While studies show that discharge to home can be best for patient recovery from surgery, this is an area where communications and continuity of care often break-down, risking readmissions. The idea of a patient-centered medical home where the patient is at the center receiving consistent care from a group that can bring in specialists is intended to solve some of this problem, but better communications between healthcare organization, primary care physician, and patient and the patient’s care team can go a long way to improve discharge to home without requiring an entirely new model.
This post is part of a series recapping a recent training from the Institute for Healthcare Improvement’s course on Reducing Avoidable Readmissions.
Primary care physicians while often the most trusted person in the care team, and besides the patient the person with the best insight into the patient’s overall wellbeing are often out of the loop when it comes to hospitalization. Once a patient is referred to a specialist for surgery the hospital team takes over, and the primary care physician has little insight into what happens, even though when the patient is discharged they are back in the care of the primary care physician. Often the primary care physician has no idea when the patient has been hospitalized or re-hospitalized.
Primary care physicians who were participating in the course expressed both their desire to participate in this post-acute care follow up and frustration at both the lack of insight they had and felt powerless to influence the hospitals.
While the evidence on post-hospitalization follow up visits is mixed, common sense does point to following up with patients as being a good thing to prevent readmissions. However, depending on the model of care, this is either with a primary care physician or a hospitalist. Considering the PCP is responsible for the general health of the patient, moving to reimbursement models where this is possible also seems to make more sense.
One example cited was from Capitol District Physicians Health Plan, where physicians were paid to do post acute care follow-ups. The program plus a phone call from a case manager decreased readmissions from 14% to 6%. (Although it would be interesting to know whether the in-person visit or the phone call had the biggest impact.)
As with other sessions in this course, the keys to improving discharge to home were in communication with the patient and patient caregivers around expectations and communication back to the hospitalist or family physician about medication usage at home, and any concerning symptoms. Too often patients understand “You’re discharged” as “You’re better” and miss their responsibilities for doing follow-up care whether that is physical therapy, wound care, or just easing back into activities they participated in prior to surgery. Ensuring patients and their care givers understand that discharge to home still requires follow-up is a key to decreasing readmissions from this setting.
New models of transitional care and intensive care where patients receive personalized follow-up care and regular check-ins with a healthcare professional after hospital discharge were shown to improve overall function in patients, decrease readmissions, and decrease costs. These types of new models become more practical with the carrot of value-based payments coupled the stick of penalties for readmissions. While the overarching goal of decreasing readmissions is about improving patient care, having financial incentives aligned will provide an extra boost.
Continuing with the theme of the course, there is no one silver bullet. There is no one reason that patients readmit. That’s the bad news. The good news is that some basic common sense improvements, like better communication with patients and their care teams can decrease readmissions. We’ll go into more detail on how to improve communications in the next post on this topic.