Fixing Fumbled Handoffs

I recently participated in a meeting whose aim was to develop safety measures for hospital units (ie, med-surg, ED, L&D). As various measures were being ticked off, I muttered that we should also try to capture errors that occur as patients move between units. One of my colleagues, quite sensibly, asked, “but who will be accountable for that?”  

“Exactly!” I said. “You’ve put your finger on why we stink at handoffs. If transitional glitches were measured, and if botching them carried consequences, every hospital in the country would identify an accountable person in a nanosecond.”

Get ready to clear out the corner office of the C-Suite for the Chief Transitions Officer.

Although we’re not very good at washing our hands, we are terrific at washing our hands of patients who leave our medical radar screens. Just consider these scary facts:

  • Half of all medical patients experience at least one error in the post-discharge period (shown here).
  • Two-thirds of post-discharge hospital visits take place without a hospital discharge summary available (shown here).
  • In more than two-thirds of outpatient subspecialty referrals, the specialist received no information from the primary care physician to guide the consultation.
  • Then again, in one-quarter of the specialty consultations, the primary care physician received no information back from the consultant within a month (this and previous bullet shown here).

Overall, these data paint a picture of a healthcare system that would lead the NFL in fumbles, and seems profoundly unmotivated to do much of anything about it.

A few months ago, I had the opportunity to spend a few days with the person in the U.S. who is most aggressively attacking this shameful situation. Eric Coleman is a geriatrician at the University of Colorado, a tall man with a shining pate whose imposing physical presence is softened by his wispy beard, soft voice, and gentle manner. Well before it became fashionable, Eric was troubled by the transitions problem and began focusing his considerable energies on fixing it. This month’s issue of AHRQ WebM&M carries an interview I did with him, along with a companion piece on transitional errors by Sunil Kripalani of Vanderbilt.

Eric’s model is called the “Care Transitions Intervention”, and it centers on the assignment of a “transitions coach” to help patients through the post-discharge period. Studies by Coleman and colleague have shown that using such coaches can lead to marked decreases in readmission rates for discharged patients, more than covering the modest cost of the intervention.

Eric lists three key attributes of transition coaches, each far more important than their professional pedigrees:

  • He or she coaches rather than does (ie, teaching the patient self-efficacy).
  • He or she understands medications.
  • He or she knows the difference between being persistent and being a pest.

In a wonderful lecture he gave during his UCSF visit this fall, I was particularly struck by Eric’s description of the remarkable shift in mindset that happens as we approach hospital discharge, particularly in frail elders. “We foster complacency and dependency while the patient is in the hospital,” he observed, “and then sometime between 7 and 13 minutes before discharge, there is this abrupt shift to everything being the patient’s responsibility.” With this in mind, the transitions coach helps prepare patients for their next clinic visit, assists with medication reconciliation (particularly at home, where medications are often scattered all over the house), makes follow-up phone calls, and serves as a single point of contact for the patient.  

But where will the money come from to improve transitions, you wonder? Up until now, there has been no penalty for poor transitions, no skin in this particular game. Although the Joint Commission has, for years, judged hospitals’ performance on transitions, with the vast majority of hospitals receiving a perfect score from the Joint, it isn’t exactly clear what they are scrutinizing in this area. And, if your cup of tea is transparency rather than accreditation, consider that none of today’s quality measures really get at the quality of care transitions. (Yes, I know that we check a box saying we performed discharge planning for the patient with CHF, but far more places have gotten good at checking boxes than at improving transitions.)

All of this is about to change. Look for oodles of publicly-reported measures of case-mix-adjusted readmission rates coming online in the next few years, which will force us finally to focus on filling the post-discharge black hole. And that won’t be all. How about a measure of the percent of hospital discharge summaries that made it to the primary physician within 72 hours? The Joint Commission is considering it. Or try this one: a consultant doesn’t get paid until there is documentation that his or her consult report made it back to the requesting doc. Impossible? It’s being batted around in policy circles.

The point is that we need a much more holistic view of quality and safety, and that will require measures that look beyond static care – when the patient is cooperative enough to stay glued to one spot – to consider actual care, when patients and providers are moving around in diverse, complex patterns. Eric Coleman’s pioneering work has demonstrated that these transitions can be improved, at a relatively low cost. We’re on the cusp of aggressive performance measures in this area, measures that will cause providers and healthcare systems to sit up and notice Eric’s research and other innovations to improve transitions. It’s about time.

***

I’m taking a break for about a week – I’ll be back just after the New Year. Happy and healthy holidays to you and yours.

4 Responses to “Fixing Fumbled Handoffs”

  1. josh December 28, 2007 at 8:06 pm #

    The ability to Coordinate discharge care is one of my major concerns regarding hospitalists in tertiary care, especially pediatric patients with chronic medical conditions. I have worked at institutions with an “in-patient service” and have found a lot problems can arise when your goal for an admisson is discharge. If the same physicians that are caring for the patient in the hospital are not the ones seeing the patient in follow-up, then there is room for many loose ends.

    Patients get discharged with tests pending, plans unfinished and in conditions not really ready for home care. If their next 2 weeks are hell, that gets reported to their out patient doc (primary or specialist, in my case) but no feed back to the hospitalist. There is no learning opportunity to avoid such problems in the future.

    A “bounce-back” is easy to measure, but a miserable month a home on the “edge of admission” isn’t.

  2. WRS December 29, 2007 at 1:43 pm #

    It is an unfortunate day in the sport of medicine when the “coach” is doing what the “quarterback” should have done.

  3. Jennifer Green January 4, 2008 at 4:17 am #

    I’ll broaden the dialogue a little bit to include transitions among multiple settings, not just from hospital to home.

    The ‘low-hanging fruit’ for improving the quality of transitions for frail elders through a range of settings (home>hospital>SNF>home) is medication reconciliation. While inpatient medication errors have received the most attention, their estimated number, 400K annually, is much less than in LTC settings (800K) or among just Medicare recipients in outpatient settings (530K).

    http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=11623

    A Kaiser Permanente operational study found that meds reconciliation (part of a model based on Eric Coleman’s work) during the transition from SNF to home reduced mortality and ED visits and improved f/u with primary care docs. Clinical pharmacists provided this service, but, as you note, professional preparation is less important than a clear understanding of medications and why reconciliation, which can be a tedious and time-consuming effort over the phone with a frail elder, is critical.

    http://xnet.kp.org/permanentejournal/Fall07/transition_care.html

  4. pharmocist January 4, 2008 at 3:59 pm #

    I would like to support the concept of team coordination, particularly for the pharmacist’s role, in the discharge process. Pharmacists can do medication reconciliation and perhaps more importantly insure access to needed medications post discharge. Follow up phone calls by a pharmacist have also been shown to increase patient satisfaction. This may be because medication related questions are answered and medication problems may be solved.

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