Our discharge–transfer intervention proposes a new paradigm; that the systematic transfer of patient care to the PCP becomes an integral part of the discharge process. The goal is to provide seamless medical care during the transition from hospital to home and to formalize communication to ensure that all parties are well-informed about the post-discharge plan.
As the results show, among a culturally and linguistically diverse population, the intervention significantly increased the rates of timely outpatient follow-up and the completion rates of recommended outpatient workups. Subgroup analysis suggested that the intervention may be effective with non-English speakers, weekend discharges, shorter stay and older patients.
What may have contributed to the success of our discharge–transfer intervention? First, the intervention formalized the roles of the transferring and accepting parties. The hospital-based care team had a standardized means of communicating information to patients and their PCPs. Upon receipt of this information, the PCP and a primary care RN explicitly assumed patient care responsibility.
Second, the discharge–transfer intervention utilized medical personnel who often knew the patient well; the clinical nurses at the primary care site. Their outreach may have been particularly effective with patients who could benefit from such individualized care. Given that 15% of their calls resulted in a modification of the medical plan, this outreach might represent a real way to reduce medical errors and improve quality in the post-discharge period.
Third, the Patient Discharge Form provided written discharge information for the patient. This minimized the need to remember verbal instructions, which are often rapidly forgotten.26
These informed patients may have been empowered to participate more actively in their outpatient care.
Fourth, the intervention incorporated a level of redundancy, a key element of good system design,26
which helped to ensure implementation of the discharge plan. Examples of redundancy included: the patient reviewed the Patient Discharge Form twice, once with the floor nurse and once with the primary care RN; the Patient Discharge Form was transferred to the primary care site by two means—electronically and hand-carried by the patient; and both the primary care RN and the PCP reviewed the discharge plan to ensure that patients’ needs were being met.
Fifth, the intervention deepened the role of both the inpatient and primary care RNs. With increasing demands on physician time, it becomes essential to meaningfully involve RNs in patient care. Via the Patient Discharge Form, the inpatient RNs communicated to the primary care team concerns regarding home safety, patterns of medication compliance, and subtle memory problems. Such vital information may have helped the primary care team to work with patients to identify and address post-discharge problems.
Finally, the costs associated with the discharge–transfer intervention were low. Unlike other interventions reported in the literature,2,21–23
no additional personnel were required and the roles of existing personnel were only incrementally expanded. The inpatient RN expended approximately 15 minutes per patient to create the Patient Discharge Form. In the future, much of this work could be automated. Medication reconciliation was performed by the discharging physician, and while time consuming, is becoming a standard discharge task. Finally, the primary care RNs made a targeted patient outreach, typically lasting 5–10 minutes. Thus, a simple restructuring of discharge responsibilities served to improve communication and care continuity.
There were a number of limitations to this study that could affect its generalizability. First, an underlying clinical assumption is that timely outpatient follow-up after every hospitalization is desirable. There are, however, no published guidelines as to when or whether a patient should have outpatient follow-up after hospitalization. We selected a 21-day follow-up to accommodate both the seriously ill patients who need rapid follow-up and those patients who can reasonably wait longer. Beyond 21 days, we believe the immediacy and relevancy of the hospitalization diminish. Future studies may wish to examine other time periods.
Second, the study was conducted within a single safety net hospital system. As all patients had their PCP within this system and most lacked private insurance, it was likely that patients received the majority of their care within this system. Whereas it is possible that patients could have had an ED visit, a readmission, or specialty care at an outside institution, it is unlikely that this would have altered our results given the randomization of the groups.
Third, our system serves primarily a lower socioeconomic group of patients. Whether similar benefits would be realized with more affluent patients remains uncertain. However, studies of various populations have reported quality problems during care transitions, indicating that not only low-income patients are at risk in the post discharge period.1,3–6,8–14,20,27–29
Fourth, our intervention requires that a patient has a PCP and that the PCP’s office conducts a telephone outreach after hospital discharge. Whereas an integrated medical and information system such as CHA’s is ideal, the intervention could readily be implemented with associated independent practices, if these practices were willing and able to carry out the post discharge outreach. Still, some patients do not have a PCP or their PCP’s office may not be prepared to perform such outreach. As evidence accumulates regarding the benefits of coordinated inpatient and outpatient care, medical standards will ideally advance so that more patients have a medical home to actively manage their post-discharge care.
Fifth, the study was small in size and was not powered to examine important outcomes such as cost savings, health improvements, or decreased resource utilization. Larger studies could answer these questions.
In conclusion, there is a well-documented imperative to improve care transitions,8,30–32
and the present study is one of only a few randomized controlled trials to address this issue.2,21–23,33
The low-cost discharge–transfer intervention used in this study improved the rates of outpatient follow-up and of completed outpatient workups. Gaps in care were reduced by improving patient preparation for discharge, formalizing inpatient-to-outpatient communication, and promptly reconnecting patients with their medical home. As EMRs advance and become more widespread, comprehensive inpatient-to-outpatient communication could become a precondition for discharge, whereas electronic prompts could facilitate telephone contact with patients immediately upon discharge. Such innovations could help to further the goal, advocated by the Institute of Medicine,26
that high-quality medical care be uniformly delivered by failsafe medical systems.