Communication, interdisciplinary approaches key to effective transitions


Improving patient discharges and reducing preventable "bounce-back" readmissions will have increasing implications for hospitals’ bottom lines—especially if proposed Medicare payment bundling reforms are adopted by Congress. Discharge improvement also enhances a hospital’s reputation with patients and providers, says Neil Gupta, MD, a hospitalist at the University of California at San Francisco.

"I think we all recognize in our daily practice that there are things we can do better for patients at discharge," Dr. Gupta says. "It's sometimes hard to get the resources and motivation to do this. But we know it could really impact patient care and make it better."

Dr. Gupta's hospital is one of 24 participating in SHM's Project BOOST (Better Outcomes for Older Adults through Safe Transitions). The mentorship program is developing a consensus and resources for best practices in patient discharges. National data show that about one in five hospitalized Medicare patients are readmitted within 30 days. While some of these readmissions are appropriate, the sheer quantity of readmissions shows room for improvement, says Dr. Gupta's colleague, Arpana Vidyarthi, MD, a hospitalist and director of quality at UCSF. "In reality, no one in the United States is doing it very well," she says.

Drs. Gupta and Vidyarthi suggest focusing your HM group's communication with primary-care physicians (PCPs): Study whether the hospitalist's messages are getting through to the PCPs and ask for their feedback. Other targets should include identifying high-risk patients, reconciling medications, scheduling the patient's first outpatient visit prior to discharge, and confirming the patient's understanding of the discharge plan.

The first step is to form an interdisciplinary team that approaches discharges as a QI project, Dr. Gupta explains. "Building that team is huge," he says. "It adds a whole new perspective." At UCSF, the team meets monthly and includes hospitalists, PCPs, staff nurses and nursing supervisors, pharmacists, care managers, and patients.

For more information about Project BOOST, visit SHM's resource room.

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