Discharge and Follow-Up
Nurcan Ilksoy, MD
Hospitalists can help coordinate complex inpatient medical care from admission through all care transitions to discharge, leading multidisciplinary teams within their institutions to improve care processes.According to the Society of Hospital Medicine (SHM), the hospitalist should be able to implement systems to ensure hospital-wide adherence to national standards and document those measures as specified by recognized organizations (JCAHO, AHA, ACC, AHRQ, and others) (SHM). To improve efficiency and quality within their organizations, hospitalists should be prepared to lead, coordinate, or participate in multidisciplinary teams (which may include nursing, social services, nutrition, pharmacy, and physical therapy) early in the hospital course to facilitate patient education and discharge planning. The SHM also indicates that hospitalists should advocate patient outreach post-discharge, and recommend to hospital administrators the establishment and support of outpatient heart failure teams, which have been shown to reduce readmission rates and possibly morbidity and mortality through outreach to patients with heart failure. Hospitalists are involved in the transfer of patient care on a daily basis and can lead institutional initiatives that promote optimal transfer of information between healthcare providers.In this context, hospitalists can provide leadership to promote efficient, safe transitions of care to reduce loss of information and maintain the continuum of care.
Effective communication is central to the role of the hospitalist in promoting efficient, safe, and high quality care and to reduce discontinuity of care. Hospitalists communicate in multiple modalities with patients, families, other healthcare providers, and administrators. Hospitalists can lead initiatives to improve communication among team members, patients, families, primary care physicians, and receiving physicians within the hospital and at extended care facilities beginning with admission and through all care transitions.
The hospitalist’s communication function extends to outpatient providers. According to the SHM, hospitalists should communicate to outpatient providers the relevant events of the hospitalization and post-discharge needs, including pending tests, and determine who is responsible for checking the results (SHM). Hospitalists should communicate with patients and families to explain the history and prognosis of heart failure, and the importance of home self-monitoring and adherence to medication regimens, nutritional recommendations, and physical rehabilitation. Communication with patients and families should also include an explanation of tests and procedures, and the use and potential side effects of pharmacologic agents. In addition, the hospitalist should communicate to patients and families the goals of the care plan, discharge instructions, and management after release from hospital. (Adapted from SHM Medsite-CME Case: Optimizing the Heart Failure Discharge Transition)
Recommendations from HFSA 2006 HF Practice Guideline
- Providers who care for patients with HF are challenged daily with preventing common, recurrent rehospitalizations for exacerbations. Most of the staggering cost associated with the care of HF patients is attributable to these hospitalizations. As many as one-half to two-thirds of hospital readmissions are thought to be preventable with attention to modifiable factors, which include those listed in Table 8.2.
- Recognizing the deficiencies in traditional or "usual care" has led to the testing of comprehensive, integrated, interdisciplinary disease management models of care that demonstrate markedly improved outcomes.
Table 8.2: Modifiable Factors Leading to Hospital Readmissions for HF
Inadequate patient and family or caregiver education and counseling
|
Poor communication and coordination of care among health care providers |
Inadequate discharge planning |
Failure to organize adequate follow-up care |
Clinician failure to emphasize nonpharmacologic aspects of HF care, such as dietary, activity, and symptom monitoring recommendations |
Failure to address the multiple and complex medical, behavioral, psychosocial, environmental, and financial issues that complicate care, such as older age, presence of multiple comorbidities, lack of social support or social isolation, failure of existing social support systems, functional or cognitive impairments, poverty, presence of anxiety or depression |
Failure of clinicians to use evidence-based practice and follow published guidelines in the prescription of pharmacologic and nonpharmacologic therapy |
- Patients recently hospitalized for HF and especially the patients at high risk should be considered for referral to a comprehensive HF disease management program that delivers individualized care. High-risk patients include those with renal insufficiency, low output state, diabetes, chronic obstructive pulmonary disease, persistent NYHA class III or IV symptoms, frequent hospitalization for any cause, multiple active comorbidities, or a history of depression, cognitive impairment, or persistent nonadherence to therapeutic regimens.
- HF disease management programs should include the components shown in Table 8.3 based on patient characteristics and needs.
Table 8.3: Recommended Components of a HF Disease Management Program
Comprehensive education and counseling individualized to patient needs
|
Promotion of self care, including self-adjustment of diuretic therapy in appropriate patients (or with family member/caregiver assistance) |
Emphasis on behavioral strategies to increase adherence |
Vigilant follow-up after hospital discharge or after periods of instability |
Optimization of medical therapy |
Increased access to providers |
Early attention to signs and symptoms of fluid overload |
Assistance with social and financial concerns |
- It is recommended that HF disease management include integration and coordination of care between the hospitalist, the primary care physician and HF care specialists and with other agencies, such as home health and cardiac rehabilitation.
View Ideal Discharge for the Heart Failure Patient Hospital Checklist
For more information regarding discharge and follow-up of HF patients go to the
CME section and review the Optimizing the Heart Failure Discharge Transition CME Module
|
