In Part 1 of The Post Hospitalization Conundrum, I noted that research consistently shows that ineffective management of care transitions poses risks to patients. In Part 2, we look at three models and approaches to care management and their outcomes.
A 2008 study by Balaban, Weissman, Samuel, and Woolhandler, published in the Journal of General Internal Medicine, measured four undesirable outcomes after hospital discharge: 1) no outpatient follow-up within 21 days; 2) readmission within 31 days; 3) emergency department visit within 30 days; and 4) failure by the primary care provider to complete an outpatient workup recommended by the hospital doctors.
The hospital in the study instituted an intervention designed to promptly reconnect patients to their homes after hospital discharge. The intervention patients received a standardized, user-friendly, patient discharge form and upon arrival at home, a phone call outreach from a nurse at their primary care site. The study found:
- 25.5 percent of intervention patients had one or more undesirable outcomes, compared to 55 percent of the concurrent and historic controls;
- About 15 percent of the intervention patients failed to follow up within 21 days compared to 41 percent of the concurrent and 35 percent of the historic controls;
- 12 percent of recommended outpatient workups were incomplete versus 1 percent in the concurrent and historical controls.
In 2009, the Picker Institute launched an initiative to impact the patient experience by identifying those things that are so important to patients and families that they should occur in every healthcare interaction for every patient, every time. The Institute moved from “Never Events” to “Always Events,” a significant change in how to think about not just the patient experience, but the physician and staff experience as well. (In 2013, the Picker Institute’s Always Events initiative was moved to the Institute for Healthcare Improvement, where the initiative’s materials and references can now be found.) The Always Events Healthcare Solutions Book offers information and tools to improve coordination and integration of care, and to help avoid the frustrating, expensive, and even life-threatening consequences of poor transitions of care.
Anne Arundel Medical Center (AAMC) in Annapolis, Maryland, received a grant from the Picker Institute and put it to work to develop the SMART Discharge Protocol. The SMART discharge process helps to insure that key information is consistently discussed and understood. A SMART discharge includes communication about:
- S – Symptoms
- M – Medications
- A – Appointments
- R – Results
- T – Talk with me
Available materials for reference include the SMART Discharge Worksheet, FAQs, the SMART Discharge Self- Learning Packet for staff, and the SMART Discharge Training Presentation. AAMC reported decreased emergency department and inpatient hospital utilization, and an increased percentage of patients seeing the correct physician after the transition.
The Lahey Clinic Palliative Care Services and the Middlesex East VNA/Hospital in Massachusetts also received a grant and developed “Partnering with Patients and Families to Reduce Readmissions. “ The commitment is to always actively partner with patients and families through use of transitions liaisons and personalized educational tools.
Available tools include:
- Transitions of Care Partnership Project Overview
- Transitions of Care Management Call and Questionnaire
- Case Management Initial Assessment and Readmission 30 Day Assessment
- Patient Medical Journal Templates
The Patient Medical Journal enables patients and families to record and organize healthcare information. The Lahey Clinic reported a decreased readmission rate; an increase in patients reporting they felt ready to go home; an increase in patients reporting they understood their medications at time of discharge; and caregivers report that the medical journal is an effective family communication tool.
Literature reviews identify 46 articles describing 24 handoff mnemonics published since 1987, most since 2006. Our job is to identify the at-risk populations we encounter, and the information, tools, and behaviors we need to mobilize to seal the cracks and effectively transfer patient information among the members of the patient’s healthcare team.
In practical terms, at every step in the patient’s and family’s experience, there is the opportunity to get everyone on the same page. At every step there is the opportunity to build trust and alleviate anxiety.
Carole Lambert is assistant vice president, membership review and education and residents program director for the Cooperative of American Physicians, Inc. (CAP).