My pager interrupts a conversation with a patient’s caregiver. It’s an outside pharmacy, the message reads, “Mr. Smith needs a refill on his diuretic, please call xxx.” I pause, Mr. Smith, who was he? I recall he was discharged 4 weeks ago! He was pretty ill when he presented to the hospital with heart failure, but he pulled through after a few tough days. We managed to discharge him home with prescriptions for a month and asked that he follow up with his PCP within 7 days. So, what happened? Did he not see his doctor? I hope he’s not getting worse and about to be readmitted. I promptly investigated and discovered that the earliest appointment with his PCP was 6 weeks after discharge.
Transitions of care expose the weaknesses in our fragmented health care system. Despite all the best care and attention, the risk of some malfunction remains high. In the current system, there are many barriers to care coordination, including the lack of interoperable electronic health records, the lack of integrated health care delivery, and primary care provider shortages to name but a few. From the patient perspective, the discharge instructions can be very complicated; they’re hard to comprehend when you are well and even more challenging when you are recovering from an illness.
What is clear is that timely follow-up with a provider is critical. A landmark study in 2010 by Hernandez et al, looked at the relationship between early physician follow-up, defined as an outpatient visit within 7 days, and all-cause 30-day readmissions among Medicare patients hospitalized for heart failure between 2003 and 2006. It concluded that there was great variation in outpatient follow-up after discharge and that hospitals with higher rates of early follow-up had a lower risk of readmission. Other studies have also shown that early follow up, especially in high-risk patients, helps reduce readmissions. The Commonwealth Fund recently released the results of a study of 428 hospitals that participated in national efforts to reduce readmissions, including the State Action on Avoidable Rehospitalizations (STAAR) and Hospital-to-Home (H2H) initiatives. The study reported that the only strategy consistently associated with reduced readmissions was discharging patients with their appointments already made. The value of early follow-up is not just about mitigating readmission, but also ongoing patient education, medication reconciliation and most importantly patient and caregiver understanding of how to manage the patient’s medical condition and maintain reasonable function.
As we travel the pathway to value-based healthcare, we have to innovate on the way coordination occurs from acute to post acute care. CMS is taking steps through readmission penalties, Accountable Care Organizations, Patient Centered Medical Homes and Bundled Payments. Some Hospitalists and other physician groups are providing discharge clinics, and extending their reach into post acute care facilities and into the home.
We need to go further and develop care transition strategies that engage physicians and providers in the care continuum in a meaningful way that ultimately provides high quality care and high value to the patient. We need to better understand the barriers that prevent early physician/provider assessment after hospital discharge and to think of new ways of smoothing care transitions. For example, should Hospitalists or ‘transitionalists’ manage high-risk patients for a few post-acute visits to help transition the patient back to the primary care provider? Are there existing resources in a health system that could be deployed to help solve this problem, without creating a further divide in care, such as urgent care clinics managed by health delivery system.
As for Mr. Smith, it was pure luck that the pharmacy had contacted me and I’m hoping that he will not be readmitted. However, I remain unsettled with this outcome, there has to be a better way….
 Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. A.F. Hernandez et al. JAMA May 5, 2010 Volume 303, No. 17
 Commonwealthfund.org/publications/blog/2015/oct/national-campaigns-to-reduce-readmissions accessed October 23, 2015.