Friday, March 09, 2007

Poor communication at hospital discharge

The hospitalist model of care has advantages. Hospitalists can gain superior skills because inpatient medicine is all they do. The continuous presence of a hospitalist team free from competing demands of the clinic creates opportunities for efficiency. It’s been surprising and disappointing to some, then, that the hospitalist model of care has not been convincingly shown to improve outcomes.

Why these disappointing results? One reason may be that the advantages of the model are neutralized by its weakest point: discontinuity between hospital and ambulatory care. The problem was highlighted by a recent JAMA review documenting poor information transfer between hospital and ambulatory physicians at hospital discharge. Discharge summaries were available to clinic physicians at the time of the first follow up visit at a disturbingly low rate and often lacked critical information about medications, follow up needs and test results.

The authors note the potential adverse impact on patient safety and resource utilization. They suggest standards for quality and timeliness of discharge summaries as well as the use of templates and computer generated summaries. Somehow I’m not sure that will be enough. Such measures have been in place for a while. My suggestion is for a hospitalist group to hire a liaison who would be responsible for filling in the communication gaps. This person could call patients after discharge to make sure instructions were properly communicated, call PCPs to make sure vital information was received and track down missing documents. In busy hospitalist programs it would be a full time job for a nurse case manager or could be part of the responsibility of a physician extender. As far as I know this approach is not yet evidence based and could be studied. It could potentially improve efficiency and outcomes. Its impact on patient and referring physician satisfaction would be a no brainer.

Whatever the solution, I expect this to be a major initiative for the Society of Hospital Medicine. Hospitalist thought leader Robert Wachter, interviewed last summer by Internal Medicine World Report, said communication was key, and the quality of communication is an attribute that separates good hospitalist programs from bad ones.

Background: Retired Doc and DB comment.

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