Improving care transitions: Hospitalists partnering with primary care

Hospital readmissions are common, costly in both economic and human terms, and often preventable. This ‘‘perfect storm’’ of attributes has placed hospital readmissions at the center of discourse among payers, providers, and policy makers, which is leading to innovations in care delivery. Evolving efforts to enhance discharge communication, to improve care coordination and accountability, and to meaningfully involve primary care, show promise of reducing readmissions. These pockets of success demonstrate that improving care transitions can increase quality of care while decreasing costs. Within the hospital, it is now clear that the discharge process typically requires the same intensity of effort as admission. The hospitalist guides an interdisciplinary team, including nurses, pharmacists, case managers, and social workers, through a checklist of discharge tasks. Some tasks require substantial hospitalist involvement and expertise, such as medication reconciliation—a detail-oriented, time-consuming process. Other tasks can be accomplished by team members, overseen by the hospitalist, such as scheduling timely follow-up appointments, coordinating outpatient services, and assembling educational materials. Taken as a whole, significant time and effort must be devoted by the inpatient team to address the complex landscape of a patient’s medical and psychosocial needs. That of course, is only half of the equation, as patient care must be transferred to an equally invested outpatient team led by a primary care provider (PCP). Several influential medical societies have endorsed the medical home (a multidisciplinary care team led by a PCP) as the primary agent to coordinate patient care across settings. Indeed, promptly reconnecting with their PCP and primary care team after discharge can have profound meaning for patients, who may otherwise be unsupported with their postdischarge clinical needs. In this issue of the Journal of Hospital Medicine, 4 important articles provide evidence in support of an outpatient partner to actively assume patient care responsibility after hospital discharge. van Walraven et al. conducted an elegant study to evaluate the impact of postdischarge PCP visits on readmissions. Following more than 5000 patients for nearly 6 months, they demonstrated that increased PCP follow-up was significantly and independently associated with a decreased risk of hospital readmission. This confirms the positive impact that a primary care connection can have on postdischarge care. This study also highlights some challenges: 18% of the original cohort were excluded from the final analyses because they had only 1 or no PCP visit in the 6 months following discharge, indicating inadequate postdischarge follow-up for a substantial sub-group. Misky et al. similarly established that patients with ‘‘timely’’ PCP followup (within one month of discharge) were 10 times less likely to be readmitted for the same condition as their index admission. These are also encouraging findings for those patients with PCP follow-up. Yet among patients in their study, PCP follow-up was even less common, with only 49% of patients having appointments within one month. Future studies should consider how more intensive outreach strategies might engage difficult-to-reach patients and communities. PCP follow-up may be beneficial because discharged patients often have ongoing issues that need to be addressed. Arora et al. surveyed inner city patients and their PCPs 2 weeks after hospital discharge to assess whether patients experienced any ‘‘problems’’ in the postdischarge period, and whether PCPs were aware of their patients’ hospitalization. Nearly half of all patients recounted 1 or more postdischarge problems. The likelihood of reporting such a problem was twice as common among those patients whose PCP was unaware of their hospitalization. Again, this is strong validation of the importance of PCP involvement in posthospital care, but equally concerning is their finding that fully 3 in 10 PCPs were unaware of their patient’s hospitalization. Finally, Mitchell et al. further refine our understanding of risk factors for readmission. In an ethnically diverse inner city population, they screened 738 inpatients for depression. Among the 238 (32%) patients who screened positive, there was a marked 73% increase in hospital utilization (emergency department [ED] visits and readmissions) within 30 days of discharge. This confirms previous research that