It Takes a Village


Gregory Misky, MD, has been a hospitalist for 12 years, first at a community hospital and for the past seven years at the University of Colorado Denver. In recent years, his frustration has grown over the challenges of discharge planning, care transitions, and preventing readmissions for vulnerable, disadvantaged patients, including the uninsured, underinsured, and medically indigent.

“There’s a big elephant in the room that we’re not talking about, and that elephant is having babies,” he says. “Access is such a big problem for these patients and, as a hospitalist, it’s just not OK to me anymore. I need to be proactive about finding solutions.”

Dr. Misky’s concerns led him to do research with mentor Eric Coleman, MD, the university’s creator of the Care Transitions Program (www.caretransitions.org), studying patients who lacked primary-care physicians (PCPs) or timely PCP follow-up, and their resulting higher rates of readmissions.1 Dr. Misky also helped develop care pathways, including post-discharge care, for VTE patients, a “common, costly, and dangerous” condition. He is working with a hospitalist colleague to explore how electronic health records (EHR) might be used to help trigger post-discharge follow-up for at-risk patients.

University of Colorado Hospital (UCH), a 425-bed urban academic tertiary-care center, is not the designated safety net hospital for metro Denver, yet 28% to 32% of patients discharged from its medical services are uninsured, Dr. Misky says. He finds that academic physicians at UCH are not always able to take on large numbers of uninsured patients in their clinics, given the productivity demands they face, while the hospital has not been able to participate in systemwide, comprehensive national models for improving care transitions, such as SHM’s Project BOOST (www.hospitalmedicine.org/boost) or Boston Medical Center’s Project RED (www.bu.edu/fammed/projectred/).

Dr. Misky is in discussions with local community services, such as the Metro Community Provider Network (MCPN) of clinics for underserved patients, and exploring the development of a collaborative model for integrating post-hospital care between UCH and MCPN. “A lot of our ideas are still very exploratory—trying to get the key providers to the table to talk about what these approaches might look like,” Dr. Misky explains. “I’ve been part of ongoing meetings, and I think similar kinds of conversations are happening at many levels at UCH, but there’s not a unified, consensus approach to care transitions—and that’s a problem. But I’m in the midst of it all, trying to highlight the issues and explore solutions.”

This is not a hospital problem—it’s a communitywide problem. So there’s not just a hospital solution; it will take the whole village.

—Patricia Rutherford, RN, MS, vice president, Institute for Healthcare Improvement

Dr. Misky says every hospital-based provider—hospitalist, nurses, social workers—feels the same frustration and worry about the level of care when indigent patients are discharged to the community. Uninsured patients can run into problems post-hospitalization and return to the ED for their primary care because they lack other options, he says. “Without established liaisons to the community clinics,” he notes, “it can take three or four months for a new indigent patient to get seen at one.”

Disproportional Issues of the Uninsured

Hospitalists at San Francisco General Hospital, which is the safety-net provider for the Bay Area, are looking at similar issues, says Jeff Critchfield, MD, division chief of hospital medicine. “What we know about the uninsured is that they have a wealth of other challenges and barriers that they bring to the table,” he says. “First of all, un- and underinsured patients are more likely to have chronic illnesses, to be hospitalized for those illnesses, and then to be rehospitalized after discharge.”

Figure 1. Proactive Steps You Can Take to Improve Care Transitions

Recommendations for hospitalists to improve care transitions for indigent patients, gathered from sources for this article, include:

  • If the hospital doesn’t have a team talking about care transitions, start one.
  • Explore the possibility of a quality improvement project, such as Project BOOST or Project RED. The next deadline for BOOST applications is Aug. 1 (www.hospitalmedicine.org/boost).
  • Create a multidisciplinary task force to forge partnerships with primary-care physicians. Find ways to involve them in providing access to indigent patients without placing undue burdens on a few doctors. Find the doctors who are providing pro bono medical care in free clinics or church basements.
  • Screen for eligibility for all appropriate entitlement programs, and get the applications rolling while the patient is still in the hospital.
  • Always ask (respectfully) about housing status as part of the patient’s social history. In addition to patients in shelters or on the street, others may be living in cars or “couch-surfing” with friends and families.
  • Connect with homeless resources, such as medical respite programs, now in 60 communities with 15 more under development, according to the National Health Care for the Homeless Council of Nashville, Tenn. (www.nhchc.org). Programs rotating medical residents through homeless healthcare services have also been shown to change doctors’ attitudes toward homeless patients.11
  • Avoid generic counseling about exercise or nutrition without first assessing the patient’s living situation and access to needed resources.
  • Know the costs of medications and their accessibility or barriers for a given patient. Learn how to connect patients with indigent drug programs, or have the hospital provide a supply of needed medications to prevent relapse and readmission.
  • Partner in more integrated ways with community health clinics and explore cross-referral relationships that work for both parties.
  • Some hospitals have successfully targeted care transitions for patients with specific conditions, such as heart failure, diabetes or pneumonia. Quantify and stratify the need at your hospital.
  • Home health agencies can be invaluable sources of support for hospitals willing to meet with them to establish working relationships and protocols for indigent patients.
  • Floor nurses often know more about readmission risks and patients’ stories than administrators give them credit for. Find ways to regularly tap into that expertise.
  • Listen to your patients and find ways to include their input in quality initiatives.

Other issues disproportionally impacting uninsured or indigent patients include low literacy, low healthcare literacy, language barriers, cross-cultural barriers, substance abuse and mental health issues, homelessness or marginal housing, transportation barriers, and “social isolation, which also plagues our population and, I believe, places patients at risk, as does depression,” says Dr. Critchfield’s colleague Michelle Schneidermann, MD.

One-third of San Francisco General’s patients are uninsured and 40% have Medi-Cal (California’s version of Medicaid), which basically means they are underinsured.

“California has 19 safety-net hospitals, with 6% of the state’s inpatient beds but 50% of its uninsured population. So that’s what we do,” Dr. Critchfield says. But almost any hospital or hospitalist will see many of the same issues and problems, just not in the same proportions. “These are patients who can be most frustrating to hospitalists, requiring a disproportionate amount of our time,” he says, adding the greatest difficulty is helping these patients understand and follow post-discharge care plans. But if someone is ill enough to need acute hospitalization and is later discharged back to the street, readmission should not be a surprise. “We’ve done that experiment for many years, and we know how it turns out,” he says.

Dr. Schneidermann serves as medical director of San Francisco General’s medical respite program, a 45-bed emergency shelter that accepts homeless or marginally housed patients in need of follow-up care following discharge from any of the city’s acute-care hospitals. Research has shown that the programs can have a major effect on keeping discharged patients off the street, reducing their rates of rehospitalization by as much as 50%.2,3

“We know that homeless patients have longer lengths of hospital stay because their discharges are fraught with problems,” she says. A homeless patient hospitalized with a blood clot potentially could be kept in the hospital for a week while transitioning from heparin to Coumadin, while similar patients with community support might get discharged in a day.

“We are also fortunate to have a program called Healthy San Francisco,” which isn’t a health insurance program per se but since 2007 has provided access to outpatient, inpatient, and preventive care and medications for indigent patients, Dr. Schneidermann says. Sponsored by the city’s Department of Public Health, it is accessed through 32 medical homes located in both public and private clinics. The hospitalists’ goal is to have a follow-up appointment set with a receiving provider at the time of discharge. “It doesn’t always happen, but that’s the goal,” she explains. “Someone, by name, who has accepted the referral.”

Dr. Critchfield is running a randomized controlled trial of the hospital’s interventions to stem the tide of readmissions in patients 60 and older; many of these patients share the same indigent demographics of the rest of San Francisco General’s caseload, although most patients 65 and older qualify for Medicare. He describes the program as a hybrid of Project RED and Dr. Coleman’s Care Transitions Program, although it targets patients who speak English, Spanish, Cantonese, and Mandarin.

How many Americans are uninsured today is a moving target in the context of healthcare reform and its uncertain future, but the number increased to 53 million in 2007 from 42 million in 1998.4 The number of hospitalizations of uninsured patients also grew to 2.3 million from 1.8 million in the same time period, an increase of 31%, while total hospitalizations were increasing by 13%. A May 2011 research brief from the U.S. Department of Health and Human Services estimates that uncompensated costs of hospital care incurred for uninsured patients total $73 billion per year.5

The homeless in shelters or on the street number about 630,000 on any given evening, and 1.5 million Americans experienced homelessness last year, says Sabrina Edgington, MSSW, program and policy specialist at the National Health Care for the Homeless Council in Nashville, Tenn. That said, 30% of the U.S. homeless have health insurance. Uninsured patients are less likely to receive necessary diagnostic tests and labs while in the hospital, and they face limited access and longer wait times—even in the facilities that are willing to take them.7 Research published in the Journal of Hospital Medicine finds that uninsured or Medicaid patients with three common conditions are more likely to die in the hospital than insured patients.8 A 2008 national sample survey of physicians found that “most U.S. physicians limit their care of medically indigent patients.”9 Other recent research suggests that readmission rates are affected by race and by site of care—with hospitals serving a higher proportion of black patients also having higher readmission rates.10

Listen to Jane Brock, MD, discuss medication management's role in safe transitions of care for indigent patients

“This is not a hospital problem—it’s a communitywide problem. So there’s not just a hospital solution; it will take the whole village,” says Patricia Rutherford, RN, MS, vice president of the Institute for Healthcare Improvement (IHI), which sponsors initiatives targeting care transitions.

The major national care-transitions programs that assist hospitals with addressing rehospitalizations all share similar objectives, Rutherford says, and all could be helpful in improving hospitals’ responses to indigent patients. The recognized programs include IHI’s STAAR (State Action on Avoidable Rehospitalizations: www.ihi.org/IHI/Programs), a multistate, multistakeholder quality improvement (QI) program; Project BOOST; Project RED; Dr. Coleman’s Care Transitions Project; the nursing-based Transitional Care Model (www.transitionalcare.info); and the American College of Cardiology’s Hospital to Home (www.cardiosource.org).

I would never ask an individual hospitalist to reduce readmissions. It requires a multidisciplinary, all-hands-on-deck approach by the hospital.

—Amy Boutwell, MD, MPP, hospitalist, Newton (Mass.) Wellesley Hospital, president, Collaborative Healthcare Strategies

Most of these “well-established, evidence-based interventions,” including BOOST, will be given preference in applications for grants from the federal Community-Based Care Transitions Program (CCTP). The program recently committed $500 million to support community-based coalitions that include hospitals that are working with community partners to create seamless care transitions. “It’s most important that hospitalists are integrally involved with these care-transition teams—if not leading them,” Rutherford says.

BOOST’s approach is built on a major change-management strategy to reconstruct hospitals’ care transitions and discharge processes from the ground up, says Tina Budnitz, MPH, the project’s director at SHM (see “Discharge Improvement,” p. 7.) “The first thing we do, we literally get out pens and paper and chart what happens before patients get into the hospital and what happens after they are discharged, all of the services that touch them—or should,” she says. “The planning process occurs on many levels, with all of the stakeholders in the community looking at the process map and seeing where people fall off and end up readmitted.”

What we know about the uninsured is that they have a wealth of other challenges and barriers that they bring to the table. Un- and underinsured patients are more likely to have chronic illnesses, to be hospitalized for those illnesses, and then to be rehospitalized after discharge.

—Jeff Critchfield, MD, division chief of hospital medicine, San Francisco General Hospital

SHM is planning to launch several new BOOST cohorts for participating hospitals this fall, along with a wider range of technical support, Budnitz says.

The Cross-Setting Team

Research on care transitions for uninsured or indigent patients “is not very robust,” observes Amy Boutwell, MD, MPP, a hospitalist at Newton Wellesley Hospital in Newton, Mass., former director of health policy at IHI and president of Collaborative Healthcare Strategies. “We don’t have the information we need, but there are great opportunities to improve our research base,” she explains.

Dr. Boutwell is a big fan of the “cross-setting team,” which brings together around a conference table professionals who work in different care settings, including the hospital, long-term care, and home-based care. She says it’s her job “to make sure patients are safe upon discharge, but if the community is under-resourced for primary-care physicians, if the patient is uninsured and we can’t find a PCP, the hospitalist and cross-setting team need to say, ‘We just can’t accept that.’ ”

What Do HM’s Community Partners Think About the Problem?

Dr. Heim

Lori J. Heim, MD, FAAFP, board chair of the American Academy of Family Physicians, a family physician in Vass, N.C., and hospitalist at Scotland Memorial Hospital in Laurinburg, N.C., says the unassigned patient who lacks a PCP might be the hardest issue to overcome in improving care transitions.

“We have a lot of members who volunteer at free clinics. Others are part of revolving lists of physicians willing to take unassigned call and accept referrals of indigent patients from the hospital,” Dr. Heim says. “If you look at the number of primary-care practices that are barely surviving, most hospitalists I know are very cognizant of how financially strapped family practice and general internist physicians are these days.”

It isn’t always clear who benefits financially from improved care transitions, particularly for indigent patients, Dr. Heim says. But the growth of patient-centered medical homes through the rollout of national healthcare reform, opportunities for community clinics to become those medical homes, and the wider dissemination of electronic medical records are all important components of the changes that need to take place.

“I would encourage hospitalists to be involved with their hospital leadership on these issues and have ongoing communication with community physicians. Both sides need to think more in terms of the systemic demands,” she says. “Often the ED doctor or the hospitalist knows about these issues and can help hospital leaders understand potential solutions for uninsured patients.–LB

A proper handoff should be done in a way that helps the patient and the physician providing the follow-up care. “But you won’t know what that is unless you ask the people you’re sending patients to how you’re doing,” she explains. “When we routinely review readmitted patients in cross-setting groups, it quickly breaks down the mindset that we in the hospital did everything we could have done to make the discharge successful.”

Dr. Boutwell recommends that hospitalists avoid thinking of these issues in a vacuum, as medical-clinical issues that only doctors can fix. “Because you can’t,” she says. “I would never ask an individual hospitalist to reduce readmissions. It requires a multidisciplinary, all-hands-on-deck approach by the hospital. This is different and more exciting than other quality-improvement efforts.” What’s more, she says, the day is coming—and soon—when failing to manage these readmissions will be a bad business proposition for the hospital (see “Value-Based Purchasing Raises the Stakes,” May 2011, p. 1).

IHI’s STAAR Initiative is working with coalitions of providers in Massachusetts, Michigan, Ohio, and Washington. One of those coalitions, Detroit CARR (Community Action to Reduce Rehospitalizations), convened by MPRO, a Michigan-based quality-improvement organization, is a great example of a cross-continuum team involving five inner-city hospitals, Dr. Boutwell says.

“CARR has really dug deeply into the needs of vulnerable patients in one of America’s most economically challenged communities, with a high proportion of Medicaid, uninsured, and disabled patients” and a shrinking population, she says. Many rehospitalizations are related to socio-economics. “The CARR coalition is meeting with the homeless shelters, the food pantries, and the faith-based agencies,” she says. “They’re really getting at the root of significant issues in their community.”

Nancy Vecchioni, RN, MSN, CPHQ, vice present of Medicare operations at MPRO, says CARR involves more than just healthcare providers; it also brings community agencies together with them to take ownership of the patient. Organizations that a year ago weren’t talking to each other are now meeting regularly to focus on the most vulnerable patients, reviewing cases of rehospitalized homeless patients, and sharing their experiences. Rehospitalized patients are being interviewed, using a prepared script (see Figure 1, p. 34), which allows the patient to tell their story. The information is shared within the coalition.

Each hospital has its own transition team, with post-acute providers, physicians, home health agencies, and community service providers, Vecchioni says. For patients who can’t get in to see a PCP within five days of discharge, some hospitals are opening continuity clinics. Others give patients three- to 30-day supplies of needed medications. “There’s no magic bullet—it’s just a different way of looking at how we do this work,” she adds. “Every day we see new barriers. But we’ve already seen a 5% overall reduction in readmissions. And I think hospitalists can be the champions and leaders of these efforts.”

Listen to Jeff Critchfield and Michelle Schneidermann, hospitalists at San Francisco General Hospital, discuss barriers to treating indigent patients and new SFGH programs to help the homeless and uninsured populations

Hospitalists have to raise the bar for themselves, Dr. Schneidermann says, “doing our best while recognizing we can only do so much. There is a lot we can learn from geriatrics, starting with truly embracing the multidisciplinary team.” If hospitalists feel like they are functioning in isolation, she says, they need to look around. “Are these kinds of interdisciplinary meetings happening? If so, join them. If not, light a fire. Convert your frustrating experiences with patients into action.” TH

Larry Beresford is a freelance medical writer based in California.


  1. Misky GJ, Wald HL, Coleman EA. Post-hospitalization transitions: Examining the effects of timing of primary care provider follow-up. J Hosp Med. 2010;5:392-397.
  2. Buchanan D, Doblin B, Sai T, Garcia P. The effects of respite care for homeless patients: a cohort study. Am J Public Health. 2006;96:1278-1281.
  3. Kertesz SG, Posner MA, O’Connell JJ, et al. Post-hospital medical respite care and hospital readmission of homeless persons. J Prev Inter Community. 2009;37:129-142.
  4. Nagamine M, Stocks C, Merrill C. Trends in uninsured hospital stays, 1998-2007. Health Care Cost & Utilization Project (HCUP) Statistical Brief #88. May 2010.
  5. U.S. Department of Health and Human Services. ASPE Research Brief. The value of health insurance: few of the uninsured have adequate resources to pay potential hospital bills. May 2011.
  6. U.S. Department of Housing and Urban Development. The Annual Housing Assessment Report to Congress, 2009.
  7. Kellerman A, Coleman M. Care without Coverage: Too Little, Too Late. Report by Institute of Medicine, May 2002.
  8. Hasan O, Orav EJ, Hicks LS. Insurance status and hospital care for myocardial infarction, stroke, and pneumonia. J Hosp Med. 2010;5(8):452-459.
  9. Chirayath HT, Wentworth AL. Constraints to caring: Service to medically indigent patients by allopathic and osteopathic physicians. J Health Care Poor Underserved. 2008;19:500-511.
  10. Joynt KE, Orav EJ, Jha AK. Thirty-day readmission rates for Medicare beneficiaries by race and site of care. JAMA. 2011;305:675-681.
  11. Buchanan D, Rohr L, Kehoe L, Glick SB, Jain S. Changing attitudes toward homeless people. J Gen Intern Med. 2004;19(5 Pt 2):566-568.

Liability and Compliance Issues

Liability and Compliance Issues Listen to Jane Brock, MD, discuss medication management's role in safe transitions of care for indigent patients

Hospitalists and other experts say medical/legal liability for indigent patients resulting from readmissions has not been a major focus of their care-transitions initiatives. Even as bundled care models will give hospitals greater financial responsibility for episodes of care across settings, getting sued by patients is not said to be a major concern.

“What we try to do is put together the most robust plan of care that we can for patients, whether insured or not,” says Jeff Critchfield, MD, chief of hospital medicine and medical director of risk management at San Francisco General Hospital. “The tone of the conversation for patients without insurance is different—because the options are fewer. We may have to keep these patients longer because of the absence of options. But rarely does risk management come into it. We don’t get sued by these patients, so that’s not a driving force.”

State and local regulations and Medicare conditions of participation also define expectations for hospitals regarding the care of indigent patients who present at the hospital with acute medical needs. In Los Angeles, a controversy emerged in 2005 when several hospitals were accused of dumping homeless patients on skid row. Local governments responded by approving a $100 million plan to provide homeless shelters across Los Angeles County; in 2008, the same public officials passed an ordinance making it illegal for hospitals to discharge homeless patients to the streets without their consent.

There can be liability issues for any patient who gets transferred out of the hospital and the transition is not a good one, Dr. Critchfield adds, “but I try to think about this population the same as any other.”—LB

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