As we all know, the time around discharge from the hospital is a tricky one.
In more ways than one can imagine, patients are in a delicate state, judged by those caring for them to no longer be sick enough to need to remain in the hospital, but possibly not quite completely ready to be fully back in the community, on their own at home.
Over the past few years, there have been a lot of interventions aimed at focusing resources on this transition time, trying to figure out the best way to make it a successful one.
All parties involved clearly want to make this smooth and error-free — first and foremost, the patient. Really, no one wants to be in the hospital, no one wanted to be sick, no one wanted to have all those tests done, the IVs, the beeping monitors, the frequent awakenings, getting “rounded on” by the team, the endless questions and invasion of privacy, and so on.
And the doctors and the rest of the health care team want the patient’s discharge home to be successful. They want to think that they’ve done their best for the patient, that their treatments were as beneficial as possible, and that patients are ready to go.
And no one wants to see the patient you sent home but clearly wasn’t really ready to be at home, and had to come right back in, what in the parlance of residency admissions is called the dreaded “bounce back” to your service.
So how do we make it safer, better, less likely to go awry?
Rapid discharge appointments
As I’ve written about before, one of the things we’ve built into our practice has been what we call rapid discharge appointments, where one resident has a practice session set aside exclusively to see patients who’ve recently been discharged from our own institution.
Patients being discharged from the hospital deemed by the inpatient team to be in need of some expedited tender loving care at the hands of an outpatient provider are ideal for these appointments.
When the inpatient team is working toward discharge on patients, they get together during discharge rounds and decide that Mr. Smith should be seen in the outpatient setting within 24, 48, or 72 hours. The discharge coordinators on the inpatient service contact our practice, and schedule patients to be seen according to the requested timeframe.
We’ve made these appointments available in the belief that this is in the best interest of patients in terms of safety, in making sure that the discharge plan is being carried out successfully, and that the patients are adjusting well to life at home without all the support, observation, and treatments that come with being in a hospital.
As with many things, for these visits, communication is the key.
Interrupting the relationship
I remember training as a medicine resident long ago, and one of the first questions we were trained to ask on admission was, “Who is your primary care provider?”
Whose care, whose long-term relationship, are we as the inpatient team stepping into the middle of, intervening to apply resources that are not available in the outpatient doctor’s world? In reality, this is what a hospitalization is, an interruption in the continuum of the outpatient doctor-patient relationship.
When you’re an intern on the admitting service, this question is useful because you want to contact that provider, find out about the patient’s medical history, what was going on recently in the office, and what may have prompted the provider to send them into the hospital.
And equally important is communication at the time of discharge, helping re-establish that care, that ongoing symbiotic health care relationship.
This week, one of the residents I was supervising in the outpatient clinic was seeing rapid discharge patients scheduled in our practice. Through the morning session, not a single patient who had been scheduled for one of these appointments showed up.
Some may have just decided they were too tired, just wanted to recover at home for a bit. Some may have felt they did not need this appointment. Some may have forgotten. (We are planning to study these reasons as part of the research we are doing on these appointments.)
For one patient, in particular, we looked back, and this patient had previously had multiple admissions to our hospital, and at the end of each one had been scheduled for a rapid discharge appointment, for each one he had not shown up.
Looking deeper into his medical record, we found that he’d received care with multiple subspecialists in our institution, but never primary care in our practice. And in reviewing his inpatient chart, several admissions back, we found one of the interns had in fact ascertained who the patient’s primary care doctor was at the time they entered the hospital, but then that all-important discharge contact never happened.
Working with some of our inpatient hospitalist colleagues, we’ve been trying to further develop the concept of a more robust transition process, involving communication between all members of the inpatient team and the outpatient team as they go through the process of adjusting how much responsibility each has for the care of the patient.
In an idealized world, these rapid discharge appointments will be made after consultation with either the patient’s primary care provider, or someone else at the same practice.
This way the rapid discharge appointment becomes not just a checkbox completed, something that the intern was told to make sure happened, but true value added to the care of the patient, further enhancing their recovery and ensuring that the best-laid plans of the inpatient team don’t fall apart when the patient walks out the hospital front door.
Now everyone will know what everyone was thinking, what needed follow-up, what needed further testing, what was still a mystery, what was still bothering the patient, what we need to do to help get them further towards their health goals.
This consultation between providers will undoubtedly strengthen the discharge process, make it a better one, and enhance the care of our patients. I think of this as a warm handoff, with one team relinquishing their role like the baton in a relay race — instead of what happens now, where some resident who has not been involved in the care of a patient meets them one morning in our practice, and tries to reconstruct what happened during the admission and what was expected of them during this visit.
We hope to build a more enlightened visit which will enable everybody to achieve their goals. And above all, we meet the need to make sure the right patient gets to the right primary care provider with the right information at the right time.
Someone has got to call their doctor, and make sure they get seen in their practice, otherwise we’re re-creating the wheel, risking harm when we think we’re benefiting the patient.
If they are not followed in our practice and don’t want to be, we should have no longitudinal role in their health care, and we shouldn’t be doing their rapid discharge appointments. If they are ours, we want to make this happen.
Things can rapidly go right, or rapidly go wrong.
Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at MedPage Today’s Building the Patient-Centered Medical Home.
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