharged from the hospital and told he needs to make an appointment with me in three days. I may get nothing more than that."
The university's health system has a shared electronic health record, so sometimes there is a way to find out more, says Cooke. "But the ED may use a template that says the following: that my patient was seen for chest pain and that certain tests were done but nothing alarming was found. It will note that my patient needs to see me in three days. But that third day may be a Saturday and I can't do that suggested interval."
She says it's even more frustrating that it's often not clear to her why the patient, having just been cleared by ED docs, needs to see a primary care physician in such a short period of time. "If he isn't having acute coronary syndrome, but they fear that, it could be a reason to be seen quickly. But it doesn't say that. I need clear information about why they want me to see him in a particular interval. Without it, the patient has expectations that something is going to happen or be done, or there is something to worry about. If it's a 72-year-old who just wasn't feeling well generally, there is more reason to get a quick appointment than if it was a 20-year-old with anxiety and a tight chest."
A template that includes clear spots for information on pending tests, when to see the patient next, and why would be much more helpful, Cooke notes. "And include a list of red flags that, if we see them, mean we should call the hospital provider."
Good transitions of care require more than just checking off a list of to-do items, Cooke says. Those check boxes are great for internal and external quality metrics. But they say nothing about high-quality communication, which doesn't always happen. Many physicians use templates of admission notes, or copy and paste notes from one part of a record to another. Those copied bits can include statements that the inpatient doctor has contacted the primary care physician to notify her of the patient's admission when that didn't happen this time. Or last time. It happened three or four times ago, and the inpatient doctor is simply copying the admission notes over and over.
4. How many charts of readmitted patients and frequent flyers have cut and pasted portions of charts from one place to another with no changes at all?
5. Facilitate a meeting between primary care and inpatient physicians about what data needs to be transmitted when. Compare it to what you are already doing.
If you find gaps between what is needed and what is done, Shaikh says, that's fodder for a great QI project that could pay dividends — not just in quality of care, but in actual financial benefit.
- Tang, N. (2013), A primary care physician's ideal transitions of care—where's the evidence?. J Hosp Med, 8: 47247