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Sep 23, 2014 - standardized postdischarge call from a nurse and ... and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, TX (M.J.H., D.E.S.,.
Clinician Update

Improving Patients’ Postdischarge Communication Making Every Word Count Molly J. Horstman, MD; Diana E. Stewart, MD; Aanand D. Naik, MD

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r W is a 74-year-old gentleman with ischemic cardiomyopathy and severe chronic obstructive pulmonary disease who is discharged after a hospitalization for heart failure. On his first day home, Mr W receives a standardized postdischarge call from a nurse and reports no problems. In the first week, Mr W follows-up in his primary care clinic, but his primary provider has no available appointments, and Mr W sees a different physician. Mr W describes taking all medications as prescribed. The provider does not have access to the discharge summary and cannot see that some of Mr W’s inhalers were left off the discharge medication list. One week later, Mr W notices shortness of breath with activity, but decides to wait it out, hoping that he will start breathing better soon. By Saturday, he feels short of breath walking to the bathroom. He decides to call a 24-hour nursing help line and tells the nurse that he has been short of breath for the past 5 days. The nurse reviews his discharge summary and instructs him to increase his diuretics and to contact his primary provider.

On Sunday, he is increasingly alarmed by his symptoms and sends a secure message to his primary provider telling him that he is struggling to breathe. Mr W is not aware that hospital policy gives providers 72 hours to respond to secure messages. By the time his primary provider sees the message on Monday afternoon, Mr W is already in the Emergency Department being readmitted for a COPD exacerbation. Reducing preventable readmissions is a major quality improvement effort for hospitals across the country. Among Medicare fee-for-service beneficiaries, a quarter of all patients with an index hospitalization for congestive heart failure and 1 in 5 patients with an index hospitalization for acute myocardial infarction will be readmitted within 30 days.1 Like Mr W, these readmitted patients represent a vulnerable population in whom the cause for readmission often differs from the index hospitalization diagnosis.1–3 With the passage of the Affordable Care Act, hospitals face financial penalties for excess allcause 30-day readmission rates among Medicare recipients admitted for acute

myocardial infarction, pneumonia, and congestive heart failure. In 2014, roughly two-thirds of hospitals in the United States will incur financial penalties from the Centers for Medicare and Medicaid for higher-than-average readmission rates.4 Initiatives that have been successful at reducing readmissions have relied on bundled discharge interventions that provide patients with a standard set of services aimed at improving discharge planning and arranging after-hospital care.5,6 These bundled interventions include services such as medication reconciliation, inpatient education, coordination of medical equipment, and postdischarge communication. Despite the success of these bundled interventions in clinical trials, hospitals continue to struggle with reducing preventable readmissions. Postdischarge communication is a common component of bundled discharge interventions. Providers use postdischarge phone calls and schedule follow-up appointments to maintain contact between the healthcare system and the patient after discharge. This current model for postdischarge

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs, or the United States government, or other affiliated institutions. From the Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, TX (M.J.H., D.E.S., A.D.N.); and the Section of General Internal Medicine (M.J.H., D.E.S.) and the Section of Health Services Research (A.D.N.), Department of Medicine, Baylor College of Medicine, Houston, TX. Correspondence to Molly J. Horstman, MD, VA Health Services Research Fellow, Michael E. DeBakey VA Medical Center, 2002 Holcombe Blvd, Center for Innovations in Quality, Effectiveness and Safety (152), Houston, TX 77030. E-mail [email protected] (Circulation. 2014;130:1091-1094.) © 2014 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org

DOI: 10.1161/CIRCULATIONAHA.114.010621

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communication suffers from several limitations that impede its effectiveness in the dynamic and vulnerable postdischarge period. Three key areas that require improvement are the following: (1) communication needs to become more patient-centered; (2) the most effective methods for patients to communicate with the healthcare system following discharge must be identified; and (3) the most appropriate provider needs to respond to patient concerns. Unifying these 3 areas for improvement is the need for patients and providers to create a shared postdischarge language that promotes effective decision-making by patients and the healthcare system. Our first concern is that postdischarge communication is largely unidirectional and arranged for the convenience of the healthcare system (it is too provider-centric). Patients often have minimal input on the timing of scheduled follow-up appointments and postdischarge phone calls occur based on the availability of healthcare providers. Furthermore, there is equivocal evidence supporting either of these means of communication as effective tools for reducing hospital readmissions. In a Cochrane Review, postdischarge telephone calls by hospital-based medical providers did not influence readmission rates in cardiac patients as compared with usual care.7 The impact of outpatient follow-up on readmissions has been disappointing, with studies showing little to no impact for patients with congestive heart failure, acute myocardial infarction, and patients discharged from general medicine services.8–10 Why do these healthcare-initiated communication methods not lead to improved

outcomes for 30-day readmissions? Too often, provider-driven communication is dominated by provider-centric education materials with information that is too detailed and complex for patients and family members who are emotionally and physically exhausted from their hospital experience.3 To improve postdischarge communication, patients need succinct information, consisting of cognitively simple descriptions of warning signs commonly associated with readmissions before primary care follow-up (see first oval in the Figure).11 Furthermore, patients need basic instructions about when to contact the healthcare system if warning signs arise and how to describe warning signs in ways that have meaning to responding providers. This patient-centered approach will require healthcare systems to have interactive forms of communication that patients can initiate 24 hours a day. Although provider-initiated communication will always have a role in postdischarge care, healthcare systems must become less provider-centric and focus more attention on the timeliness of care: helping patients receive care when actually needed.12 Second, there is no gold standard for what methods of communication with patients are effective postdischarge. With the development of patientcentered medical homes, patients are encouraged to communicate with a provider 24 hours a day, often using new technology.13 At our institution, there are at least 8 ways a patient can seek assistance: presenting to the institution’s Emergency Department or an outside hospital, presenting to their primary care clinic for a walk-in visit,

calling their primary care clinic or a specialty clinic, calling a telemonitoring nurse, sending a secure message to a provider, or calling a 24-hour nurse help line.14 Providing patients with numerous ways to contact the healthcare system offers flexibility, but it does not ensure that each method provides patients with the services they require at the appropriate time. As patients navigate the world of nursing help lines and secure messaging, there are strengths and limitations for each method that may not be intuitively obvious. Patients may not receive a response from secure messaging for up to 3 days, making it inappropriate for urgent concerns. Conversely, routine issues may be inappropriately triaged to the Emergency Department by helpline staff who are unfamiliar with a patient’s medical condition. Frustrating trial and error should not define how patients communicate their postdischarge concerns. Instead, patients need clear instructions on where to call and what to say when warning signs present. To ensure that patients receive the care they need, healthcare systems must also train responding providers to recognize and react to patient warning signs in a standardized, effective fashion (see oval 2 in the Figure). Finally, there is a lack of clarity on which provider should respond to medical questions from patients after discharge. Although primary-care teams traditionally provide follow-up care, direct communication between hospital-based providers and primary care physicians is uncommon, and the timely transmission of discharge instructions to outpatient providers is an acknowledged problem.15,16

Figure. Using shared language to facilitate postdischarge communication.

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Horstman et al   Improving Patients’ Postdischarge Communication   1093

Initially, primary care providers may not be aware of the physiological aberrations, multiple tests, and medication changes that occurred during the recent hospitalization. In the immediate postdischarge period, inpatient teams understand their patient’s recent medical history and may better grasp potential reasons for a patient’s difficulties. With many readmissions occurring in the first 7 days after discharge, hospital-based providers and inpatient nurse case managers could offer an alternative as the first point of contact for patients until an appropriate handoff to the primary care team can be completed.1,17 Although there are a number of providers who could provide postdischarge care, choosing a single provider who can address postdischarge care needs is important for patients and healthcare systems. To make postdischarge communication effective, the responsible provider must be alert to patient descriptions of warning signs and trigger a set of timely actions by the healthcare system that mitigate preventable readmissions (see oval 3 in the Figure). In the vulnerable postdischarge period, communication between patients and the healthcare system is 1 of the few modifiable factors that may reduce preventable readmissions.5,6 However, postdischarge communication in its current form is haphazard, with confusion for patients over when to contact the healthcare system, whom to contact, how the contact should be made, and what should be said once contact is established. This is in contrast to consensus guidelines from Transitions of Care Consensus Conference, which recommend that patients and their caregivers know who is responsible for their care at every point during a care transition and how to contact them.18 To improve postdischarge communication, we propose the adoption of a streamlined approach for communication, in which a shared language is used by patients and all types of providers to trigger actions in postdischarge care.

Discharge instructions to patients can be distilled down to succinct warning signs using simple language and can stress to patients how to recognize warning signs, how to contact the healthcare system, and how to use standardized language when communicating warning signs to providers. This shared language can shape provider behaviors by triggering specific actions that result in patients getting the right care at the right time. For example, Mr W would have recognized his early warning sign of shortness of breath with activity, which would have triggered him to contact the 24-hour nursing help line immediately and thereby eliminating the initial delay in care (see boxes in the Figure). The responding nurse would have recognized the early warning sign, which would have triggered a page to the hospital-based provider who was aware of Mr W’s previous admission to assist Mr W in managing his symptoms. That provider would have noticed that Mr W’s COPD medications were left off his discharge medication list and would have restarted the inhalers, thereby avoiding a potential readmission. By thinking beyond provider-initiated phone calls and follow-up appointments, postdischarge communication can become more timely, effective, and patient-centered and may move us closer toward our goal of reducing preventable readmissions.

Acknowledgments We thank Vineet Arora, MD, MAPP and Salim Virani, MD, PhD for reviewing an earlier draft of this manuscript.

Sources of Funding This material is based on work supported by the Department of Veterans Affairs, Quality Enhancement Research Initiative (QUERI; RRP 12–532; PI: Naik); and the VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety (CIN 13–413) at the Michael E. DeBakey VA Medical Center, Houston, TX. Dr Horstman was partially supported by the VA Office of Academic Affiliations Chief Resident in Quality and Safety program.

Disclosures None.

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Improving Patients' Postdischarge Communication: Making Every Word Count Molly J. Horstman, Diana E. Stewart and Aanand D. Naik Circulation. 2014;130:1091-1094 doi: 10.1161/CIRCULATIONAHA.114.010621 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2014 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539

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