Transitions in Care, a Primary Care Perspective to Reduce Hospital Readmissions

Local hospital readmission data mirrors national data. Twenty percent of hospitalized patients are readmitted within 12 days of discharge, 30% within 30 days. Hospital reimbursement has changed to global, not fee for service payment. Hospitals need to create effective ways to prevent readmission. Readmissions also portend poorer outcomes. Therefore, it is our task, to work collaboratively in this process.

Currently, most patients have no contact with their primary care physician while hospitalized or at the skilled care facility. At discharge, the patient or caregiver is given a few pieces of paper with confusing instructions and a handful of new prescriptions (several are for medications that they already have, and therefore fill none), or a medication sheet is faxed to the skilled care facility with the admission (from the hospitalist who knows little about the patient) and the patient is wished good luck.
Effective factors proven to reduce readmission rates include;
     A primary care follow-up visit within a week of discharge, with transportation arranged if it cannot    be done by family.
     Demonstration that the patient and or caregivers are fully informed and can show understanding by “teach back” techniques as to medication regimen as well as “red flags” indicating deterioration and when to call for help.
     Regular daily phone or direct visit contact with someone (Primary care doctor or delegate, nurse, disease manager, or trained member from a community resource) for several days after care transition to home or skilled facility.
     Medication adjudication as well as making sure that transition medications are available, affordable, preauthorized, as well as delivered.
     Identify frequent fliers arriving in the ER, and provide proactive actions to prevent readmission.
Historically, the health care system has relegated most of this as the often uncompensated responsibility of the primary care provider.

Now the reality;
     The average primary care provider has 2,000 patients and sees 20 patients a day. The average patient comes in 3x a year. So, the doctor can provide 4,200 visits a year. Yet their panel of 2,000 patients will request 6,000 office visits a year.
     Add to this the frail elderly patients with some anxiety or cognitive impairment, typically on 10 prescription medicines, with 8 chronic medical conditions (4 of which are co-managed by specialists), who come in with 2 acute problems. These at risk patients need visits 6-10 times a year and each requires significantly more time than 20 minutes. The disconnect gets exponentially wider.
     Even before the post hospital visit, as the patient arrives home or in an unfamiliar skilled care facility, the primary care provider gets the call after hours, weekends etc. We are tasked by the patient or concerned family to discuss conditions and prognosis, and review medication changes.
     Next, the post hospital office visit is predictably a schedule wrecker, should the provider take ownership of the process. The typical complex patient takes 90+ minutes, which cannot be pre planned for in the 15 minute same day access slot. Often, the discharge summary is not available and must be faxed at the time of the visit. The visit agenda; review all the exams, consultations, labs, diagnostic studies and interventions provided during the stay, assess ability to acquire, take, refill, or pre authorize medications, assess social supports, evaluate emotional linguistic or intellectual barriers to compliance, assess access to transportation, nutritional status, fall risk, the patient or caregivers knowledge of red flags of early deterioration and the medication regimen through the “teach back” process, discuss and document advance directives and care goals, help coordinate follow up labs/diagnositc testing, specialist visits, review, fill out and sign numerous pages of home visiting nurse, PT/OT/Nutritional assessments and correct conflicting medication lists by each agency, and do a physical exam, all in the allotted 15 minutes.

No surprise then, that the default response to an urgent request of a complex patient for an acute visit or a “red flag” post discharge concern becomes “go to the ER.”

We need to create a system wide team approach and work collaboratively. Each player needs to be sensitive to the roll and needs of their downstream teammates, and if possible, do as much of the processes as can be done at the time they are interacting with the patient. We need to either off load the downstream expectations of primary care or find ways to vastly improve the resources available to the primary care player’s role in transitions.

Perhaps resolutions through organized medical societies, hospital, and skilled facility associations can put pressure on the payers and Medicare/Medicaid to consider adequate payment or savings to be shared with community based primary care, thereby supporting involvement in admissions and transitions to and from hospital and skilled care facilities even without face to face contact with the patient.