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Continuity of care between inpatient and outpatient settings appears to be declining in conjunction with organizational changes in medical practice, including the growth of inpatient care provided by full-time hospitalists (JW Gen Med Apr 30 2009). When patients leave the hospital without clear understanding of their diagnoses, medication instructions, or need for primary care follow-up, many will wind up back in an emergency department, and some will be readmitted. Researchers addressed this issue in several studies that were published in 2009.
An analysis of Medicare beneficiary data from 2003–2004 revealed that 20% of discharged patients were readmitted within 30 days. The cost of unplanned rehospitalizations in 2004 was estimated to account for US$17.4 billion of the $102.6 billion in hospital payments from Medicare (JW Hosp Med Apr 1 2009). To compound matters, physicians apparently aren't communicating with each other about patient transitions. In a study performed at two Boston teaching hospitals, discharging teams were aware that their patients had been readmitted in only 49% of cases, and communication occurred between discharging and readmitting teams in only 44% of cases (JW Gen Med Apr 2 2009).
In a randomized controlled trial that was performed at an urban academic medical center, researchers evaluated a discharge intervention that involved nurse advocates and clinical pharmacists. The nurses coordinated discharge plans with the hospital team and educated patients on discharge items such as medications, follow-up appointments, and pending tests. The pharmacists contacted patients 2 to 4 days after discharge to reinforce discharge plans and to address any medication-related problems. The results showed an impressive 30% reduction from baseline in the rehospitalization rate and a savings of $412 per person who received the intervention. Given that the Centers for Medicare and Medicaid Services are considering providing lower payments for hospitals that have high readmission rates, this intervention also makes good economic sense (JW Hosp Med Feb 2 2009).
As these data suggest, a large percentage of bounce-back admissions are related directly to poorly coordinated transitions of care. Improving the process is long overdue and will take a multidisciplinary approach as well as shared accountability among hospitals and primary care providers. To address these issues, the American College of Physicians, the Society of Hospital Medicine, and the Society of General Internal Medicine recently convened a multistakeholder consensus conference (representing more than 30 medical professional organizations); they examined quality gaps in care transitions between inpatient and outpatient settings and developed consensus standards for these transitions (JW Hosp Med Oct 9 2009).