Thursday, October 1, 2015

Physicians May Not Be Necessary For Transitions of Care Discharge Planning from Hospitals?

Going home? Where's the doc?
When Disease Management Care Blog readers say they believe patients would benefit from better hospital discharge planning, exactly what do they mean?  What comprises "planning?"  Just how would patients "benefit?"

To get a sense of how the academic-medical-industrial complex can make getting patients out of the hospital complicated, check out two recent articles appearing in a recent issue of the Annals of Internal Medicine.  Good thing the DMCB can cut through the clutter and spot three insights that might have otherwise been missed:

1. Physicians may not need to be personally involved in discharge planning.
2. The science of discharge planning is vulnerable to attack by skeptics
3. The success of discharge planning grows exponentially as more mutually supporting interventions are added.

The first article by Hesselink et al looks at what goes into Improving Patient Handovers from Hospital to Primary Care. The authors were interested in care interventions that improved a broad range of quality and safety measures over the three months following discharge. Two decades' worth of research were reviewed and, based on study quality and transparency, they focused on 36 studies.

They found three categories of beneficial interventions:

1. Information sharing that bridged the inpatient and outpatient settings that included including medical lists, clinical templates, structured discharge summaries and careful follow-up for inpatient test results that were pending when the patient went home;

2. Coordination of care with organized outpatient follow-up visits, prioritizing patients with high needs, discharge planning protocols, nurse involvement, general practitioner input into the discharge planning process, telephone as well as in person post-discharge "check ups" and transparent, available and formal discharge plans;

3.Communication using "liason" nonphysicians (such as nurses or pharmacists) who work with community-based providers and the use of fax, email or web-based portals to transmit information.

In contrast, Bettger et al in the second article found precious little. They "adapted the National Quality Forum's episode care care framework" and focused solely on published studies dealing with Transitional Care After Hospitalization for Acute Stroke or Myocardial Infarction. They eventually settled on 62 studies and ultimately found, other than "moderate" impact on length of stay in stroke and "low strength" evidence on mortality for heart attack, that the "evidence about benefits ... was insufficient. "  What's more, much of the research had been done outside of the U.S., making it less appliable to our system.

The DMCB's three takeaways?

1. None of the interventions described by Hesselink et al really require the direct personal involvement of the inpatient physicians.  It would appear that once the physician determines that an inpatient setting is no longer necessary, information sharing, coordination and communication can be largely automated and/or implemented by nonphysicians. Why not?

2. The published science on how to safely discharge patients from the hospital is not up to withstanding intense scrutiny by skeptics like Bettger.  It comes down to how the data are extracted and interpreted. Could this be used by an insurer, policymaker or bureaucrat to deny payment for discharge planning?  You betcha.

3. Hesselink made the point in their Discussion, but it's worth repeating: the outcomes from multiple interventions are greater than the sum of their parts.  In other words, successful transitional care leverages the synergies of overlapping programs that build off each other.

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