Eric A. Coleman, MD, MPH

Under the national leadership of AARP, 42 states and territories have introduced the Caregiver Advise Record and Enable (CARE) Act, 32 have passed it, and the following 30 have enacted it into law: Arkansas, California, Colorado, Connecticut, District of Columbia, Illinois, Indiana, Louisiana, Maine, Maryland, Michigan, Minnesota, Mississippi, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, Oklahoma, Oregon, Pennsylvania, Puerto Rico, Rhode Island, Utah, Virginia, Virgin Islands, West Virginia, Washington and Wyoming (as of June 6, 2016). The CARE Act requires hospitals to: (1) record the name of the family caregiver in the medical record, (2) inform the family caregiver when the patient is to be discharged, and (3) provide the family caregiver with education and instruction on the medical tasks that he or she will need to perform for the patient upon return home.[1, 2]

The family caregiver is to be identified by the patient. Because the patient is the source of the information, Health Insurance Portability and Accountability Act concerns are minimal. A family caregiver need not be related to the patient by blood or marriage; a friend, neighbor, partner, or paid caregiver could be identified by the patient as serving in this role. If the patient does not identify a family caregiver (due to the absence of such an individual, concern for potential burden on a loved one, desire for confidentiality, transient or progressive cognitive impairment, or other reasons), this also needs to be documented, though the additional provisions of the CARE Act would not be applicable. As some states have made additions or individual modifications to the CARE Act, the reader is encouraged to learn more about state‐specific differences that might impact implementation.[2, 3]

The impetus for the CARE Act emerges from challenges faced by both family caregivers and healthcare professionals. The 3 care elements included in the Act appear to have considerable face validity for what would constitute good transitional care. To further explore why this is necessary, we need to begin by asking why are these 3 care elements not routine, and why did an advocacy organization resort to a legislative solution to formally recognize and include family caregivers in discharge preparation?

Family caregivers, when able and willing, often play an instrumental role in the care of their loved ones, particularly during the vulnerable time of transitions out of the hospital.[4, 5] They are often the first line of defense for detecting lapses in quality or safety as care is transitioned from the hospital. Family caregivers frequently take on a primary or secondary role in operationalizing and executing the discharge plan. Nearly half of family caregivers perform skilled medical or nursing tasks for their loved ones (eg, wound care, injections, complex medication management, operating specialized medical equipment) often with insufficient assistance or training from healthcare professionals.[6]

Lack of sufficient time might be a major reason why the 3 care elements identified in the CARE Act are not routinely addressed by the discharging team, which may include hospitalists, nurses, pharmacists, social workers, and other clinicians. However, there may be other reasons as well, including a lack of knowledge, confidence, or tools for how to best prepare the patient and family caregiver. This is compounded by the absence of routine feedback loops for gauging the effectiveness of discharge preparation beyond a patient's readmission to the same facility. If hospital‐based clinicians were asked to rank order their daily tasks from greatest sense of professional gratification to lowest, discharge preparation would likely appear toward the bottom of the list.[7, 8]

Meanwhile, hospitalists and hospital clinical leaders are struggling to keep pace with a confluence of new demands that include value‐based purchasing initiatives and population health efforts, to name but a few. Although current Centers for Medicare and Medicaid Services' (CMS) Hospital Conditions of Participation for Discharge Planning do not require recognition or preparation of family caregivers, CMS' newly proposed revisions emphasize better preparation of family caregivers to be active partners upon hospital discharge.[9] Thus, although it might be reflexive to view the CARE Act in isolation as yet 1 more initiative requiring new effort and resources to address, widening the lens may confirm that the contributions of family caregivers are integral and aligned across nearly all efforts aimed at promoting greater value, and in this light could be viewed as complementary rather than competitive.

Innovation or new resources may be needed to implement the CARE Act. In the absence of a step‐by‐step user's guide, hospitals may wish to take advantage of valuable publicly available resources that encourage more effective collaboration between family caregivers and healthcare professionals (Table 1).

Operationalizing the CARE Act may initially appear simple but in practice will not be easy. The first care element focuses on identifying the family caregiver. Next, Step in Care offers a practical guide for how to identify the family caregiver in a busy hospital environment (Table 1). The guide advises health professionals on how to identify the person most likely to assume responsibility for care after discharge by asking a series of questions: Who assists you at home? Who do you call in case of emergency? Who helps with medications or doctor appointments? The guide cautions health professionals not to assume that individuals encountered at the patient's bedside are necessarily the family caregivers. They may be covering for the family caregiver, who has other duties (eg, job, child care).

The second CARE Act element entails informing the family caregiver when the patient will be discharged. At present there is no standardization of this practice. Many hospitals conduct interdisciplinary rounds, during which a discharge date is frequently estimated. A designated member of the inpatient team (eg, primary nurse, social worker, care manager) might be tasked with notifying the family caregiver of this estimated date (either in person, by telephone, or using other approved mode[s] of communication). Ideally, this notification should be conveyed as soon as the inpatient care team can foresee a discharge date, as it would be preferable to give the family caregiver an estimate that turns out to be a day or 2 off and needs to be revised than to inform the family caregiver at the last minute. The white board in the patient's room may serve as a reminder to both the patient and family caregiver as well as to other members of the inpatient care team.

The third CARE Act element could be facilitated with the Family Caregiver Activation in Transitions (FCAT) tool, a self‐efficacy measure of transition specific tasks. The FCAT tool is designed to facilitate more productive interactions and guide the care team in understanding what common transition‐related areas family caregivers would like to feel more prepared for or confident with. The FCAT tool can be administered by a health professional or self‐administered by a family caregiver and takes approximately 2 minutes to complete[10] (Table 1).

Hospital leaders might consider creating an interdisciplinary team charged with facilitating the implementation of the CARE Act. Specifically, this team might develop guidelines and serve as a forum whereby clinicians might share particularly challenging cases. Similarly, for ongoing input and suggestions for how to further improve all aspects of hospital care, including the discharge experience, hospitals are encouraged to form and foster patient and family advisory councils (Table 1).

Finally, when it comes to improving the hospital discharge experience for family caregivers, there is no us and them. Despite our professional advantages, each of has had or will likely have an opportunity to overcome the many gaps in hospital discharge planning, not just as healthcare professionals but also in our roles as adult children, spouses, and parents. In this regard, we are all invested in improving the discharge experience.

Under the national leadership of AARP, 42 states and territories have introduced the Caregiver Advise Record and Enable (CARE) Act, 32 have passed it, and the following 30 have enacted it into law: Arkansas, California, Colorado, Connecticut, District of Columbia, Illinois, Indiana, Louisiana, Maine, Maryland, Michigan, Minnesota, Mississippi, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, Oklahoma, Oregon, Pennsylvania, Puerto Rico, Rhode Island, Utah, Virginia, Virgin Islands, West Virginia, Washington and Wyoming (as of June 6, 2016). The CARE Act requires hospitals to: (1) record the name of the family caregiver in the medical record, (2) inform the family caregiver when the patient is to be discharged, and (3) provide the family caregiver with education and instruction on the medical tasks that he or she will need to perform for the patient upon return home.[1, 2]

The family caregiver is to be identified by the patient. Because the patient is the source of the information, Health Insurance Portability and Accountability Act concerns are minimal. A family caregiver need not be related to the patient by blood or marriage; a friend, neighbor, partner, or paid caregiver could be identified by the patient as serving in this role. If the patient does not identify a family caregiver (due to the absence of such an individual, concern for potential burden on a loved one, desire for confidentiality, transient or progressive cognitive impairment, or other reasons), this also needs to be documented, though the additional provisions of the CARE Act would not be applicable. As some states have made additions or individual modifications to the CARE Act, the reader is encouraged to learn more about state‐specific differences that might impact implementation.[2, 3]

The impetus for the CARE Act emerges from challenges faced by both family caregivers and healthcare professionals. The 3 care elements included in the Act appear to have considerable face validity for what would constitute good transitional care. To further explore why this is necessary, we need to begin by asking why are these 3 care elements not routine, and why did an advocacy organization resort to a legislative solution to formally recognize and include family caregivers in discharge preparation?

Family caregivers, when able and willing, often play an instrumental role in the care of their loved ones, particularly during the vulnerable time of transitions out of the hospital.[4, 5] They are often the first line of defense for detecting lapses in quality or safety as care is transitioned from the hospital. Family caregivers frequently take on a primary or secondary role in operationalizing and executing the discharge plan. Nearly half of family caregivers perform skilled medical or nursing tasks for their loved ones (eg, wound care, injections, complex medication management, operating specialized medical equipment) often with insufficient assistance or training from healthcare professionals.[6]

Lack of sufficient time might be a major reason why the 3 care elements identified in the CARE Act are not routinely addressed by the discharging team, which may include hospitalists, nurses, pharmacists, social workers, and other clinicians. However, there may be other reasons as well, including a lack of knowledge, confidence, or tools for how to best prepare the patient and family caregiver. This is compounded by the absence of routine feedback loops for gauging the effectiveness of discharge preparation beyond a patient's readmission to the same facility. If hospital‐based clinicians were asked to rank order their daily tasks from greatest sense of professional gratification to lowest, discharge preparation would likely appear toward the bottom of the list.[7, 8]

Meanwhile, hospitalists and hospital clinical leaders are struggling to keep pace with a confluence of new demands that include value‐based purchasing initiatives and population health efforts, to name but a few. Although current Centers for Medicare and Medicaid Services' (CMS) Hospital Conditions of Participation for Discharge Planning do not require recognition or preparation of family caregivers, CMS' newly proposed revisions emphasize better preparation of family caregivers to be active partners upon hospital discharge.[9] Thus, although it might be reflexive to view the CARE Act in isolation as yet 1 more initiative requiring new effort and resources to address, widening the lens may confirm that the contributions of family caregivers are integral and aligned across nearly all efforts aimed at promoting greater value, and in this light could be viewed as complementary rather than competitive.

Innovation or new resources may be needed to implement the CARE Act. In the absence of a step‐by‐step user's guide, hospitals may wish to take advantage of valuable publicly available resources that encourage more effective collaboration between family caregivers and healthcare professionals (Table 1).

Operationalizing the CARE Act may initially appear simple but in practice will not be easy. The first care element focuses on identifying the family caregiver. Next, Step in Care offers a practical guide for how to identify the family caregiver in a busy hospital environment (Table 1). The guide advises health professionals on how to identify the person most likely to assume responsibility for care after discharge by asking a series of questions: Who assists you at home? Who do you call in case of emergency? Who helps with medications or doctor appointments? The guide cautions health professionals not to assume that individuals encountered at the patient's bedside are necessarily the family caregivers. They may be covering for the family caregiver, who has other duties (eg, job, child care).

The second CARE Act element entails informing the family caregiver when the patient will be discharged. At present there is no standardization of this practice. Many hospitals conduct interdisciplinary rounds, during which a discharge date is frequently estimated. A designated member of the inpatient team (eg, primary nurse, social worker, care manager) might be tasked with notifying the family caregiver of this estimated date (either in person, by telephone, or using other approved mode[s] of communication). Ideally, this notification should be conveyed as soon as the inpatient care team can foresee a discharge date, as it would be preferable to give the family caregiver an estimate that turns out to be a day or 2 off and needs to be revised than to inform the family caregiver at the last minute. The white board in the patient's room may serve as a reminder to both the patient and family caregiver as well as to other members of the inpatient care team.

The third CARE Act element could be facilitated with the Family Caregiver Activation in Transitions (FCAT) tool, a self‐efficacy measure of transition specific tasks. The FCAT tool is designed to facilitate more productive interactions and guide the care team in understanding what common transition‐related areas family caregivers would like to feel more prepared for or confident with. The FCAT tool can be administered by a health professional or self‐administered by a family caregiver and takes approximately 2 minutes to complete[10] (Table 1).

Hospital leaders might consider creating an interdisciplinary team charged with facilitating the implementation of the CARE Act. Specifically, this team might develop guidelines and serve as a forum whereby clinicians might share particularly challenging cases. Similarly, for ongoing input and suggestions for how to further improve all aspects of hospital care, including the discharge experience, hospitals are encouraged to form and foster patient and family advisory councils (Table 1).

Finally, when it comes to improving the hospital discharge experience for family caregivers, there is no us and them. Despite our professional advantages, each of has had or will likely have an opportunity to overcome the many gaps in hospital discharge planning, not just as healthcare professionals but also in our roles as adult children, spouses, and parents. In this regard, we are all invested in improving the discharge experience.

Under the national leadership of AARP, 42 states and territories have introduced the Caregiver Advise Record and Enable (CARE) Act, 32 have passed it, and the following 30 have enacted it into law: Arkansas, California, Colorado, Connecticut, District of Columbia, Illinois, Indiana, Louisiana, Maine, Maryland, Michigan, Minnesota, Mississippi, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, Oklahoma, Oregon, Pennsylvania, Puerto Rico, Rhode Island, Utah, Virginia, Virgin Islands, West Virginia, Washington and Wyoming (as of June 6, 2016). The CARE Act requires hospitals to: (1) record the name of the family caregiver in the medical record, (2) inform the family caregiver when the patient is to be discharged, and (3) provide the family caregiver with education and instruction on the medical tasks that he or she will need to perform for the patient upon return home.[1, 2]

The family caregiver is to be identified by the patient. Because the patient is the source of the information, Health Insurance Portability and Accountability Act concerns are minimal. A family caregiver need not be related to the patient by blood or marriage; a friend, neighbor, partner, or paid caregiver could be identified by the patient as serving in this role. If the patient does not identify a family caregiver (due to the absence of such an individual, concern for potential burden on a loved one, desire for confidentiality, transient or progressive cognitive impairment, or other reasons), this also needs to be documented, though the additional provisions of the CARE Act would not be applicable. As some states have made additions or individual modifications to the CARE Act, the reader is encouraged to learn more about state‐specific differences that might impact implementation.[2, 3]

The impetus for the CARE Act emerges from challenges faced by both family caregivers and healthcare professionals. The 3 care elements included in the Act appear to have considerable face validity for what would constitute good transitional care. To further explore why this is necessary, we need to begin by asking why are these 3 care elements not routine, and why did an advocacy organization resort to a legislative solution to formally recognize and include family caregivers in discharge preparation?

Family caregivers, when able and willing, often play an instrumental role in the care of their loved ones, particularly during the vulnerable time of transitions out of the hospital.[4, 5] They are often the first line of defense for detecting lapses in quality or safety as care is transitioned from the hospital. Family caregivers frequently take on a primary or secondary role in operationalizing and executing the discharge plan. Nearly half of family caregivers perform skilled medical or nursing tasks for their loved ones (eg, wound care, injections, complex medication management, operating specialized medical equipment) often with insufficient assistance or training from healthcare professionals.[6]

Lack of sufficient time might be a major reason why the 3 care elements identified in the CARE Act are not routinely addressed by the discharging team, which may include hospitalists, nurses, pharmacists, social workers, and other clinicians. However, there may be other reasons as well, including a lack of knowledge, confidence, or tools for how to best prepare the patient and family caregiver. This is compounded by the absence of routine feedback loops for gauging the effectiveness of discharge preparation beyond a patient's readmission to the same facility. If hospital‐based clinicians were asked to rank order their daily tasks from greatest sense of professional gratification to lowest, discharge preparation would likely appear toward the bottom of the list.[7, 8]

Meanwhile, hospitalists and hospital clinical leaders are struggling to keep pace with a confluence of new demands that include value‐based purchasing initiatives and population health efforts, to name but a few. Although current Centers for Medicare and Medicaid Services' (CMS) Hospital Conditions of Participation for Discharge Planning do not require recognition or preparation of family caregivers, CMS' newly proposed revisions emphasize better preparation of family caregivers to be active partners upon hospital discharge.[9] Thus, although it might be reflexive to view the CARE Act in isolation as yet 1 more initiative requiring new effort and resources to address, widening the lens may confirm that the contributions of family caregivers are integral and aligned across nearly all efforts aimed at promoting greater value, and in this light could be viewed as complementary rather than competitive.

Innovation or new resources may be needed to implement the CARE Act. In the absence of a step‐by‐step user's guide, hospitals may wish to take advantage of valuable publicly available resources that encourage more effective collaboration between family caregivers and healthcare professionals (Table 1).

Operationalizing the CARE Act may initially appear simple but in practice will not be easy. The first care element focuses on identifying the family caregiver. Next, Step in Care offers a practical guide for how to identify the family caregiver in a busy hospital environment (Table 1). The guide advises health professionals on how to identify the person most likely to assume responsibility for care after discharge by asking a series of questions: Who assists you at home? Who do you call in case of emergency? Who helps with medications or doctor appointments? The guide cautions health professionals not to assume that individuals encountered at the patient's bedside are necessarily the family caregivers. They may be covering for the family caregiver, who has other duties (eg, job, child care).

The second CARE Act element entails informing the family caregiver when the patient will be discharged. At present there is no standardization of this practice. Many hospitals conduct interdisciplinary rounds, during which a discharge date is frequently estimated. A designated member of the inpatient team (eg, primary nurse, social worker, care manager) might be tasked with notifying the family caregiver of this estimated date (either in person, by telephone, or using other approved mode[s] of communication). Ideally, this notification should be conveyed as soon as the inpatient care team can foresee a discharge date, as it would be preferable to give the family caregiver an estimate that turns out to be a day or 2 off and needs to be revised than to inform the family caregiver at the last minute. The white board in the patient's room may serve as a reminder to both the patient and family caregiver as well as to other members of the inpatient care team.

The third CARE Act element could be facilitated with the Family Caregiver Activation in Transitions (FCAT) tool, a self‐efficacy measure of transition specific tasks. The FCAT tool is designed to facilitate more productive interactions and guide the care team in understanding what common transition‐related areas family caregivers would like to feel more prepared for or confident with. The FCAT tool can be administered by a health professional or self‐administered by a family caregiver and takes approximately 2 minutes to complete[10] (Table 1).

Hospital leaders might consider creating an interdisciplinary team charged with facilitating the implementation of the CARE Act. Specifically, this team might develop guidelines and serve as a forum whereby clinicians might share particularly challenging cases. Similarly, for ongoing input and suggestions for how to further improve all aspects of hospital care, including the discharge experience, hospitals are encouraged to form and foster patient and family advisory councils (Table 1).

Finally, when it comes to improving the hospital discharge experience for family caregivers, there is no us and them. Despite our professional advantages, each of has had or will likely have an opportunity to overcome the many gaps in hospital discharge planning, not just as healthcare professionals but also in our roles as adult children, spouses, and parents. In this regard, we are all invested in improving the discharge experience.

Care transitions between the inpatient and outpatient settings are a known period of risk in a patient's care. For instance, 1 in 5 medical patients suffers an adverse event during the first several weeks after hospital discharge, with half of these requiring the use of additional healthcare resources.1 Additionally, medication and lab monitoring errors occur in up to half of all discharged patients.2 Nearly 1 in 5 hospitalized patients, admitted with 1 of 16 different conditions including asthma, diabetes, congestive heart failure and urinary tract infection is readmitted to the hospital within six months. Up to 60% of resources are used in rehospitalized patients.3, 4 In Medicare beneficiaries, the readmission rate is as high as 20% at 30 days. The same study suggests that up to half of Medicare patients readmitted within 30 days are not seen in the outpatient setting following discharge.5 Such statistics underscore the need for seamless post‐discharge care.

Studies of post‐discharge primary care provider (PCP) follow‐up highlight the gaps in current practice within the transition from the hospital to PCP follow‐up. For instance, while more than 1 in 4 discharged patients (27.6%) at one large teaching hospital had outpatient work‐ups recommended by their hospital physicians, more than a third (35.9%) of these recommendations were ultimately not completed. Furthermore, at this same center, an increased time interval between hospital discharge and PCP follow‐up decreased the likelihood that a work‐up recommended by a hospital physician was completed.6 In patients who do have a PCP, post‐hospitalization follow‐up is frequently impacted by a variety of factors, including co‐payment requirements, transportation issues, lack of health insurance, as well as scheduling a follow‐up appointment while in the hospital.710 Uninsured patients are at particular risk for failures in transitions, have poorer health outcomes and higher mortality than insured counterparts, and are nearly 3 times more likely to make an ED visit following hospital discharge.1113

In order to better understand the role of post‐discharge PCP follow‐up, we sought to identify: (1) the percentage of general medical inpatients lacking timely PCP follow‐up after discharge from the hospital, and (2) the impact of patients lacking timely PCP follow‐up on 30‐day readmission rate and hospital length of stay (LOS). For the purposes of this study, we have defined timely PCP follow up as occurring within 4 weeks of hospital discharge.

Methods

Results

Sixty‐five patients completed this study. The mean age of the study population was 55.3 years and approximately half (52.3%) of the study participants were female. Fifty‐two subjects reported having an established PCP on admission to the hospital (80%). The rate of timely PCP follow‐up overall was 49.2%. Table 1 shows the study population characteristics stratified by presence of timely PCP follow‐up. Patients lacking timely PCP follow‐up were much younger (48.4 vs. 62.4 years; P < 0.001) than those with timely PCP follow‐up; there were also non‐significant trends toward patients lacking timely PCP follow‐up being non‐white: (33.3% vs. 25%, P = 0.23) and having lower education level (72.7% with high school or lower education vs. 56.2% for those with PCP follow‐up, P = 0.15) than those with timely PCP follow‐up. Of the 32 patients having timely PCP follow‐up, 15.6% were uninsured. In comparison, among the 33 patients lacking timely PCP follow‐up after hospital discharge, over a third (36%) were uninsured (P = 0.06). Among the uninsured, a large majority (70.5%) lacked timely PCP follow‐up (P = 0.06). In contrast, only 11 of the 26 Medicare patients (42.3%) lacked timely PCP follow‐up (P = 0.13).

Discussion

A growing body of work highlights the role of multiple, varied interventions at, or following discharge, in improving outcomes during the transition from inpatient to outpatient care. Examples include care coordination by advanced nurse practitioners, follow‐up pharmacist phone calls, and involvement of a transition coach encouraging active patient involvementall are known to improve patient outcomes following a hospitalization.1418 The active involvement of a PCP is central to a number of these proven interventions to ensure effective completion of ongoing patient care. And while some previous studies suggest increased overall resource utilization when PCP follow‐up occurs after hospitalization,19 the level of fragmented care that occurs in today's hospitalized patient, as well as the fact many patients lack PCP care at all, raises questions about clinical outcomes after hospitalization related to timely PCP follow‐up. The issue of appropriateness of resources utilized has also not been adequately explored.

Within this context, this study examines the role that PCP follow‐up might play in such interventions and its' effects on patient outcomes. Notably, in this urban academic medical center, we found that timely PCP follow‐up after hospital discharge occurred in fewer than half of general medical inpatients. Lack of timely PCP follow‐up was associated with increased hospital readmission for the same condition and a trend toward a longer index hospital LOS.

While this small study cannot fully elucidate the impact of lack of timely PCP follow‐up on post‐discharge care, our findings suggest some mechanisms by which lack of timely PCP follow‐up might result in poor outcomes. For instance, patients lacking a PCP visit after discharge may not obtain needed follow‐up care in the post‐discharge period, leading to clinical deterioration and hospital readmission. Uninsured patients may be at particular risk for failed transition because they are less likely to have consistent PCP access, whether as an already established patient or one newly assigned.20, 21 Perhaps a larger study would better demonstrate statistical significance in reflecting the association between uninsured patients, lack of a PCP, and post‐discharge follow‐up deficiencies. There may, in fact, be issues related to patient attitudes and beliefs, such as subjectively feeling better or even an implicit distrust of the healthcare system among the uninsured, that exist as well. Even among patients with a PCP prior to hospitalization, PCP follow‐up after hospital discharge may be lacking due to modifiable factors such as patient attitudes and beliefs and logistical barriers in arranging follow‐up.

Patients without potential for timely PCP follow‐up might be kept in the hospital longer to ensure they are well enough medically to sufficiently meet their own follow‐up needs. Hospital LOS might be increased by providers to compensate for the lack of PCP follow‐up. Alternatively, these patients may be sicker with their index hospitalization.

It is not surprising that payer source appears to influence a patients' ability to obtain timely PCP follow‐up. It is well documented that uninsured patients have higher healthcare resource utilization.2224 Lack of access to primary care in such patients contributes to a cycle of using the most expensive sites of care. In our study, we found many of the patients lacking timely PCP follow‐up were younger, perhaps reflecting the same patient population who have higher rates of being uninsured. Conversely, older patients are more likely to have PCP access, in large part due to having Medicare benefits (although this dynamic has shown a shift in recent years). The uninsured may present sicker as a result of lacking pre‐hospital PCP access or transportation to a PCP visit.

Care transitions between the inpatient and outpatient settings are a known period of risk in a patient's care. For instance, 1 in 5 medical patients suffers an adverse event during the first several weeks after hospital discharge, with half of these requiring the use of additional healthcare resources.1 Additionally, medication and lab monitoring errors occur in up to half of all discharged patients.2 Nearly 1 in 5 hospitalized patients, admitted with 1 of 16 different conditions including asthma, diabetes, congestive heart failure and urinary tract infection is readmitted to the hospital within six months. Up to 60% of resources are used in rehospitalized patients.3, 4 In Medicare beneficiaries, the readmission rate is as high as 20% at 30 days. The same study suggests that up to half of Medicare patients readmitted within 30 days are not seen in the outpatient setting following discharge.5 Such statistics underscore the need for seamless post‐discharge care.

Studies of post‐discharge primary care provider (PCP) follow‐up highlight the gaps in current practice within the transition from the hospital to PCP follow‐up. For instance, while more than 1 in 4 discharged patients (27.6%) at one large teaching hospital had outpatient work‐ups recommended by their hospital physicians, more than a third (35.9%) of these recommendations were ultimately not completed. Furthermore, at this same center, an increased time interval between hospital discharge and PCP follow‐up decreased the likelihood that a work‐up recommended by a hospital physician was completed.6 In patients who do have a PCP, post‐hospitalization follow‐up is frequently impacted by a variety of factors, including co‐payment requirements, transportation issues, lack of health insurance, as well as scheduling a follow‐up appointment while in the hospital.710 Uninsured patients are at particular risk for failures in transitions, have poorer health outcomes and higher mortality than insured counterparts, and are nearly 3 times more likely to make an ED visit following hospital discharge.1113

In order to better understand the role of post‐discharge PCP follow‐up, we sought to identify: (1) the percentage of general medical inpatients lacking timely PCP follow‐up after discharge from the hospital, and (2) the impact of patients lacking timely PCP follow‐up on 30‐day readmission rate and hospital length of stay (LOS). For the purposes of this study, we have defined timely PCP follow up as occurring within 4 weeks of hospital discharge.

Methods

Results

Sixty‐five patients completed this study. The mean age of the study population was 55.3 years and approximately half (52.3%) of the study participants were female. Fifty‐two subjects reported having an established PCP on admission to the hospital (80%). The rate of timely PCP follow‐up overall was 49.2%. Table 1 shows the study population characteristics stratified by presence of timely PCP follow‐up. Patients lacking timely PCP follow‐up were much younger (48.4 vs. 62.4 years; P < 0.001) than those with timely PCP follow‐up; there were also non‐significant trends toward patients lacking timely PCP follow‐up being non‐white: (33.3% vs. 25%, P = 0.23) and having lower education level (72.7% with high school or lower education vs. 56.2% for those with PCP follow‐up, P = 0.15) than those with timely PCP follow‐up. Of the 32 patients having timely PCP follow‐up, 15.6% were uninsured. In comparison, among the 33 patients lacking timely PCP follow‐up after hospital discharge, over a third (36%) were uninsured (P = 0.06). Among the uninsured, a large majority (70.5%) lacked timely PCP follow‐up (P = 0.06). In contrast, only 11 of the 26 Medicare patients (42.3%) lacked timely PCP follow‐up (P = 0.13).

Discussion

A growing body of work highlights the role of multiple, varied interventions at, or following discharge, in improving outcomes during the transition from inpatient to outpatient care. Examples include care coordination by advanced nurse practitioners, follow‐up pharmacist phone calls, and involvement of a transition coach encouraging active patient involvementall are known to improve patient outcomes following a hospitalization.1418 The active involvement of a PCP is central to a number of these proven interventions to ensure effective completion of ongoing patient care. And while some previous studies suggest increased overall resource utilization when PCP follow‐up occurs after hospitalization,19 the level of fragmented care that occurs in today's hospitalized patient, as well as the fact many patients lack PCP care at all, raises questions about clinical outcomes after hospitalization related to timely PCP follow‐up. The issue of appropriateness of resources utilized has also not been adequately explored.

Within this context, this study examines the role that PCP follow‐up might play in such interventions and its' effects on patient outcomes. Notably, in this urban academic medical center, we found that timely PCP follow‐up after hospital discharge occurred in fewer than half of general medical inpatients. Lack of timely PCP follow‐up was associated with increased hospital readmission for the same condition and a trend toward a longer index hospital LOS.

While this small study cannot fully elucidate the impact of lack of timely PCP follow‐up on post‐discharge care, our findings suggest some mechanisms by which lack of timely PCP follow‐up might result in poor outcomes. For instance, patients lacking a PCP visit after discharge may not obtain needed follow‐up care in the post‐discharge period, leading to clinical deterioration and hospital readmission. Uninsured patients may be at particular risk for failed transition because they are less likely to have consistent PCP access, whether as an already established patient or one newly assigned.20, 21 Perhaps a larger study would better demonstrate statistical significance in reflecting the association between uninsured patients, lack of a PCP, and post‐discharge follow‐up deficiencies. There may, in fact, be issues related to patient attitudes and beliefs, such as subjectively feeling better or even an implicit distrust of the healthcare system among the uninsured, that exist as well. Even among patients with a PCP prior to hospitalization, PCP follow‐up after hospital discharge may be lacking due to modifiable factors such as patient attitudes and beliefs and logistical barriers in arranging follow‐up.

Patients without potential for timely PCP follow‐up might be kept in the hospital longer to ensure they are well enough medically to sufficiently meet their own follow‐up needs. Hospital LOS might be increased by providers to compensate for the lack of PCP follow‐up. Alternatively, these patients may be sicker with their index hospitalization.

It is not surprising that payer source appears to influence a patients' ability to obtain timely PCP follow‐up. It is well documented that uninsured patients have higher healthcare resource utilization.2224 Lack of access to primary care in such patients contributes to a cycle of using the most expensive sites of care. In our study, we found many of the patients lacking timely PCP follow‐up were younger, perhaps reflecting the same patient population who have higher rates of being uninsured. Conversely, older patients are more likely to have PCP access, in large part due to having Medicare benefits (although this dynamic has shown a shift in recent years). The uninsured may present sicker as a result of lacking pre‐hospital PCP access or transportation to a PCP visit.

Care transitions between the inpatient and outpatient settings are a known period of risk in a patient's care. For instance, 1 in 5 medical patients suffers an adverse event during the first several weeks after hospital discharge, with half of these requiring the use of additional healthcare resources.1 Additionally, medication and lab monitoring errors occur in up to half of all discharged patients.2 Nearly 1 in 5 hospitalized patients, admitted with 1 of 16 different conditions including asthma, diabetes, congestive heart failure and urinary tract infection is readmitted to the hospital within six months. Up to 60% of resources are used in rehospitalized patients.3, 4 In Medicare beneficiaries, the readmission rate is as high as 20% at 30 days. The same study suggests that up to half of Medicare patients readmitted within 30 days are not seen in the outpatient setting following discharge.5 Such statistics underscore the need for seamless post‐discharge care.

Studies of post‐discharge primary care provider (PCP) follow‐up highlight the gaps in current practice within the transition from the hospital to PCP follow‐up. For instance, while more than 1 in 4 discharged patients (27.6%) at one large teaching hospital had outpatient work‐ups recommended by their hospital physicians, more than a third (35.9%) of these recommendations were ultimately not completed. Furthermore, at this same center, an increased time interval between hospital discharge and PCP follow‐up decreased the likelihood that a work‐up recommended by a hospital physician was completed.6 In patients who do have a PCP, post‐hospitalization follow‐up is frequently impacted by a variety of factors, including co‐payment requirements, transportation issues, lack of health insurance, as well as scheduling a follow‐up appointment while in the hospital.710 Uninsured patients are at particular risk for failures in transitions, have poorer health outcomes and higher mortality than insured counterparts, and are nearly 3 times more likely to make an ED visit following hospital discharge.1113

In order to better understand the role of post‐discharge PCP follow‐up, we sought to identify: (1) the percentage of general medical inpatients lacking timely PCP follow‐up after discharge from the hospital, and (2) the impact of patients lacking timely PCP follow‐up on 30‐day readmission rate and hospital length of stay (LOS). For the purposes of this study, we have defined timely PCP follow up as occurring within 4 weeks of hospital discharge.

Methods

Results

Sixty‐five patients completed this study. The mean age of the study population was 55.3 years and approximately half (52.3%) of the study participants were female. Fifty‐two subjects reported having an established PCP on admission to the hospital (80%). The rate of timely PCP follow‐up overall was 49.2%. Table 1 shows the study population characteristics stratified by presence of timely PCP follow‐up. Patients lacking timely PCP follow‐up were much younger (48.4 vs. 62.4 years; P < 0.001) than those with timely PCP follow‐up; there were also non‐significant trends toward patients lacking timely PCP follow‐up being non‐white: (33.3% vs. 25%, P = 0.23) and having lower education level (72.7% with high school or lower education vs. 56.2% for those with PCP follow‐up, P = 0.15) than those with timely PCP follow‐up. Of the 32 patients having timely PCP follow‐up, 15.6% were uninsured. In comparison, among the 33 patients lacking timely PCP follow‐up after hospital discharge, over a third (36%) were uninsured (P = 0.06). Among the uninsured, a large majority (70.5%) lacked timely PCP follow‐up (P = 0.06). In contrast, only 11 of the 26 Medicare patients (42.3%) lacked timely PCP follow‐up (P = 0.13).

Discussion

A growing body of work highlights the role of multiple, varied interventions at, or following discharge, in improving outcomes during the transition from inpatient to outpatient care. Examples include care coordination by advanced nurse practitioners, follow‐up pharmacist phone calls, and involvement of a transition coach encouraging active patient involvementall are known to improve patient outcomes following a hospitalization.1418 The active involvement of a PCP is central to a number of these proven interventions to ensure effective completion of ongoing patient care. And while some previous studies suggest increased overall resource utilization when PCP follow‐up occurs after hospitalization,19 the level of fragmented care that occurs in today's hospitalized patient, as well as the fact many patients lack PCP care at all, raises questions about clinical outcomes after hospitalization related to timely PCP follow‐up. The issue of appropriateness of resources utilized has also not been adequately explored.

Within this context, this study examines the role that PCP follow‐up might play in such interventions and its' effects on patient outcomes. Notably, in this urban academic medical center, we found that timely PCP follow‐up after hospital discharge occurred in fewer than half of general medical inpatients. Lack of timely PCP follow‐up was associated with increased hospital readmission for the same condition and a trend toward a longer index hospital LOS.

While this small study cannot fully elucidate the impact of lack of timely PCP follow‐up on post‐discharge care, our findings suggest some mechanisms by which lack of timely PCP follow‐up might result in poor outcomes. For instance, patients lacking a PCP visit after discharge may not obtain needed follow‐up care in the post‐discharge period, leading to clinical deterioration and hospital readmission. Uninsured patients may be at particular risk for failed transition because they are less likely to have consistent PCP access, whether as an already established patient or one newly assigned.20, 21 Perhaps a larger study would better demonstrate statistical significance in reflecting the association between uninsured patients, lack of a PCP, and post‐discharge follow‐up deficiencies. There may, in fact, be issues related to patient attitudes and beliefs, such as subjectively feeling better or even an implicit distrust of the healthcare system among the uninsured, that exist as well. Even among patients with a PCP prior to hospitalization, PCP follow‐up after hospital discharge may be lacking due to modifiable factors such as patient attitudes and beliefs and logistical barriers in arranging follow‐up.

Patients without potential for timely PCP follow‐up might be kept in the hospital longer to ensure they are well enough medically to sufficiently meet their own follow‐up needs. Hospital LOS might be increased by providers to compensate for the lack of PCP follow‐up. Alternatively, these patients may be sicker with their index hospitalization.

It is not surprising that payer source appears to influence a patients' ability to obtain timely PCP follow‐up. It is well documented that uninsured patients have higher healthcare resource utilization.2224 Lack of access to primary care in such patients contributes to a cycle of using the most expensive sites of care. In our study, we found many of the patients lacking timely PCP follow‐up were younger, perhaps reflecting the same patient population who have higher rates of being uninsured. Conversely, older patients are more likely to have PCP access, in large part due to having Medicare benefits (although this dynamic has shown a shift in recent years). The uninsured may present sicker as a result of lacking pre‐hospital PCP access or transportation to a PCP visit.

A lack of communication and accountability among healthcare professionals in general, and physicians in particular, jeopardizes quality and safety for our patients who are transitioning across sites of care.1, 2 Our patients, their family caregivers, and our health care professional colleagues on the receiving end of these transfers are often left flying blind without adequate information or direction to make sound clinical decisions.

Beyond our attempts to ensure effective transitions on a professional level, many of the readers of the Journal of Hospital Medicine likely have struggled to ensure seamless transitions for our families, despite the benefits of our training and experience.3 If some of the nation's most respected healthcare leaders are unable to make this work for their loved ones,48 one can only imagine the challenges faced by those without such advantages.

National and local quality collaboratives aimed at improving communication and collaboration across settings have found physicians difficult to engage as partners in these efforts.9 All too often there is a false expectation that these types of activities are best left to nonphysician healthcare professionals on the sending side of the transfer or to those receiving the transfer.10, 11

In this issue of the Journal, we commend the leadership provided by representatives of 6 of the nation's leading physician professional societies to join forces toward the common purpose of articulating physicians' roles and accountability for care delivered during transitions.12 Ensuring effective care transitions is a team sport, yet rarely do we have a clear understanding of who are the other members of our team, how to interact with them, or a clear delineation of their respective roles. Simply stated, this article is a key step to facilitating teamwork across settings among physicians, our interdisciplinary healthcare professional colleagues, our patients, and their family caregivers. These standards clearly convey the type of care we expect for our loved ones.

Drawing from proven strategies used in nonhealthcare industries, the standards assert that the sending provider or institution retains responsibility for the patient's care until the receiving team confirms receipt of the transfer and assumes responsibility. Further, the receiving team is given the opportunity to ask questions and clarify the proposed care plan in recognition of the fact that communication is more than simply the transfer of information. Rather, such communication involves the need to ensure comprehension and provide an opportunity to have a 2‐way dialog. These standards distinguish between the transmission of information and true communication.

The timing of the release of these standards is ideal. As physicians concentrate their practice within particular settings we can no longer rely on casual random interchanges in hospital parking lots or the hospital's physician lounge. Rather, we need to take a more active and reliable approach to ensuring timely and accurate exchanges. These standards cut to the essence of how we communicate with our physician and nonphysician colleagues alike, and in so doing move us away from nonproductive blame and finger‐pointing.

Although the implications for these standards are far reaching in terms of raising the quality bar, they could reach even further with respect to the types of settings they address. These standards need to extend beyond hospitals and the outpatient arena to include nursing homes, rehabilitation facilities, home care agencies, adult day health centers, and other settings where chronic care services are delivered.

Further, the standards devote considerable focus to the transfer of health information. Even with advances in health information exchange technologies, we must recognize that information is necessary but not sufficient for ensuring safe and high‐quality transfers. Implementing these standards will undoubtedly require that we reconfigure our daily workflows.13 The article in this issue by Graumlich et al.14 emphasizes the challenges of how to introduce technology into our daily clinical routines. The standards also open the door for how we can best ensure not just the transmission of information, but also the comprehension of transfer instructions to our patients with attention to health literacy, cognitive ability, and the patient's level of activation.15 Best and Young16 provide valuable action steps for how to address the needs of diverse and underserved populations.

These standards may serve to uncover the fact that most physicians have not received formal training in executing high‐quality care transitions in the role of either the sender or the receiver. Further, few physicians have a mechanism in place to evaluate their performance. The American Board of Internal Medicine and the American Board of Family Practice has developed Maintenance of Certification Practice Improvement Modules (PIM) on care coordination that provide an excellent opportunity to sharpen our skills. The HMO Care Management Workgroup has also attempted to summarize the essential skills necessary to care for patients during transitions.17

Perhaps the greatest value of these standards is that they lay the framework for actionable improvement. Local, state, and national quality collaboratives can immediately incorporate these recommendations into their overall strategy. These standards will likely influence the design and implementation of the Medical Home.18 As national attention focuses on how to operationalize bundled payment approaches and Accountable Care Organizations,19 these standards provide a clear consensus on communication, accountability, and ensuring patient‐centeredness. The standards are an excellent start and provide a framework for further innovation.

One area in particular may be the opportunity to reinvent the format, content, and medium by which essential information is transferred. For example, one might envision the value of producing a scaled down version of the discharge summary with a limited core set of data elements that could be quickly completed and communicated to the next care team via fax, e‐mail, or text messaging.

Complementing new strategies to improve the exchange of health information are opportunities to reconsider the culture within which this communication occurs. Our profession has a long‐standing tradition of not providing directives to our colleagues on the details of clinical management. Hospitalists develop important insights during a patient's hospital stay and are in an ideal position to anticipate potential developments in the subsequent course after discharge. Contrast this with the 5 to 10 minutes that a primary care physician or specialist may have to come up to speed on the hospital and posthospital events in order to manage the patient in the ambulatory arena. Thus, rather than the traditional historical orientation to a discharge summary, one could envision a more future‐orientated document characterized by a series of if‐then statements that outline a series of possible clinical scenarios that may play out over the weeks after discharge along with recommendations for adjustments to the treatment plan.

At a broader level, the release of these standards demonstrate to our communities and to our nation that physicians can join forces to address a particularly complex and challenging aspect of healthcare. Change can indeed come from within our profession rather than being imposed by outside influences such as government administrators, regulatory bodies, or malpractice attorneys. I applaud such efforts and believe that hospitalists will continue to play a central role in national efforts to improve transitions of care.

A lack of communication and accountability among healthcare professionals in general, and physicians in particular, jeopardizes quality and safety for our patients who are transitioning across sites of care.1, 2 Our patients, their family caregivers, and our health care professional colleagues on the receiving end of these transfers are often left flying blind without adequate information or direction to make sound clinical decisions.

Beyond our attempts to ensure effective transitions on a professional level, many of the readers of the Journal of Hospital Medicine likely have struggled to ensure seamless transitions for our families, despite the benefits of our training and experience.3 If some of the nation's most respected healthcare leaders are unable to make this work for their loved ones,48 one can only imagine the challenges faced by those without such advantages.

National and local quality collaboratives aimed at improving communication and collaboration across settings have found physicians difficult to engage as partners in these efforts.9 All too often there is a false expectation that these types of activities are best left to nonphysician healthcare professionals on the sending side of the transfer or to those receiving the transfer.10, 11

In this issue of the Journal, we commend the leadership provided by representatives of 6 of the nation's leading physician professional societies to join forces toward the common purpose of articulating physicians' roles and accountability for care delivered during transitions.12 Ensuring effective care transitions is a team sport, yet rarely do we have a clear understanding of who are the other members of our team, how to interact with them, or a clear delineation of their respective roles. Simply stated, this article is a key step to facilitating teamwork across settings among physicians, our interdisciplinary healthcare professional colleagues, our patients, and their family caregivers. These standards clearly convey the type of care we expect for our loved ones.

Drawing from proven strategies used in nonhealthcare industries, the standards assert that the sending provider or institution retains responsibility for the patient's care until the receiving team confirms receipt of the transfer and assumes responsibility. Further, the receiving team is given the opportunity to ask questions and clarify the proposed care plan in recognition of the fact that communication is more than simply the transfer of information. Rather, such communication involves the need to ensure comprehension and provide an opportunity to have a 2‐way dialog. These standards distinguish between the transmission of information and true communication.

The timing of the release of these standards is ideal. As physicians concentrate their practice within particular settings we can no longer rely on casual random interchanges in hospital parking lots or the hospital's physician lounge. Rather, we need to take a more active and reliable approach to ensuring timely and accurate exchanges. These standards cut to the essence of how we communicate with our physician and nonphysician colleagues alike, and in so doing move us away from nonproductive blame and finger‐pointing.

Although the implications for these standards are far reaching in terms of raising the quality bar, they could reach even further with respect to the types of settings they address. These standards need to extend beyond hospitals and the outpatient arena to include nursing homes, rehabilitation facilities, home care agencies, adult day health centers, and other settings where chronic care services are delivered.

Further, the standards devote considerable focus to the transfer of health information. Even with advances in health information exchange technologies, we must recognize that information is necessary but not sufficient for ensuring safe and high‐quality transfers. Implementing these standards will undoubtedly require that we reconfigure our daily workflows.13 The article in this issue by Graumlich et al.14 emphasizes the challenges of how to introduce technology into our daily clinical routines. The standards also open the door for how we can best ensure not just the transmission of information, but also the comprehension of transfer instructions to our patients with attention to health literacy, cognitive ability, and the patient's level of activation.15 Best and Young16 provide valuable action steps for how to address the needs of diverse and underserved populations.

These standards may serve to uncover the fact that most physicians have not received formal training in executing high‐quality care transitions in the role of either the sender or the receiver. Further, few physicians have a mechanism in place to evaluate their performance. The American Board of Internal Medicine and the American Board of Family Practice has developed Maintenance of Certification Practice Improvement Modules (PIM) on care coordination that provide an excellent opportunity to sharpen our skills. The HMO Care Management Workgroup has also attempted to summarize the essential skills necessary to care for patients during transitions.17

Perhaps the greatest value of these standards is that they lay the framework for actionable improvement. Local, state, and national quality collaboratives can immediately incorporate these recommendations into their overall strategy. These standards will likely influence the design and implementation of the Medical Home.18 As national attention focuses on how to operationalize bundled payment approaches and Accountable Care Organizations,19 these standards provide a clear consensus on communication, accountability, and ensuring patient‐centeredness. The standards are an excellent start and provide a framework for further innovation.

One area in particular may be the opportunity to reinvent the format, content, and medium by which essential information is transferred. For example, one might envision the value of producing a scaled down version of the discharge summary with a limited core set of data elements that could be quickly completed and communicated to the next care team via fax, e‐mail, or text messaging.

Complementing new strategies to improve the exchange of health information are opportunities to reconsider the culture within which this communication occurs. Our profession has a long‐standing tradition of not providing directives to our colleagues on the details of clinical management. Hospitalists develop important insights during a patient's hospital stay and are in an ideal position to anticipate potential developments in the subsequent course after discharge. Contrast this with the 5 to 10 minutes that a primary care physician or specialist may have to come up to speed on the hospital and posthospital events in order to manage the patient in the ambulatory arena. Thus, rather than the traditional historical orientation to a discharge summary, one could envision a more future‐orientated document characterized by a series of if‐then statements that outline a series of possible clinical scenarios that may play out over the weeks after discharge along with recommendations for adjustments to the treatment plan.

At a broader level, the release of these standards demonstrate to our communities and to our nation that physicians can join forces to address a particularly complex and challenging aspect of healthcare. Change can indeed come from within our profession rather than being imposed by outside influences such as government administrators, regulatory bodies, or malpractice attorneys. I applaud such efforts and believe that hospitalists will continue to play a central role in national efforts to improve transitions of care.

A lack of communication and accountability among healthcare professionals in general, and physicians in particular, jeopardizes quality and safety for our patients who are transitioning across sites of care.1, 2 Our patients, their family caregivers, and our health care professional colleagues on the receiving end of these transfers are often left flying blind without adequate information or direction to make sound clinical decisions.

Beyond our attempts to ensure effective transitions on a professional level, many of the readers of the Journal of Hospital Medicine likely have struggled to ensure seamless transitions for our families, despite the benefits of our training and experience.3 If some of the nation's most respected healthcare leaders are unable to make this work for their loved ones,48 one can only imagine the challenges faced by those without such advantages.

National and local quality collaboratives aimed at improving communication and collaboration across settings have found physicians difficult to engage as partners in these efforts.9 All too often there is a false expectation that these types of activities are best left to nonphysician healthcare professionals on the sending side of the transfer or to those receiving the transfer.10, 11

In this issue of the Journal, we commend the leadership provided by representatives of 6 of the nation's leading physician professional societies to join forces toward the common purpose of articulating physicians' roles and accountability for care delivered during transitions.12 Ensuring effective care transitions is a team sport, yet rarely do we have a clear understanding of who are the other members of our team, how to interact with them, or a clear delineation of their respective roles. Simply stated, this article is a key step to facilitating teamwork across settings among physicians, our interdisciplinary healthcare professional colleagues, our patients, and their family caregivers. These standards clearly convey the type of care we expect for our loved ones.

Drawing from proven strategies used in nonhealthcare industries, the standards assert that the sending provider or institution retains responsibility for the patient's care until the receiving team confirms receipt of the transfer and assumes responsibility. Further, the receiving team is given the opportunity to ask questions and clarify the proposed care plan in recognition of the fact that communication is more than simply the transfer of information. Rather, such communication involves the need to ensure comprehension and provide an opportunity to have a 2‐way dialog. These standards distinguish between the transmission of information and true communication.

The timing of the release of these standards is ideal. As physicians concentrate their practice within particular settings we can no longer rely on casual random interchanges in hospital parking lots or the hospital's physician lounge. Rather, we need to take a more active and reliable approach to ensuring timely and accurate exchanges. These standards cut to the essence of how we communicate with our physician and nonphysician colleagues alike, and in so doing move us away from nonproductive blame and finger‐pointing.

Although the implications for these standards are far reaching in terms of raising the quality bar, they could reach even further with respect to the types of settings they address. These standards need to extend beyond hospitals and the outpatient arena to include nursing homes, rehabilitation facilities, home care agencies, adult day health centers, and other settings where chronic care services are delivered.

Further, the standards devote considerable focus to the transfer of health information. Even with advances in health information exchange technologies, we must recognize that information is necessary but not sufficient for ensuring safe and high‐quality transfers. Implementing these standards will undoubtedly require that we reconfigure our daily workflows.13 The article in this issue by Graumlich et al.14 emphasizes the challenges of how to introduce technology into our daily clinical routines. The standards also open the door for how we can best ensure not just the transmission of information, but also the comprehension of transfer instructions to our patients with attention to health literacy, cognitive ability, and the patient's level of activation.15 Best and Young16 provide valuable action steps for how to address the needs of diverse and underserved populations.

These standards may serve to uncover the fact that most physicians have not received formal training in executing high‐quality care transitions in the role of either the sender or the receiver. Further, few physicians have a mechanism in place to evaluate their performance. The American Board of Internal Medicine and the American Board of Family Practice has developed Maintenance of Certification Practice Improvement Modules (PIM) on care coordination that provide an excellent opportunity to sharpen our skills. The HMO Care Management Workgroup has also attempted to summarize the essential skills necessary to care for patients during transitions.17

Perhaps the greatest value of these standards is that they lay the framework for actionable improvement. Local, state, and national quality collaboratives can immediately incorporate these recommendations into their overall strategy. These standards will likely influence the design and implementation of the Medical Home.18 As national attention focuses on how to operationalize bundled payment approaches and Accountable Care Organizations,19 these standards provide a clear consensus on communication, accountability, and ensuring patient‐centeredness. The standards are an excellent start and provide a framework for further innovation.

One area in particular may be the opportunity to reinvent the format, content, and medium by which essential information is transferred. For example, one might envision the value of producing a scaled down version of the discharge summary with a limited core set of data elements that could be quickly completed and communicated to the next care team via fax, e‐mail, or text messaging.

Complementing new strategies to improve the exchange of health information are opportunities to reconsider the culture within which this communication occurs. Our profession has a long‐standing tradition of not providing directives to our colleagues on the details of clinical management. Hospitalists develop important insights during a patient's hospital stay and are in an ideal position to anticipate potential developments in the subsequent course after discharge. Contrast this with the 5 to 10 minutes that a primary care physician or specialist may have to come up to speed on the hospital and posthospital events in order to manage the patient in the ambulatory arena. Thus, rather than the traditional historical orientation to a discharge summary, one could envision a more future‐orientated document characterized by a series of if‐then statements that outline a series of possible clinical scenarios that may play out over the weeks after discharge along with recommendations for adjustments to the treatment plan.

At a broader level, the release of these standards demonstrate to our communities and to our nation that physicians can join forces to address a particularly complex and challenging aspect of healthcare. Change can indeed come from within our profession rather than being imposed by outside influences such as government administrators, regulatory bodies, or malpractice attorneys. I applaud such efforts and believe that hospitalists will continue to play a central role in national efforts to improve transitions of care.

As the counterpart to hospital admission, hospital discharge is a necessary process experienced by each living patient. For all patients except those being transferred to a continuing care facility, discharge is a period of transition from hospital to home that involves a transfer in responsibility from the inpatient provider or hospitalist to the patient and primary care physician (PCP).1 Prescription medications are commonly altered at this transition point, with patients asked to discontinue some medications, switch to a new dosage schedule of others, or begin new treatments.2, 3 Self‐care responsibilities also increase in number and importance, presenting new challenges for patients and their families as they return home.4 Under these circumstances, ineffective planning and coordination of care can undermine patient satisfaction, facilitate adverse events, and contribute to more frequent hospital readmissions.58

Following hospital discharge nearly half (49%) of hospitalized patients experience at least 1 medical error in medication continuity, diagnostic workup, or test follow‐up.7 It has been reported that 19%23% of patients suffer an adverse event, most frequently an adverse drug event (ADE).911 Half of ADEs are considered preventable or ameliorable (ie, their severity or duration could have been decreased). Most errors and adverse events in this setting result from a breakdown in communication between the hospital team and the patient or primary care physician.10

To promote more effective care transitions, The Joint Commission now requires accredited facilities to accurately and completely reconcile medications across the continuum of care.12 The Society of Hospital Medicine recently published recommendations for the discharge of elderly patients.13 The joint Society of Hospital MedicineSociety of General Internal Medicine Continuity of Care Task Force also recently published a systematic review with recommendations for improving the handoff of patient information at discharge.14 Apart from these reports, however, it is uncommon to find evidence‐based recommendations for hospital discharge applicable to a broad range of patients.15 This review highlights several important challenges for physicians who seek to provide high‐quality care during hospital discharge and the subsequent period of transition. Based on the best available evidence, recommendations are also provided for how to improve communication and facilitate the care transition for adult inpatients returning home.

INPATIENTOUTPATIENT PHYSICIAN DISCONTINUITY

Traditionally, primary care physicians have admitted their own patients, provided hospital care (in addition to seeing outpatients during the day), and followed patients after discharge. Under this model, continuity of care has been preserved; however, this method of care has faltered under the weight of inpatients and outpatients with more severe illnesses, rapid technological advancements, managed care pressuring outpatient physicians to see more patients, and a thrust toward reduced hospital costs and length of stay.16 Increases in the efficiency and quality of hospital care have accompanied a new reliance on the field of hospital medicine, while allowing PCPs to focus on outpatient care.1719 With more than 14,000 hospitalists currently practicing in the United States and 25,000 anticipated to be practicing by 2010, transfer of care from hospital‐based providers to PCPs has become increasingly common at discharge.20

Patient discharge summaries are the most common means of communication between inpatient and outpatient providers. However, numerous studies have shown that discharge summaries often fail to provide important administrative and medical information, such as the primary diagnosis, results of abnormal diagnostics, details about the hospital course, follow‐up plans, whether laboratory test results are pending, and patient or family counseling.14 Summaries also may not arrive in a timely manner and sometimes may not reach the PCP at all.2123

At the time patients first follow up with their PCPs after hospitalization, discharge summaries have not yet arrived about 75% of the time,22, 24, 25 restricting the PCPs' ability to provide adequate follow‐up care in 24% of hospital follow‐up visits, according to one study.26 In another investigation, PCPs reported being unaware of 62% of the pending test results that returned after discharge, of which 37% were considered actionable.27

CHANGES AND DISCREPANCIES IN THE MEDICATION REGIMEN

Medication errors make up a large portion of the adverse events patients may experience in the period following hospital discharge.7 In fact, errors during the ordering of admission or discharge medications make up almost half of all hospital medication errors.4043 At transition points such as admission and discharge, errors are often associated with changes in the medication regimen, including discrepancies between the new set of medication orders and what the patient was taking previously. In 2 recent studies, 54% of patients experienced at least 1 unintended medication discrepancy on admission to the hospital, and 39%‐45% of these discrepancies were considered a potential threat to the patient.44, 45

At discharge, differences between the prescribed medication regimen and the prehospital regimen may exist for several reasons. First, physicians may not obtain a comprehensive and accurate medication history at the time of admission.46 The medication history elicited from the patient at hospital admission is often affected by health literacy, language barriers, current health status, medication‐history interviewing skills, and time constraints.47 Physicians may not consult other important sources of medication information, including family members, prescription lists or bottles, and community pharmacy records. The most common error in the admission medication history is omitting a medication taken at home.46 Additionally, several providers, including a physician, a nurse, and an inpatient pharmacist, may independently take medication histories for the same patient. These multiple accounts lead to discrepancies that are rarely recognized or corrected.

Second, a patient's medication regimen can be significantly altered several times during a hospitalization. Acute illness may cause physicians to hold certain medications, discontinue others, or change prescribed doses during hospitalization.48 In addition, at most hospitals closed drug formularies necessitate automatic substitution of 1 medication for another drug in the same class during the patient's hospital stay.49 Changes from long‐acting to short‐acting medications are also routinely made in the name of tighter control (eg, of blood pressure). One study of hospitalized elders found that 40% of all admission medications had been discontinued by discharge and that 45% of all discharge medications were newly started during the hospitalization.3

Finally, at discharge, the current medication regimen needs to be reconciled with the preadmission medication regimen in a thoughtful manner.2 This includes resuming medications held or modified at admission for clinical reasons, resuming medications that were substituted in the hospital for formulary or pharmacokinetic reasons, and stopping newly started medications that were only required during the hospitalization (eg, for prevention of venous thromboembolism or stress ulcers).50 It is difficult, even in hospitals with advanced electronic health information systems, to prompt physicians to make these necessary changes. In a recent study, unexplained discrepancies between the preadmission medication list and discharge medication orders were noted in 49% of hospital discharges.51 Errors in discharge medication reconciliation may subsequently increase the risk of postdischarge ADEs.51

SELF‐CARE RESPONSIBILITIES AND SOCIAL SUPPORT

Compounding the difficulties at discharge are the economic pressures on our health care system, causing patients to be released from the hospital quicker and sicker than ever before.68 The scope of care provided to patients also undergoes a major shift at discharge. Multidisciplinary providers no longer continually review the health status and needs of patients; instead, patients must follow up with their outpatient physician over a period of days to weeks. In the interim, the patients themselves are responsible for administering new medications, participating in physical therapy, and tracking their own symptoms to see if they are worsening. For many patients, sufficient social and family support is not available to help perform these activities effectively. Unfortunately, hospital personnel often inaccurately assess patients' functional status and overestimate patients' knowledge of required self‐care activities.69

INEFFECTIVE PHYSICIANPATIENT COMMUNICATION

Physicianpatient communication is fundamental to the practice of medicine and is crucially important at discharge. However, several studies have demonstrated a disconnect between physician information giving and patient understanding.76, 9690 When providing instructions, physicians commonly use medical jargon and attempt to cover a wealth of information in a limited amount of time.69, 87 They also tend to rely on verbal instructions and fail to provide supplementary audiovisual materials (eg, educational handouts or videos) that could aid patient comprehension. Physicians may not point out important self‐care tasks that patients should carry out at home. The entire interaction may be rushed or seem rushed. Moreover, when physicians solicit questions from patients, they may only allow for yes/no responses by using statements like Any questions? or Do you have any questions? that make it easy for patients to simply respond, No. The encounter usually comes to an end without true confirmation of a patient's level of understanding or assessment of a patient's ability to perform the self‐care activities and medication management required on returning home.81

Adding to the challenges of effective physicianpatient communication is the large number of adult Americans (more than 90 million) who have limited functional literacy skills.91, 92 Such patients typically have difficulty reading and understanding medical instructions, medication labels, and appointment slips.9396 Not surprisingly, patients with limited literacy skills know less about their chronic illnesses and how to manage their diseases.97 Having low literacy is also linked to increased use of emergency department services, a higher risk of hospitalization, and higher health care costs.9799 Patients with limited English proficiency have similar or even greater challenges and also have longer stays in the hospital.100

CONCLUSIONS

The transition from hospital to home is a vulnerable period of discontinuity and potential adverse events. Hospitalists and other inpatient providers should not view discharge as an end to their obligation to patients but rather should attempt to promote a safe and efficient transition of care. Hospitalists can play an important role in bridging the gap between inpatient and outpatient care through appropriate discharge planning and effective communication with patients, their family members, and outpatient physicians.

As the counterpart to hospital admission, hospital discharge is a necessary process experienced by each living patient. For all patients except those being transferred to a continuing care facility, discharge is a period of transition from hospital to home that involves a transfer in responsibility from the inpatient provider or hospitalist to the patient and primary care physician (PCP).1 Prescription medications are commonly altered at this transition point, with patients asked to discontinue some medications, switch to a new dosage schedule of others, or begin new treatments.2, 3 Self‐care responsibilities also increase in number and importance, presenting new challenges for patients and their families as they return home.4 Under these circumstances, ineffective planning and coordination of care can undermine patient satisfaction, facilitate adverse events, and contribute to more frequent hospital readmissions.58

Following hospital discharge nearly half (49%) of hospitalized patients experience at least 1 medical error in medication continuity, diagnostic workup, or test follow‐up.7 It has been reported that 19%23% of patients suffer an adverse event, most frequently an adverse drug event (ADE).911 Half of ADEs are considered preventable or ameliorable (ie, their severity or duration could have been decreased). Most errors and adverse events in this setting result from a breakdown in communication between the hospital team and the patient or primary care physician.10

To promote more effective care transitions, The Joint Commission now requires accredited facilities to accurately and completely reconcile medications across the continuum of care.12 The Society of Hospital Medicine recently published recommendations for the discharge of elderly patients.13 The joint Society of Hospital MedicineSociety of General Internal Medicine Continuity of Care Task Force also recently published a systematic review with recommendations for improving the handoff of patient information at discharge.14 Apart from these reports, however, it is uncommon to find evidence‐based recommendations for hospital discharge applicable to a broad range of patients.15 This review highlights several important challenges for physicians who seek to provide high‐quality care during hospital discharge and the subsequent period of transition. Based on the best available evidence, recommendations are also provided for how to improve communication and facilitate the care transition for adult inpatients returning home.

INPATIENTOUTPATIENT PHYSICIAN DISCONTINUITY

Traditionally, primary care physicians have admitted their own patients, provided hospital care (in addition to seeing outpatients during the day), and followed patients after discharge. Under this model, continuity of care has been preserved; however, this method of care has faltered under the weight of inpatients and outpatients with more severe illnesses, rapid technological advancements, managed care pressuring outpatient physicians to see more patients, and a thrust toward reduced hospital costs and length of stay.16 Increases in the efficiency and quality of hospital care have accompanied a new reliance on the field of hospital medicine, while allowing PCPs to focus on outpatient care.1719 With more than 14,000 hospitalists currently practicing in the United States and 25,000 anticipated to be practicing by 2010, transfer of care from hospital‐based providers to PCPs has become increasingly common at discharge.20

Patient discharge summaries are the most common means of communication between inpatient and outpatient providers. However, numerous studies have shown that discharge summaries often fail to provide important administrative and medical information, such as the primary diagnosis, results of abnormal diagnostics, details about the hospital course, follow‐up plans, whether laboratory test results are pending, and patient or family counseling.14 Summaries also may not arrive in a timely manner and sometimes may not reach the PCP at all.2123

At the time patients first follow up with their PCPs after hospitalization, discharge summaries have not yet arrived about 75% of the time,22, 24, 25 restricting the PCPs' ability to provide adequate follow‐up care in 24% of hospital follow‐up visits, according to one study.26 In another investigation, PCPs reported being unaware of 62% of the pending test results that returned after discharge, of which 37% were considered actionable.27

CHANGES AND DISCREPANCIES IN THE MEDICATION REGIMEN

Medication errors make up a large portion of the adverse events patients may experience in the period following hospital discharge.7 In fact, errors during the ordering of admission or discharge medications make up almost half of all hospital medication errors.4043 At transition points such as admission and discharge, errors are often associated with changes in the medication regimen, including discrepancies between the new set of medication orders and what the patient was taking previously. In 2 recent studies, 54% of patients experienced at least 1 unintended medication discrepancy on admission to the hospital, and 39%‐45% of these discrepancies were considered a potential threat to the patient.44, 45

At discharge, differences between the prescribed medication regimen and the prehospital regimen may exist for several reasons. First, physicians may not obtain a comprehensive and accurate medication history at the time of admission.46 The medication history elicited from the patient at hospital admission is often affected by health literacy, language barriers, current health status, medication‐history interviewing skills, and time constraints.47 Physicians may not consult other important sources of medication information, including family members, prescription lists or bottles, and community pharmacy records. The most common error in the admission medication history is omitting a medication taken at home.46 Additionally, several providers, including a physician, a nurse, and an inpatient pharmacist, may independently take medication histories for the same patient. These multiple accounts lead to discrepancies that are rarely recognized or corrected.

Second, a patient's medication regimen can be significantly altered several times during a hospitalization. Acute illness may cause physicians to hold certain medications, discontinue others, or change prescribed doses during hospitalization.48 In addition, at most hospitals closed drug formularies necessitate automatic substitution of 1 medication for another drug in the same class during the patient's hospital stay.49 Changes from long‐acting to short‐acting medications are also routinely made in the name of tighter control (eg, of blood pressure). One study of hospitalized elders found that 40% of all admission medications had been discontinued by discharge and that 45% of all discharge medications were newly started during the hospitalization.3

Finally, at discharge, the current medication regimen needs to be reconciled with the preadmission medication regimen in a thoughtful manner.2 This includes resuming medications held or modified at admission for clinical reasons, resuming medications that were substituted in the hospital for formulary or pharmacokinetic reasons, and stopping newly started medications that were only required during the hospitalization (eg, for prevention of venous thromboembolism or stress ulcers).50 It is difficult, even in hospitals with advanced electronic health information systems, to prompt physicians to make these necessary changes. In a recent study, unexplained discrepancies between the preadmission medication list and discharge medication orders were noted in 49% of hospital discharges.51 Errors in discharge medication reconciliation may subsequently increase the risk of postdischarge ADEs.51

SELF‐CARE RESPONSIBILITIES AND SOCIAL SUPPORT

Compounding the difficulties at discharge are the economic pressures on our health care system, causing patients to be released from the hospital quicker and sicker than ever before.68 The scope of care provided to patients also undergoes a major shift at discharge. Multidisciplinary providers no longer continually review the health status and needs of patients; instead, patients must follow up with their outpatient physician over a period of days to weeks. In the interim, the patients themselves are responsible for administering new medications, participating in physical therapy, and tracking their own symptoms to see if they are worsening. For many patients, sufficient social and family support is not available to help perform these activities effectively. Unfortunately, hospital personnel often inaccurately assess patients' functional status and overestimate patients' knowledge of required self‐care activities.69

INEFFECTIVE PHYSICIANPATIENT COMMUNICATION

Physicianpatient communication is fundamental to the practice of medicine and is crucially important at discharge. However, several studies have demonstrated a disconnect between physician information giving and patient understanding.76, 9690 When providing instructions, physicians commonly use medical jargon and attempt to cover a wealth of information in a limited amount of time.69, 87 They also tend to rely on verbal instructions and fail to provide supplementary audiovisual materials (eg, educational handouts or videos) that could aid patient comprehension. Physicians may not point out important self‐care tasks that patients should carry out at home. The entire interaction may be rushed or seem rushed. Moreover, when physicians solicit questions from patients, they may only allow for yes/no responses by using statements like Any questions? or Do you have any questions? that make it easy for patients to simply respond, No. The encounter usually comes to an end without true confirmation of a patient's level of understanding or assessment of a patient's ability to perform the self‐care activities and medication management required on returning home.81

Adding to the challenges of effective physicianpatient communication is the large number of adult Americans (more than 90 million) who have limited functional literacy skills.91, 92 Such patients typically have difficulty reading and understanding medical instructions, medication labels, and appointment slips.9396 Not surprisingly, patients with limited literacy skills know less about their chronic illnesses and how to manage their diseases.97 Having low literacy is also linked to increased use of emergency department services, a higher risk of hospitalization, and higher health care costs.9799 Patients with limited English proficiency have similar or even greater challenges and also have longer stays in the hospital.100

CONCLUSIONS

The transition from hospital to home is a vulnerable period of discontinuity and potential adverse events. Hospitalists and other inpatient providers should not view discharge as an end to their obligation to patients but rather should attempt to promote a safe and efficient transition of care. Hospitalists can play an important role in bridging the gap between inpatient and outpatient care through appropriate discharge planning and effective communication with patients, their family members, and outpatient physicians.

As the counterpart to hospital admission, hospital discharge is a necessary process experienced by each living patient. For all patients except those being transferred to a continuing care facility, discharge is a period of transition from hospital to home that involves a transfer in responsibility from the inpatient provider or hospitalist to the patient and primary care physician (PCP).1 Prescription medications are commonly altered at this transition point, with patients asked to discontinue some medications, switch to a new dosage schedule of others, or begin new treatments.2, 3 Self‐care responsibilities also increase in number and importance, presenting new challenges for patients and their families as they return home.4 Under these circumstances, ineffective planning and coordination of care can undermine patient satisfaction, facilitate adverse events, and contribute to more frequent hospital readmissions.58

Following hospital discharge nearly half (49%) of hospitalized patients experience at least 1 medical error in medication continuity, diagnostic workup, or test follow‐up.7 It has been reported that 19%23% of patients suffer an adverse event, most frequently an adverse drug event (ADE).911 Half of ADEs are considered preventable or ameliorable (ie, their severity or duration could have been decreased). Most errors and adverse events in this setting result from a breakdown in communication between the hospital team and the patient or primary care physician.10

To promote more effective care transitions, The Joint Commission now requires accredited facilities to accurately and completely reconcile medications across the continuum of care.12 The Society of Hospital Medicine recently published recommendations for the discharge of elderly patients.13 The joint Society of Hospital MedicineSociety of General Internal Medicine Continuity of Care Task Force also recently published a systematic review with recommendations for improving the handoff of patient information at discharge.14 Apart from these reports, however, it is uncommon to find evidence‐based recommendations for hospital discharge applicable to a broad range of patients.15 This review highlights several important challenges for physicians who seek to provide high‐quality care during hospital discharge and the subsequent period of transition. Based on the best available evidence, recommendations are also provided for how to improve communication and facilitate the care transition for adult inpatients returning home.

INPATIENTOUTPATIENT PHYSICIAN DISCONTINUITY

Traditionally, primary care physicians have admitted their own patients, provided hospital care (in addition to seeing outpatients during the day), and followed patients after discharge. Under this model, continuity of care has been preserved; however, this method of care has faltered under the weight of inpatients and outpatients with more severe illnesses, rapid technological advancements, managed care pressuring outpatient physicians to see more patients, and a thrust toward reduced hospital costs and length of stay.16 Increases in the efficiency and quality of hospital care have accompanied a new reliance on the field of hospital medicine, while allowing PCPs to focus on outpatient care.1719 With more than 14,000 hospitalists currently practicing in the United States and 25,000 anticipated to be practicing by 2010, transfer of care from hospital‐based providers to PCPs has become increasingly common at discharge.20

Patient discharge summaries are the most common means of communication between inpatient and outpatient providers. However, numerous studies have shown that discharge summaries often fail to provide important administrative and medical information, such as the primary diagnosis, results of abnormal diagnostics, details about the hospital course, follow‐up plans, whether laboratory test results are pending, and patient or family counseling.14 Summaries also may not arrive in a timely manner and sometimes may not reach the PCP at all.2123

At the time patients first follow up with their PCPs after hospitalization, discharge summaries have not yet arrived about 75% of the time,22, 24, 25 restricting the PCPs' ability to provide adequate follow‐up care in 24% of hospital follow‐up visits, according to one study.26 In another investigation, PCPs reported being unaware of 62% of the pending test results that returned after discharge, of which 37% were considered actionable.27

CHANGES AND DISCREPANCIES IN THE MEDICATION REGIMEN

Medication errors make up a large portion of the adverse events patients may experience in the period following hospital discharge.7 In fact, errors during the ordering of admission or discharge medications make up almost half of all hospital medication errors.4043 At transition points such as admission and discharge, errors are often associated with changes in the medication regimen, including discrepancies between the new set of medication orders and what the patient was taking previously. In 2 recent studies, 54% of patients experienced at least 1 unintended medication discrepancy on admission to the hospital, and 39%‐45% of these discrepancies were considered a potential threat to the patient.44, 45

At discharge, differences between the prescribed medication regimen and the prehospital regimen may exist for several reasons. First, physicians may not obtain a comprehensive and accurate medication history at the time of admission.46 The medication history elicited from the patient at hospital admission is often affected by health literacy, language barriers, current health status, medication‐history interviewing skills, and time constraints.47 Physicians may not consult other important sources of medication information, including family members, prescription lists or bottles, and community pharmacy records. The most common error in the admission medication history is omitting a medication taken at home.46 Additionally, several providers, including a physician, a nurse, and an inpatient pharmacist, may independently take medication histories for the same patient. These multiple accounts lead to discrepancies that are rarely recognized or corrected.

Second, a patient's medication regimen can be significantly altered several times during a hospitalization. Acute illness may cause physicians to hold certain medications, discontinue others, or change prescribed doses during hospitalization.48 In addition, at most hospitals closed drug formularies necessitate automatic substitution of 1 medication for another drug in the same class during the patient's hospital stay.49 Changes from long‐acting to short‐acting medications are also routinely made in the name of tighter control (eg, of blood pressure). One study of hospitalized elders found that 40% of all admission medications had been discontinued by discharge and that 45% of all discharge medications were newly started during the hospitalization.3

Finally, at discharge, the current medication regimen needs to be reconciled with the preadmission medication regimen in a thoughtful manner.2 This includes resuming medications held or modified at admission for clinical reasons, resuming medications that were substituted in the hospital for formulary or pharmacokinetic reasons, and stopping newly started medications that were only required during the hospitalization (eg, for prevention of venous thromboembolism or stress ulcers).50 It is difficult, even in hospitals with advanced electronic health information systems, to prompt physicians to make these necessary changes. In a recent study, unexplained discrepancies between the preadmission medication list and discharge medication orders were noted in 49% of hospital discharges.51 Errors in discharge medication reconciliation may subsequently increase the risk of postdischarge ADEs.51

SELF‐CARE RESPONSIBILITIES AND SOCIAL SUPPORT

Compounding the difficulties at discharge are the economic pressures on our health care system, causing patients to be released from the hospital quicker and sicker than ever before.68 The scope of care provided to patients also undergoes a major shift at discharge. Multidisciplinary providers no longer continually review the health status and needs of patients; instead, patients must follow up with their outpatient physician over a period of days to weeks. In the interim, the patients themselves are responsible for administering new medications, participating in physical therapy, and tracking their own symptoms to see if they are worsening. For many patients, sufficient social and family support is not available to help perform these activities effectively. Unfortunately, hospital personnel often inaccurately assess patients' functional status and overestimate patients' knowledge of required self‐care activities.69

INEFFECTIVE PHYSICIANPATIENT COMMUNICATION

Physicianpatient communication is fundamental to the practice of medicine and is crucially important at discharge. However, several studies have demonstrated a disconnect between physician information giving and patient understanding.76, 9690 When providing instructions, physicians commonly use medical jargon and attempt to cover a wealth of information in a limited amount of time.69, 87 They also tend to rely on verbal instructions and fail to provide supplementary audiovisual materials (eg, educational handouts or videos) that could aid patient comprehension. Physicians may not point out important self‐care tasks that patients should carry out at home. The entire interaction may be rushed or seem rushed. Moreover, when physicians solicit questions from patients, they may only allow for yes/no responses by using statements like Any questions? or Do you have any questions? that make it easy for patients to simply respond, No. The encounter usually comes to an end without true confirmation of a patient's level of understanding or assessment of a patient's ability to perform the self‐care activities and medication management required on returning home.81

Adding to the challenges of effective physicianpatient communication is the large number of adult Americans (more than 90 million) who have limited functional literacy skills.91, 92 Such patients typically have difficulty reading and understanding medical instructions, medication labels, and appointment slips.9396 Not surprisingly, patients with limited literacy skills know less about their chronic illnesses and how to manage their diseases.97 Having low literacy is also linked to increased use of emergency department services, a higher risk of hospitalization, and higher health care costs.9799 Patients with limited English proficiency have similar or even greater challenges and also have longer stays in the hospital.100

CONCLUSIONS

The transition from hospital to home is a vulnerable period of discontinuity and potential adverse events. Hospitalists and other inpatient providers should not view discharge as an end to their obligation to patients but rather should attempt to promote a safe and efficient transition of care. Hospitalists can play an important role in bridging the gap between inpatient and outpatient care through appropriate discharge planning and effective communication with patients, their family members, and outpatient physicians.