Anatomy of a hospital 'bounce-back'

Judy B., 68-year old woman with small-vessel coronary artery disease and mild unexplained iron deficiency anemia, was admitted last weekend to the hospital with worse angina, and found to be severely anemic. She required multiple blood transfusions, consultations, and endoscopies, without finding a source of blood loss. Five days later, she is now being discharged by a hospitalist in stable condition, but on several new medications and with her work-up and treatment plan still incomplete. Judy is told to have follow-up labs drawn on each of the following two days, and to call various specialists to arrange multiple tests and consultations "ASAP." She lives alone and has a limited ability to move around due to her angina.

The above scenario is not unusually complex for an average hospitalized patient. However, despite the best efforts of the hospitalist physicians and staff, Judy B. is quite likely to "fail outpatient management" and end up being readmitted to the hospital in our current medical system.

As a physician who works as a hospitalist and a primary-care doctor, I understand the complexity of discharging a patient from the hospital, and all the moving pieces that must come together to successfully transition a patient back to the outpatient setting. If even one link in the chain fails, a patient often ends up back in the emergency department and/or readmitted to the hospital as, in hospital-speak, a "bounce-back."

These readmissions are like a canary in a coal mine, alerting us that our hospital-outpatient continuum is seriously disconnected and dysfunctional. And Medicare is now tracking readmissions for several diagnoses while threatening to withhold payment to hospitals for readmissions.

A hospitalist really doesn't have any way to ensure a patient will get home, fill their discharge prescriptions, reconcile the new meds correctly with the pile of other pills sitting at home, have pending test results followed up on, have recommended follow-up blood tests drawn, schedule recommended scans and procedures, and arrange a timely appointment with their usual doctor.

Problem is, a typical primary-care doctor doesn't have any timely way to find out what happened to their patient during a hospitalization, or even that their patient was hospitalized, and is often so busy in the office that providing a seamless transition is far beyond their capabilities.

I just received a voice mail from a hospitalist discharging Judy B. from a hospital across the Bay from my office. He made a good effort to list all the pending issues and follow-up plans in his 4-minute message, but I know there's a lot more to the story, and I won't get the dictated summary for five or six days, far beyond the window in which action is needed.

As an engineer, I marvel that we haven't yet made system-wide changes to improve the process.

I think the answer lies in a combination of systems changes, along with a new attitude about investing resources in the hospital discharge process and the judicious use of novel wireless biometric monitoring technology.

Some limited studies have shown promising results for the cost-effectiveness of improved printed discharge instructions and interventions like calls from a pharmacist. But we can, and must, do so much more than this, and not just because Medicare might not pay for the readmission, but because it's the right thing to do.

Consider:

* What if a high-risk patient like Judy B. went home with a set of wireless devices that sent her vitals and symptom diary automatically to a "transition management team" that could intervene before she ended up back in the emergency department?

* What if this transition team ensured that the primary care doctor received a seamless package of data and to-dos, making outpatient follow-up actually possible in a busy office setting?

* What if the team ensured that inpatient and outpatient medications were reconciled in the patient's home, all patient and family questions after discharge were answered, and that the patient could contact someone familiar with their case 24/7 if things weren't going well?

* What if this system was mostly automated, got rave reviews from patients, families, hospitalists, and primary care doctors, and actually reduced costs?

Coming up over the next several weeks and months, I'll be blogging in Hospital Impact about our current state of knowledge on these topics and on which pieces of the puzzle we might be able to improve upon in the near future. I welcome your comments and feedback!

Paul D. Abramson, MD, MS is a UCSF and Stanford-trained hospitalist, primary care doctor, medical practice innovator, educator, and electrical engineer in San Francisco.  He is currently piloting various wireless monitoring technologies with his patients and testing the limits of what is possible in medicine. Follow him on Twitter at http://www.twitter.com/paulabramsonMD.