When pondering the question of how to better care for patients after they are discharged from the hospital, Bruce Bagley conjures up a picture of a wharf on a foggy lake. The patient — let's say she's an elderly woman with congestive heart failure — gets trundled down to the wharf and placed in a rowboat. "We don't check to see if she can row, or if there are even oars," says Bagley, the medical director for quality improvement at the American Academy of Family Physicians. "We throw a bag of pills into the boat and just shove it off into the mist." Whether she makes it to the intended destination or ends up back at the dock is a matter of chance.

No provider would want to treat patients so capriciously. And given Medicare's new emphasis on improving care across the continuum and avoiding readmissions, there are both quality and financial incentives to make sure patients get whatever help they need to stay well after they leave the hospital.

It's a challenge. Hospital physicians complain that too many of their discharged patients can't get in to see a primary care doctor within a week. Family practice doctors complain they don't get enough information from hospitals to know how their patients are doing.

Both hospitals and physician practices are trying lots of different strategies to bridge the gap: beefing up discharge planning to ensure an appointment has been made before the patient leaves the hospital, having a nurse call home within a day or two of discharge, faxing an alert to the primary care office upon discharge.

Some hospitals are going even further; they've set up post-discharge clinics to ensure that patients are seen within a week of going home. It's unclear how many of these clinics exist, and there are several different models. One that's received a lot of attention is at Beth Israel Deaconess Medical Center in Boston.

Four hospitalists staff the clinic in an unusual arrangement in which hospital-based physicians see outpatients. "We established the clinic to resolve the problem of access and to coordinate post-discharge care with the large primary care practice based here at the hospital," explains Lauren Doctoroff, a hospitalist at Beth Israel.

The hospitalists see patients who can't get appointments with their primary care doctors or follow-up specialists within the ideal time frame, which might be as short as a couple of days for some. The clinic's doctors keep the visit focused on immediate concerns and managing the discharge plan, avoiding long-term planning, which is more appropriately handled by the patient's regular physician.

The idea that hospitalists would extend their reach into what's usually thought of as primary care territory makes some uncomfortable, and Doctoroff acknowledges that even some physicians in the primary care medical group at BIDMC see the concept as threatening. Clinic staff take pains to avoid stepping on the primary care docs' toes.

A San Francisco model

The post-discharge clinic at the University of California, San Francisco hospital was started three years ago for similar reasons. "We found a lot of our patients were discharged and didn't have primary care physicians or couldn't see them as soon as we wanted them to," says hospitalist Sumana Kesh, M.D. "We were worried about them and wanted them monitored for labs or other issues."

Instead of staffing the clinic with hospitalists, the UCSF model is essentially an add-on to the hospital's existing urgent care clinic. It sees a lot of uninsured and safety-net patients, many of whom lack a regular physician.

The post-discharge clinic gets about four to six referrals each week, which is half as many as when it started. After the clinic came into existence, primary care offices soon adjusted and made more appointments available, Kesh says.

She thinks the concept could work anywhere, particularly if there is already a hospital urgent care clinic on which to piggyback. It's helpful to manage the subgroup of patients who have complicated discharge care plans and multiple medications that need adjusting. "From the hospital's point of view, it's definitely made the hospitalists and inpatient providers more comfortable that there is a safety net for these people," Kesh says.

Neither the BIDMC nor UCSF clinics are particularly expensive given that they use existing resources, simply rearranged. The BIDMC clinic relies on the fact that the hospital's physicians, including both hospitalists and primary care docs, belong to closely related medical groups with strong financial ties. The model would be more expensive at hospitals that do not have a tightly bound system of medical groups and urgent care clinics.

In contrast to BIDMC and UCSF, some hospitals use a post-discharge clinic model focused on particular diagnoses such as congestive heart failure, and staff it with advanced practice nurses.

But are they necessary?

Both BIDMC and UCSF use sophisticated discharge planning and coordinated care models along with their post-discharge clinics. Nevertheless, there are skeptics who argue that a post-discharge clinic should be unnecessary if a hospital's discharge management practices are effective. "It would make more sense to put this effort into revving up the discharge planner function to be really useful to patients and to be accountable for making sure they get a checkup in a very short time," argues Bagley. "Wouldn't it be great if everybody got a phone call to ask, 'Did you get your medicine?' It's really not a big expense to do that."

Critics also say that the transition back to a patient's regular physician needs to start sometime, so why delay it by adding an extra step? "It's kind of not addressing the true problem, which is a lack of communication," says Ann O'Malley, senior health researcher at the Center for Studying Health System Change. "I would think we would work more on the communications piece rather than creating a new structure in the hospital."

Joe Li, the hospitalist at BIDMC who got its clinic started, acknowledges that it's a Band-Aid measure, but a necessary one for a particularly difficult subgroup of patients with social issues — such as a lack of telephone service — that make follow-up difficult. "When we started the post-discharge clinic, I freely told everybody it's a workaround. In an ideal world, we wouldn't have a separate provider who is a discharge clinic provider," says Li, who is also president of the Society of Hospital Medicine. "But at the end of the day, if I cannot get the PCP to see his or her patient in a timely fashion, it's the patient who suffers."

One solution among many

Hospitals are chipping away at the readmission problem in multiple ways, with a new urgency prompted by the imminent financial penalties under the Medicare program for hospitals with higher-than-expected readmission rates.

Among the many strategies for better discharge planning are programs such as BOOST, developed by the Society of Hospital Medicine, and Project RED, designed by Boston University.

The problem is simple but not easily solved. "As crazy as it sounds, this isn't rocket science," Li notes. "We've got to make sure patients know whom to call when they're sick, know their medications, can get appropriate follow-up. We need to make sure if they can't do it themselves, if they are elderly or demented, there's somebody there to help them."

Echoing Bagley's nautical metaphor, Li says, "If we put all of our hospitalized patients on a harbor cruise for 30 days right after discharge, we could definitely get our hands around this 30-day readmission issue," he jokes.

Theoretically, the gap between hospital discharge and a primary care medical home should shrink when the American health care system transitions to the fully coordinated model that many would like to see. "In a fully integrated system where the outpatient docs are employed by the hospital system, this kind of thing can be more seamless," O'Malley says. "The question is, how are we going to spend our limited resources to improve communication, especially for high-risk patients? I don't think there's a clear-cut answer as to whether that's the way to bridge the gap between what we have now and a future primary care system that's better resourced."

Even in an integrated system, caregivers need to talk to one another about complicated patient histories and needs. Those care transitions are challenging even when they are taking place within the hospital, such as when there is a shift change for nurses, hospitalists or residents.

Meanwhile, for hospital executives considering all the tools at their disposal to reduce readmissions, the post-discharge clinic is an option. But it is only one of many ways to bridge the hospital-primary care gap. "There are so many reasons people are rehospitalized, you just have to peck away at all these individual issues," Li says.

Jan Greene is a freelance writer in Alameda, Calif.




In "What Will It Take to Ensure High Quality Transitional Care?" Eric Coleman, M.D., director of the Care Transitions Program at the University of Colorado in Denver, offers seven strategies.

1 Engage patients and family. Meet consumers where they are with respect to health literacy, cognition and engagement to provide customized care planning. They not only should have access to their care plan, but also provide direct input.

2 Elevate the status of family caregivers. Make them essential members of the care team. We can't ignore the individuals on whom we rely to execute the care plan, monitor patient safety, and serve as de facto care coordinators.

3 Implement performance measurement. An important quality improvement strategy incorporates the patient's voice in performance measurement.

4 Define accountability. The sending care team should maintain responsibility for the patient until the receiving care team reviews the goals for care and transfer information, clarifies any questions and acknowledges assumption of responsibility.

5 Build competency in care coordination. This includes both the mechanics for facilitating cross-setting communication and collaboration, and an appreciation for the differences in culture and care delivery capacity needed.

6 Explore IT communication. Establish standard operating procedures for the content, timeliness and mode of health information exchange across care settings.

7 Align financial incentives. The CMS Community Care Transitions Program, patient-centered medical home, the president's hospital patient safety initiative, bundled payment, and accountable care organizations provide opportunities to align financial incentives to promote cross-setting coordination and collaboration.