Sending patients home with a little extra care

Campaign advances care for home health patients.


Home: It's the desired destination of all hospital patients but also the point where most hospitalists expect their patient responsibilities to end. A new government campaign looks to change that by encouraging hospitalists to get more involved in what happens to patients after they leave the hospital.

Sponsored by CMS and conducted by state quality improvement organizations (QIOs), the 2007 Home Health Quality Improvement National Campaign aims to improve the quality of home health care and reduce avoidable hospitalizations. The project specifically targets home health agencies, but the active assistance of families, patients and physicians, particularly hospitalists, will be critical to its success, said campaign organizers.

Current CMS statistics are troubling, showing that more than a quarter of Medicare's 2.7 million home health patients are admitted to the hospital every year. “We know that with better communication, better interactions, there are opportunities for reducing that rate,” said David Wenner, DO, medical director of the Home Health QIO Support Center.

Dennis Manning FACP and a team of health care workers discuss home health care needs with a patient The Mayo Clinic team involves from left Alisha Banken RN from the Department of Nursing and
Dennis Manning, FACP, and a team of health care workers discuss home health care needs with a patient. The Mayo Clinic team involves (from left) Alisha Banken, RN, from the Department of Nursing, and Erin Heeden, social worker, from Medical Social Services. Photo courtesy of the Mayo Clinic.

Last year, Dr. Wenner participated on an expert panel that found handoffs—transfers of care from hospital to home or from hospitalist to primary care provider—played a significant role in avoidable hospitalizations of home health patients. He and other experts developed some suggestions for how hospitalists can help avoid these handoff gaps.

Know your patients

The process begins with an awareness of the patient's living situation, said Dennis Manning, FACP, director of quality and patient safety at the Mayo Clinic in Rochester, Minn. “Our duty is not only discerning what brought a patient to the hospital, but also discerning what his or her home life is like,” he said.

Hospitalists play a critical role in making sure the right patients receive home health care. “It's very appropriate to just order the evaluation by home health [providers], saying, in other words, I'm not sure how this patient fits,” said Stephen L. Winbery, ACP Member and associate medical director for the Tennessee QIO.

The responsibility does not end with the order for evaluation, however. “You're going to have to be available when that evaluation is near completion,” Dr. Winbery noted. Some patients may be too sick for home health or better cared for through a hospice program, he noted.

Coordinate discharges

If patients are deemed suitable for home health, or are returning to home care, timely coordination with the home health agency is the next important step.

“I've heard many, many stories of home health agencies not picking up patients after discharge. I don't think it's necessarily anybody's fault, but we can definitely do better at the handoff,” Dr. Winbery said.

Illustration by Craig Smallish Getty Images Inc
Illustration by Craig Smallish, Getty Images Inc.

Hospital discharge planners handle much of the communication with the next care providers, including home health agencies, but hospitalists also need to be involved, said Deborah Beck, RN, discharge planning supervisor at the Mayo Clinic. “I see it very much as a collaborative team effort planning for the discharge needs of the patient,” she said.

The Mayo Clinic is piloting a system in which patients have scheduled discharge appointments, so that everyone involved in the patient's care—family, physicians, nurses and home health—knows when the patient will be discharged and has an opportunity to discuss follow-up care.

Another Mayo innovation allows patients to receive a complete discharge summary upon leaving the hospital. “That's been a challenge to accomplish, but it is really valuable that the patient actually leaves with a hard copy. Getting everybody on the same page with a discharge and follow-up plan is extremely important,” said Dr. Manning.

Communicate handoffs

At hospitals without such advanced discharge procedures, there are still ways that physicians can improve care transitions and reduce the likelihood of rehospitalization, according to Eric Coleman, ACP Member, associate professor of medicine at the University of Colorado at Denver and Health Sciences Center.

“There is that vulnerable gray period between when the hospital physician is the attending of record and when the patient makes it back in for follow-up with the principal physician. I think the responsibility is a little bit nebulous,” he said. The best way to eliminate that uncertainty is to communicate and share information with the patient's primary care physician, he said.

Such communication can be as simple as a phone call, and ideally includes a home health provider as well as the primary care physician, said Dr. Winbery.

“I'm not talking about copying 95 pages of records because that doesn't get looked at. It's almost always a person-to-person communication,” he said. A phone call is often more effective than email or fax because it allows interactivity among participants.

The experts acknowledged that the busy schedules of primary care and hospital physicians sometimes make such a scenario impossible. “If you can't have an ideal situation when you can get the accepting physician to have a discussion with the hospitalist and include the home health nurse on the call, the other options are going to have to be individualized,” said Dr. Wenner.

He suggested that at minimum, a fax with the most salient points about the patient's hospital care should be sent to the primary care provider and the home health agency. Widening adoption of electronic health records should help to ease the flow of this critical information in the future, Dr. Winbery noted.

Until then, the experts hope that a little extra effort and attention from hospitalists can help the quality improvement campaign reach its goal of home health agencies making at least 5% relative improvement in patient hospitalization rates. More than 5,200 agencies have enrolled to receive monthly online best practice intervention packages.

If these efforts resulted in one fewer hospitalization per home health agency per year, that could save Medicare $13.5 million in Texas alone, said Abraham Delgado, FACP, an internist and medical director of TMF Health Quality Institute, the Texas QIO.

The savings for patients, who avoid the stress and complications of unnecessary hospital visits, add even more to the value of the project. “This isn't just an effort to save money. It's also an effort to improve the quality of care,” said Dr. Delgado.

Good discharge—it's not just for home health patients

Is there anything patients like less than hospital food? Yes, Mark V. Williams, FACP, told attendees at the Society of Hospital Medicine's (SHM) annual meeting in Grapevine, Texas, in May. There is one thing—hospital discharge.

In a recent consumer assessment of hospitals, “hospital discharge was the most unsatisfactory aspect of hospitalization for patients,” Dr. Williams said. Everyone from disgruntled patients to home health care advocates is currently targeting discharge as an area of needed improvement among U.S. hospitals.

If they haven't already, hospitalists will soon be feeling the impact of those improvement efforts, said Dr. Williams. He updated seminar participants on current research and projects regarding discharge and offered advice for physicians looking to improve their own systems.

The consequences of imperfect discharge are more severe than patient discontent, noted Dr. Williams. A 2003 study, published in Annals of Internal Medicine, found that 19% of hospitalized patients had a postdischarge adverse event. Another study, from 2005, found that 41% of patients are discharged with a test result still pending, and one in 10 of those results requires action.

“The reason there has been so much focus on this is the patient safety issues surrounding transitions of care,” said Dr. Williams. The adverse events also drive up health care costs and increase readmission rates, he noted.

Researchers have focused on a variety of potential solutions to the problems of discharge. One common area of trouble, which made a significant difference in readmission rates, was communication between hospitalists and primary care providers (PCPs). “If the PCP did not know the information from the first admission, there was a strong association with patients being rehospitalized,” Dr. Williams reported.

Efforts to ensure that PCPs regularly and rapidly receive discharge summaries will help, but it is also important that the format of discharge summaries be standardized, with all test results, medications and follow-up plans included, he said.

Other pilots have involved health care providers following patients home after discharge. Home visits after hospitalization by nurses and physicians significantly reduced rehospitalizations in studies of geriatric and post-stroke patients, Dr. Williams reported.

Pharmacists can also positively impact postdischarge care, he noted. A 2001 study found that a follow-up phone call from a pharmacist improved patient satisfaction and reduced the likelihood of an emergency department visit.

“The big issue is who is going to pay for all of this?” said Dr. Williams. For most hospitals, there is little financial incentive to improve discharge because readmissions generate income, he added. “This is one of the perverse things about our health care financing system. This is something that has got to be fixed.”

Payers, on the other hand, have strong incentives to improve discharge results. “CMS is looking at data and they're seeing huge costs to Medicare for hospital readmissions,” said Dr. Williams. He predicts that CMS will soon make changes to the reimbursement structure to motivate hospitals to reduce readmissions and improve discharge.

Physician groups and others concerned about quality of care are also working on the issue. SHM has created a discharge checklist and received a grant to disseminate a discharge toolkit to hospitals around the country. ACP, SHM and the Society of General Internal Medicine have joined forces in a transitions-of-care collaborative, and the National Quality Forum recently met to establish outcome measures for safe discharge practice.

The net result of all these efforts should be practical differences in the near future in the way hospitals and physicians approach discharge, from corrected financial incentives to discharge measures on quality dashboards. “You're going to have to be dealing with this pretty soon,” Dr. Williams told his audience. “I think there are going to be huge changes.”