Robert E. Burke, MD

Currently, healthcare systems rarely provide ideal transitions of care for discharged patients,[1] resulting in fragmented care,[2, 3, 4, 5] significant patient uncertainty about how to manage at home,[6, 7] and frequent adverse events.[8, 9] These factors are so commonly experienced by discharged patients that they are recognizable as a postdischarge syndrome.[10]

One element important for reducing the postdischarge risk of adverse events is provision of adequate follow‐up.[11, 12] However, supplying this care is challenging in the modern era, and it will become progressively more difficult to achieve. In 2004, 50% of readmitted Medicare fee‐for‐service patients had no postdischarge visit within 30 days of their discharge,[9] likely due in part to difficulty arranging such care. Changes in insurance coverage and demographics are expected to result in more than 100 million newly insured patients by 2019, yet the primary‐care workforce is projected to begin shrinking by 2016.[13, 14] In the increasingly uncommon situation that a primary‐care clinician is available promptly after discharge, information transfer is often inadequate[4, 15, 16, 17] and can be exacerbated by the growing discontinuity between inpatient and outpatient care.[2, 3, 4] Efforts to increase the supply of primary‐care clinicians and thereby improve early access to postdischarge care are important for the future, but hospitals, particularly those penalized for high risk‐adjusted readmission rates, are seeking novel solutions now.

One increasingly common innovation is to extend the role of inpatient providers (usually hospitalists) into the postdischarge period.[18] Preliminary evidence suggests improved continuity[19] and access[20] achieved by providing this care may decrease postdischarge adverse events,[19, 20, 21] though evidence is conflicting.[22]

As a closed, multilevel healthcare system, the Denver VA Medical Center is uniquely positioned to evaluate the influence of alternative postdischarge‐care strategies on subsequent adverse events. Discharged patients are seen in a well‐established hospitalist‐run postdischarge clinic (PDC), a robust urgent‐care system (UC), or by a large primary‐care provider (PCP) practice. The purpose of this study was to evaluate whether patients seen in a hospitalist‐run PDC have reduced adverse outcomes in the 30 days following hospital discharge compared with follow‐up with the patient's PCP or in an UC clinic.

METHODS

RESULTS

9952 patients who met criteria were discharged during this time period; however, 48.9% did not follow up with one of these clinics within 30 days, leaving 5085 patients in our analysis. Of these, 538 followed up in PDC (10.6%), 1848 followed up with their PCP (36.3%), and 2699 followed up in UC (53.1%). Table 1 presents predischarge characteristics of these patients. Patients seen in PDC were older and had a more significant comorbidity burden.

Patients seen in PDC had a mean 2.4‐day shorter LOS than those seen by their PCPs (PDC: 3.8 days, UC: 5.0 days, PCP: 6.2 days; P=0.04 for comparison). Neither the percentage of patients admitted to the ICU during their index hospitalization nor the ICU LOS was different between groups. Patients were seen earlier postdischarge in PDC than in other types of follow‐up (PDC: 5.0 days, UC: 9.4 days, PCP: 13.7 days; P<0.01 for comparison). In univariate analysis, there was no difference between groups in the composite 30‐day outcome (Table 2). Analysis of the individual components of the primary outcome revealed significant differences in readmission rates, with PDC having the highest rate.

Univariate analyses conducted on predischarge characteristics after multinomial propensity scoring revealed significant differences between groups no longer existed for the variables that were included in the propensity score (age, Elixhauser score, and inpatient stays prior to visit; Table 1).

In multivariate analysis comparing PDC to PCP follow‐up, there was no difference in the composite outcome after controlling for propensity score and time to outpatient visit (odds ratio [OR]: 1.07, 95% confidence interval [CI]: 0.81‐1.40). Similar results were obtained in comparing PDC with UC (OR: 1.05, 95% CI: 0.82‐1.34) and in multinomial logistic regression comparing PDC with other types of follow‐up (PDC vs PCP: OR: 1.01, 95% CI: 0.78‐1.31; PDC vs UC: OR: 0.99, 95% CI: 0.78‐1.26).

Restricting the multivariate analysis to those patients discharged with one of the 5 discharge DRGs most associated with readmission did not alter our findings regarding the primary outcome. We also found no change in the composite outcome or any subcomponent of the composite outcome when restricting the analysis to 7‐day outcomes or when excluding scheduled readmissions (which represented <5% of all readmission).

DISCUSSION

A hospitalist‐run postdischarge clinic did not reduce a composite of 30‐day postdischarge adverse outcomes in our study when compared with primary‐care or urgent‐care follow‐up. In fact, patients who followed up in PDC had a small increase in 30‐day readmissions. However, they also were sicker at baseline, considered higher risk by the discharging physician, were able to be seen significantly earlier, and had an associated 2.4‐day shorter hospital LOS than patients seen by their PCPs.

Our findings do not confirm those of prior research in this area, which indicated outpatient follow‐up by the same physician who was the treating inpatient physician was linked to lower mortality rates, hospital readmissions, and ED utilization.[19, 20, 21] In fact, in our study, there was a significant (albeit small) increase in 30‐day readmissions in patients seen in PDC. There are significant challenges to the generalizability and validity of these prior studies. In one study, inpatient care was provided by outpatient primary‐care doctors in Canada,[19] a payer and care model rare in the United States.[25] In a second, usual care was not specified, and it is likely the reduction in ED visits resulted from provision of follow‐up care of any kind compared with those who did not follow up after discharge.[20] In a third, the PDC was part of a larger bundle of postdischarge interventions, and it only reduced ED visits when compared with patients who did not have follow‐up; rates of ED visits were similar in a comparison with PCP follow‐up.[21]

There are several possible explanations for the lack of improvement in 30‐day adverse outcomes with a hospitalist‐run PDC. First, although early access to early postdischarge care was improved and evidence suggests this is important in reducing readmissions,[11, 12] in populations similar to that studied, more postdischarge care has also been linked to increased readmissions.[22] This may be due to more frequent re‐evaluation of fragile, chronically ill patients, presenting more options for readmission. Second, the intervention currently only addresses some components of the Ideal Transition of Care[1] (Figure 1) and may benefit from an enhanced visit structure using a multidisciplinary approach. Third, the intervention took place in the context of a robust primary‐care system with a universal electronic medical record; the effects of improved access and continuity may be magnified in a system without these advantages. Fourth, there was a low readmission rate overall, and it is unclear how many of these readmissions were preventable. Finally, it may be that although the initial postdischarge care was adequate, readmissions occurred after the first visit, suggesting subsequent care during the 30 days postdischarge could have been improved.

Figure 1

The most likely explanation for the substantially decreased LOS associated with follow‐up in PDC is that inpatient physicians who knew they could see their own patients early in the postdischarge process were more tolerant of uncertainty surrounding the patients' clinical course.

For example, a frequent clinical conundrum for hospitalists is when to discharge patients improving on diuretic therapy for a heart failure exacerbation or antibiotics for cellulitis. Provided a PDC, these hospitalists may choose to discharge a patient still actively being treated, because they may feel they have access to early follow‐up to change course if needed as well as the ability to see the patient themselves, allowing precise evaluation of the change in their condition. Without this clinic, the hospitalist may wonder when postdischarge follow‐up will occur. They may be more hesitant to discharge a patient who has not fully completed treatment for fear he or she will still appear decompensated to the postdischarge provider (though greatly improved from admission), or will not have timely‐enough follow‐up to change treatment if the condition worsens.

Our finding that the LOS was still shorter when comparing PDC with UC suggests continuity may be a significant component of this effect. It seems unlikely that patients following up in PDC had less complex hospitalizations given similar ICU exposure and LOS, as well as older age and larger baseline comorbidity burden.

The LOS seen in patients who followed up in PDC was lower than Medicare rates[26] but similar to reported rates at other VA acute‐care hospitals.[27] It is consistent with prior findings that hospitalist care reduces LOS,[26] though the magnitude in our study was much larger than that in prior reports. Prior studies have suggested this decreased LOS is linked to increased adverse postdischarge outcomes, such as ED visits and readmissions, as well as increased costs and decreased discharges to home.[28] The PDC was not associated with increased postdischarge adverse events measured, though a formal cost analysis and analysis of other postdischarge outcomes, such as placement in a skilled nursing or rehabilitation facility after return home, could be assessed in future work.

The findings of our study should be interpreted in the context of the study design. Our study was retrospective, observational, and single‐center. There may have been additional baseline differences between groups predisposing to bias we did not capture in the propensity score. For example, we could not measure rates of attendance at the different clinics and cannot rule out that outcomes associated with PDC were also associated with increased attendance rates. However, none of the clinics had mechanisms in place to improve follow‐up rates; patients referred to PDC were those considered highest risk for readmission and were sicker at baseline, making it very unlikely that they were predisposed to attend clinic more frequently and/or to have better outcomes; and even if PDC improved follow‐up rates, this would be a significant contribution given the limitations of primary‐care access. Our propensity score could not perfectly mimic randomization to a treatment assignment, but rather to treatment received, because of this limitation.

We did not ascertain ED visits or readmissions outside the VA system; it is possible these differentially affected one group more than another, though this seems unlikely. Our patient population was representative of veteran populations elsewhere who are at high risk of adverse postdischarge outcomes, but our findings may not be generalizable to younger, more ethnically diverse populations or to women.

CONCLUSIONS

Provision of postdischarge care by hospitalists may reduce LOS without increasing postdischarge adverse events. Further work is required to evaluate the role of hospitalist‐run PDCs in healthcare systems with more limited postdischarge access to care, to formally evaluate the costs associated with extending hospitalists to the outpatient setting, and to prospectively evaluate the role of a PDC compared with other kinds of hospital follow‐up.

Currently, healthcare systems rarely provide ideal transitions of care for discharged patients,[1] resulting in fragmented care,[2, 3, 4, 5] significant patient uncertainty about how to manage at home,[6, 7] and frequent adverse events.[8, 9] These factors are so commonly experienced by discharged patients that they are recognizable as a postdischarge syndrome.[10]

One element important for reducing the postdischarge risk of adverse events is provision of adequate follow‐up.[11, 12] However, supplying this care is challenging in the modern era, and it will become progressively more difficult to achieve. In 2004, 50% of readmitted Medicare fee‐for‐service patients had no postdischarge visit within 30 days of their discharge,[9] likely due in part to difficulty arranging such care. Changes in insurance coverage and demographics are expected to result in more than 100 million newly insured patients by 2019, yet the primary‐care workforce is projected to begin shrinking by 2016.[13, 14] In the increasingly uncommon situation that a primary‐care clinician is available promptly after discharge, information transfer is often inadequate[4, 15, 16, 17] and can be exacerbated by the growing discontinuity between inpatient and outpatient care.[2, 3, 4] Efforts to increase the supply of primary‐care clinicians and thereby improve early access to postdischarge care are important for the future, but hospitals, particularly those penalized for high risk‐adjusted readmission rates, are seeking novel solutions now.

One increasingly common innovation is to extend the role of inpatient providers (usually hospitalists) into the postdischarge period.[18] Preliminary evidence suggests improved continuity[19] and access[20] achieved by providing this care may decrease postdischarge adverse events,[19, 20, 21] though evidence is conflicting.[22]

As a closed, multilevel healthcare system, the Denver VA Medical Center is uniquely positioned to evaluate the influence of alternative postdischarge‐care strategies on subsequent adverse events. Discharged patients are seen in a well‐established hospitalist‐run postdischarge clinic (PDC), a robust urgent‐care system (UC), or by a large primary‐care provider (PCP) practice. The purpose of this study was to evaluate whether patients seen in a hospitalist‐run PDC have reduced adverse outcomes in the 30 days following hospital discharge compared with follow‐up with the patient's PCP or in an UC clinic.

METHODS

RESULTS

9952 patients who met criteria were discharged during this time period; however, 48.9% did not follow up with one of these clinics within 30 days, leaving 5085 patients in our analysis. Of these, 538 followed up in PDC (10.6%), 1848 followed up with their PCP (36.3%), and 2699 followed up in UC (53.1%). Table 1 presents predischarge characteristics of these patients. Patients seen in PDC were older and had a more significant comorbidity burden.

Patients seen in PDC had a mean 2.4‐day shorter LOS than those seen by their PCPs (PDC: 3.8 days, UC: 5.0 days, PCP: 6.2 days; P=0.04 for comparison). Neither the percentage of patients admitted to the ICU during their index hospitalization nor the ICU LOS was different between groups. Patients were seen earlier postdischarge in PDC than in other types of follow‐up (PDC: 5.0 days, UC: 9.4 days, PCP: 13.7 days; P<0.01 for comparison). In univariate analysis, there was no difference between groups in the composite 30‐day outcome (Table 2). Analysis of the individual components of the primary outcome revealed significant differences in readmission rates, with PDC having the highest rate.

Univariate analyses conducted on predischarge characteristics after multinomial propensity scoring revealed significant differences between groups no longer existed for the variables that were included in the propensity score (age, Elixhauser score, and inpatient stays prior to visit; Table 1).

In multivariate analysis comparing PDC to PCP follow‐up, there was no difference in the composite outcome after controlling for propensity score and time to outpatient visit (odds ratio [OR]: 1.07, 95% confidence interval [CI]: 0.81‐1.40). Similar results were obtained in comparing PDC with UC (OR: 1.05, 95% CI: 0.82‐1.34) and in multinomial logistic regression comparing PDC with other types of follow‐up (PDC vs PCP: OR: 1.01, 95% CI: 0.78‐1.31; PDC vs UC: OR: 0.99, 95% CI: 0.78‐1.26).

Restricting the multivariate analysis to those patients discharged with one of the 5 discharge DRGs most associated with readmission did not alter our findings regarding the primary outcome. We also found no change in the composite outcome or any subcomponent of the composite outcome when restricting the analysis to 7‐day outcomes or when excluding scheduled readmissions (which represented <5% of all readmission).

DISCUSSION

A hospitalist‐run postdischarge clinic did not reduce a composite of 30‐day postdischarge adverse outcomes in our study when compared with primary‐care or urgent‐care follow‐up. In fact, patients who followed up in PDC had a small increase in 30‐day readmissions. However, they also were sicker at baseline, considered higher risk by the discharging physician, were able to be seen significantly earlier, and had an associated 2.4‐day shorter hospital LOS than patients seen by their PCPs.

Our findings do not confirm those of prior research in this area, which indicated outpatient follow‐up by the same physician who was the treating inpatient physician was linked to lower mortality rates, hospital readmissions, and ED utilization.[19, 20, 21] In fact, in our study, there was a significant (albeit small) increase in 30‐day readmissions in patients seen in PDC. There are significant challenges to the generalizability and validity of these prior studies. In one study, inpatient care was provided by outpatient primary‐care doctors in Canada,[19] a payer and care model rare in the United States.[25] In a second, usual care was not specified, and it is likely the reduction in ED visits resulted from provision of follow‐up care of any kind compared with those who did not follow up after discharge.[20] In a third, the PDC was part of a larger bundle of postdischarge interventions, and it only reduced ED visits when compared with patients who did not have follow‐up; rates of ED visits were similar in a comparison with PCP follow‐up.[21]

There are several possible explanations for the lack of improvement in 30‐day adverse outcomes with a hospitalist‐run PDC. First, although early access to early postdischarge care was improved and evidence suggests this is important in reducing readmissions,[11, 12] in populations similar to that studied, more postdischarge care has also been linked to increased readmissions.[22] This may be due to more frequent re‐evaluation of fragile, chronically ill patients, presenting more options for readmission. Second, the intervention currently only addresses some components of the Ideal Transition of Care[1] (Figure 1) and may benefit from an enhanced visit structure using a multidisciplinary approach. Third, the intervention took place in the context of a robust primary‐care system with a universal electronic medical record; the effects of improved access and continuity may be magnified in a system without these advantages. Fourth, there was a low readmission rate overall, and it is unclear how many of these readmissions were preventable. Finally, it may be that although the initial postdischarge care was adequate, readmissions occurred after the first visit, suggesting subsequent care during the 30 days postdischarge could have been improved.

Figure 1

The most likely explanation for the substantially decreased LOS associated with follow‐up in PDC is that inpatient physicians who knew they could see their own patients early in the postdischarge process were more tolerant of uncertainty surrounding the patients' clinical course.

For example, a frequent clinical conundrum for hospitalists is when to discharge patients improving on diuretic therapy for a heart failure exacerbation or antibiotics for cellulitis. Provided a PDC, these hospitalists may choose to discharge a patient still actively being treated, because they may feel they have access to early follow‐up to change course if needed as well as the ability to see the patient themselves, allowing precise evaluation of the change in their condition. Without this clinic, the hospitalist may wonder when postdischarge follow‐up will occur. They may be more hesitant to discharge a patient who has not fully completed treatment for fear he or she will still appear decompensated to the postdischarge provider (though greatly improved from admission), or will not have timely‐enough follow‐up to change treatment if the condition worsens.

Our finding that the LOS was still shorter when comparing PDC with UC suggests continuity may be a significant component of this effect. It seems unlikely that patients following up in PDC had less complex hospitalizations given similar ICU exposure and LOS, as well as older age and larger baseline comorbidity burden.

The LOS seen in patients who followed up in PDC was lower than Medicare rates[26] but similar to reported rates at other VA acute‐care hospitals.[27] It is consistent with prior findings that hospitalist care reduces LOS,[26] though the magnitude in our study was much larger than that in prior reports. Prior studies have suggested this decreased LOS is linked to increased adverse postdischarge outcomes, such as ED visits and readmissions, as well as increased costs and decreased discharges to home.[28] The PDC was not associated with increased postdischarge adverse events measured, though a formal cost analysis and analysis of other postdischarge outcomes, such as placement in a skilled nursing or rehabilitation facility after return home, could be assessed in future work.

The findings of our study should be interpreted in the context of the study design. Our study was retrospective, observational, and single‐center. There may have been additional baseline differences between groups predisposing to bias we did not capture in the propensity score. For example, we could not measure rates of attendance at the different clinics and cannot rule out that outcomes associated with PDC were also associated with increased attendance rates. However, none of the clinics had mechanisms in place to improve follow‐up rates; patients referred to PDC were those considered highest risk for readmission and were sicker at baseline, making it very unlikely that they were predisposed to attend clinic more frequently and/or to have better outcomes; and even if PDC improved follow‐up rates, this would be a significant contribution given the limitations of primary‐care access. Our propensity score could not perfectly mimic randomization to a treatment assignment, but rather to treatment received, because of this limitation.

We did not ascertain ED visits or readmissions outside the VA system; it is possible these differentially affected one group more than another, though this seems unlikely. Our patient population was representative of veteran populations elsewhere who are at high risk of adverse postdischarge outcomes, but our findings may not be generalizable to younger, more ethnically diverse populations or to women.

CONCLUSIONS

Provision of postdischarge care by hospitalists may reduce LOS without increasing postdischarge adverse events. Further work is required to evaluate the role of hospitalist‐run PDCs in healthcare systems with more limited postdischarge access to care, to formally evaluate the costs associated with extending hospitalists to the outpatient setting, and to prospectively evaluate the role of a PDC compared with other kinds of hospital follow‐up.

Currently, healthcare systems rarely provide ideal transitions of care for discharged patients,[1] resulting in fragmented care,[2, 3, 4, 5] significant patient uncertainty about how to manage at home,[6, 7] and frequent adverse events.[8, 9] These factors are so commonly experienced by discharged patients that they are recognizable as a postdischarge syndrome.[10]

One element important for reducing the postdischarge risk of adverse events is provision of adequate follow‐up.[11, 12] However, supplying this care is challenging in the modern era, and it will become progressively more difficult to achieve. In 2004, 50% of readmitted Medicare fee‐for‐service patients had no postdischarge visit within 30 days of their discharge,[9] likely due in part to difficulty arranging such care. Changes in insurance coverage and demographics are expected to result in more than 100 million newly insured patients by 2019, yet the primary‐care workforce is projected to begin shrinking by 2016.[13, 14] In the increasingly uncommon situation that a primary‐care clinician is available promptly after discharge, information transfer is often inadequate[4, 15, 16, 17] and can be exacerbated by the growing discontinuity between inpatient and outpatient care.[2, 3, 4] Efforts to increase the supply of primary‐care clinicians and thereby improve early access to postdischarge care are important for the future, but hospitals, particularly those penalized for high risk‐adjusted readmission rates, are seeking novel solutions now.

One increasingly common innovation is to extend the role of inpatient providers (usually hospitalists) into the postdischarge period.[18] Preliminary evidence suggests improved continuity[19] and access[20] achieved by providing this care may decrease postdischarge adverse events,[19, 20, 21] though evidence is conflicting.[22]

As a closed, multilevel healthcare system, the Denver VA Medical Center is uniquely positioned to evaluate the influence of alternative postdischarge‐care strategies on subsequent adverse events. Discharged patients are seen in a well‐established hospitalist‐run postdischarge clinic (PDC), a robust urgent‐care system (UC), or by a large primary‐care provider (PCP) practice. The purpose of this study was to evaluate whether patients seen in a hospitalist‐run PDC have reduced adverse outcomes in the 30 days following hospital discharge compared with follow‐up with the patient's PCP or in an UC clinic.

METHODS

RESULTS

9952 patients who met criteria were discharged during this time period; however, 48.9% did not follow up with one of these clinics within 30 days, leaving 5085 patients in our analysis. Of these, 538 followed up in PDC (10.6%), 1848 followed up with their PCP (36.3%), and 2699 followed up in UC (53.1%). Table 1 presents predischarge characteristics of these patients. Patients seen in PDC were older and had a more significant comorbidity burden.

Patients seen in PDC had a mean 2.4‐day shorter LOS than those seen by their PCPs (PDC: 3.8 days, UC: 5.0 days, PCP: 6.2 days; P=0.04 for comparison). Neither the percentage of patients admitted to the ICU during their index hospitalization nor the ICU LOS was different between groups. Patients were seen earlier postdischarge in PDC than in other types of follow‐up (PDC: 5.0 days, UC: 9.4 days, PCP: 13.7 days; P<0.01 for comparison). In univariate analysis, there was no difference between groups in the composite 30‐day outcome (Table 2). Analysis of the individual components of the primary outcome revealed significant differences in readmission rates, with PDC having the highest rate.

Univariate analyses conducted on predischarge characteristics after multinomial propensity scoring revealed significant differences between groups no longer existed for the variables that were included in the propensity score (age, Elixhauser score, and inpatient stays prior to visit; Table 1).

In multivariate analysis comparing PDC to PCP follow‐up, there was no difference in the composite outcome after controlling for propensity score and time to outpatient visit (odds ratio [OR]: 1.07, 95% confidence interval [CI]: 0.81‐1.40). Similar results were obtained in comparing PDC with UC (OR: 1.05, 95% CI: 0.82‐1.34) and in multinomial logistic regression comparing PDC with other types of follow‐up (PDC vs PCP: OR: 1.01, 95% CI: 0.78‐1.31; PDC vs UC: OR: 0.99, 95% CI: 0.78‐1.26).

Restricting the multivariate analysis to those patients discharged with one of the 5 discharge DRGs most associated with readmission did not alter our findings regarding the primary outcome. We also found no change in the composite outcome or any subcomponent of the composite outcome when restricting the analysis to 7‐day outcomes or when excluding scheduled readmissions (which represented <5% of all readmission).

DISCUSSION

A hospitalist‐run postdischarge clinic did not reduce a composite of 30‐day postdischarge adverse outcomes in our study when compared with primary‐care or urgent‐care follow‐up. In fact, patients who followed up in PDC had a small increase in 30‐day readmissions. However, they also were sicker at baseline, considered higher risk by the discharging physician, were able to be seen significantly earlier, and had an associated 2.4‐day shorter hospital LOS than patients seen by their PCPs.

Our findings do not confirm those of prior research in this area, which indicated outpatient follow‐up by the same physician who was the treating inpatient physician was linked to lower mortality rates, hospital readmissions, and ED utilization.[19, 20, 21] In fact, in our study, there was a significant (albeit small) increase in 30‐day readmissions in patients seen in PDC. There are significant challenges to the generalizability and validity of these prior studies. In one study, inpatient care was provided by outpatient primary‐care doctors in Canada,[19] a payer and care model rare in the United States.[25] In a second, usual care was not specified, and it is likely the reduction in ED visits resulted from provision of follow‐up care of any kind compared with those who did not follow up after discharge.[20] In a third, the PDC was part of a larger bundle of postdischarge interventions, and it only reduced ED visits when compared with patients who did not have follow‐up; rates of ED visits were similar in a comparison with PCP follow‐up.[21]

There are several possible explanations for the lack of improvement in 30‐day adverse outcomes with a hospitalist‐run PDC. First, although early access to early postdischarge care was improved and evidence suggests this is important in reducing readmissions,[11, 12] in populations similar to that studied, more postdischarge care has also been linked to increased readmissions.[22] This may be due to more frequent re‐evaluation of fragile, chronically ill patients, presenting more options for readmission. Second, the intervention currently only addresses some components of the Ideal Transition of Care[1] (Figure 1) and may benefit from an enhanced visit structure using a multidisciplinary approach. Third, the intervention took place in the context of a robust primary‐care system with a universal electronic medical record; the effects of improved access and continuity may be magnified in a system without these advantages. Fourth, there was a low readmission rate overall, and it is unclear how many of these readmissions were preventable. Finally, it may be that although the initial postdischarge care was adequate, readmissions occurred after the first visit, suggesting subsequent care during the 30 days postdischarge could have been improved.

Figure 1

The most likely explanation for the substantially decreased LOS associated with follow‐up in PDC is that inpatient physicians who knew they could see their own patients early in the postdischarge process were more tolerant of uncertainty surrounding the patients' clinical course.

For example, a frequent clinical conundrum for hospitalists is when to discharge patients improving on diuretic therapy for a heart failure exacerbation or antibiotics for cellulitis. Provided a PDC, these hospitalists may choose to discharge a patient still actively being treated, because they may feel they have access to early follow‐up to change course if needed as well as the ability to see the patient themselves, allowing precise evaluation of the change in their condition. Without this clinic, the hospitalist may wonder when postdischarge follow‐up will occur. They may be more hesitant to discharge a patient who has not fully completed treatment for fear he or she will still appear decompensated to the postdischarge provider (though greatly improved from admission), or will not have timely‐enough follow‐up to change treatment if the condition worsens.

Our finding that the LOS was still shorter when comparing PDC with UC suggests continuity may be a significant component of this effect. It seems unlikely that patients following up in PDC had less complex hospitalizations given similar ICU exposure and LOS, as well as older age and larger baseline comorbidity burden.

The LOS seen in patients who followed up in PDC was lower than Medicare rates[26] but similar to reported rates at other VA acute‐care hospitals.[27] It is consistent with prior findings that hospitalist care reduces LOS,[26] though the magnitude in our study was much larger than that in prior reports. Prior studies have suggested this decreased LOS is linked to increased adverse postdischarge outcomes, such as ED visits and readmissions, as well as increased costs and decreased discharges to home.[28] The PDC was not associated with increased postdischarge adverse events measured, though a formal cost analysis and analysis of other postdischarge outcomes, such as placement in a skilled nursing or rehabilitation facility after return home, could be assessed in future work.

The findings of our study should be interpreted in the context of the study design. Our study was retrospective, observational, and single‐center. There may have been additional baseline differences between groups predisposing to bias we did not capture in the propensity score. For example, we could not measure rates of attendance at the different clinics and cannot rule out that outcomes associated with PDC were also associated with increased attendance rates. However, none of the clinics had mechanisms in place to improve follow‐up rates; patients referred to PDC were those considered highest risk for readmission and were sicker at baseline, making it very unlikely that they were predisposed to attend clinic more frequently and/or to have better outcomes; and even if PDC improved follow‐up rates, this would be a significant contribution given the limitations of primary‐care access. Our propensity score could not perfectly mimic randomization to a treatment assignment, but rather to treatment received, because of this limitation.

We did not ascertain ED visits or readmissions outside the VA system; it is possible these differentially affected one group more than another, though this seems unlikely. Our patient population was representative of veteran populations elsewhere who are at high risk of adverse postdischarge outcomes, but our findings may not be generalizable to younger, more ethnically diverse populations or to women.

CONCLUSIONS

Provision of postdischarge care by hospitalists may reduce LOS without increasing postdischarge adverse events. Further work is required to evaluate the role of hospitalist‐run PDCs in healthcare systems with more limited postdischarge access to care, to formally evaluate the costs associated with extending hospitalists to the outpatient setting, and to prospectively evaluate the role of a PDC compared with other kinds of hospital follow‐up.

Transitions of care, which encompass the patient experience of hospital discharge to the community, are frequently associated with clinically and financially costly adverse events.[1, 2] One important element for reducing the risk of postdischarge adverse events is provision of timely follow‐up by a clinician familiar with the patient and hospital course.[3, 4]

However, achieving this ideal is becoming more difficult because of an increased demand for primary care services (due to expanding coverage of Medicare and Medicaid) and the decreased supply of primary care physicians.[5, 6] When a timely visit with a clinician is available postdischarge, the widening discontinuity between inpatient and outpatient care providers often means this clinician is lacking essential details of the hospitalization.[7, 8]

One increasingly common innovation to improve postdischarge care access and continuity is to extend the role of inpatient providers (usually hospitalists) to provide care after discharge in a postdischarge clinic (PDC).[9, 10, 11] These clinics require an expansion of a hospitalist's duties to the outpatient setting, a requirement that has met with hospitalist resistance in initial reports.[12] However, little is known about hospitalists' experience with PDCs or attitudes toward postdischarge care. We aimed to explore these attitudes and experiences surrounding postdischarge care and PDCs.

METHODS

We conducted a cross‐sectional 17‐question Web‐based survey of hospitalists at 20 academic and 17 VA medical centers across the United States. Hospital medicine faculty at each site were identified by their group leader; members of each group then received an email survey up to 3 times. To collect responses from nonacademic hospitalists, the survey was also distributed to a large national private hospitalist employer. Due to internal limitations at the employer site, sampling was not feasible, and thus a convenience sample was obtained. Hospitalists who were not clinically active or did not have computer access to complete the survey were excluded. Responses were initially gathered on a 4‐point Likert scale; for comparisons between groups the scale was collapsed to a binary comparison using Fisher exact or ² tests. We included questions answered in partially completed surveys in both the numerator and denominator; questions not answered were excluded from both numerator and denominator. The denominator of all responses was noted. All analyses were conducted using SAS 9.3 (SAS Institute, Inc., Cary, NC). The study was approved by the Colorado Multiple Institutional Review Board.

RESULTS

Of 814 hospitalists, 228 responded to the survey (28.3%). Table 1 illustrates characteristics of responding hospitalists, who were divided between university hospitals, community teaching hospitals, and community nonteaching hospitals in diverse practices in terms of location and group size.

Sixty‐one percent of responding hospitalists believed most patient problems after discharge were due to poor follow‐up with primary care providers, and 55% found it difficult to arrange timely primary care follow up (Table 2). Despite this, 87% thought patient problems after discharge should be cared for by primary care physicians, and 62% opposed the idea of hospitalists seeing patients in the clinic after discharge.

When asked if hospitalists were responsible for patients after discharge from the hospital, only 50% responded positively. However, when asked how long hospitalists were responsible for patients after discharge, 71% gave a response longer than hospital discharge, including 60% who believed this responsibility ended at 1 week or less following discharge. A minority (12%) felt it extended to 1 month following discharge (Table 3).

Responding hospitalists expressed confidence in a PDC to reduce postdischarge emergency department visits (74%). However, most felt they would require extra compensation to staff a PDC (77%). They were divided on whether they would discharge patients from the hospital earlier if they could see those patients in postdischarge follow‐up (51% would discharge patients earlier).

Compared to those who had not experienced a PDC, responding hospitalists who had provided care in a PDC trended toward responding more positively that hospitalists should provide postdischarge care (P = 0.054). Few responding hospitalists had such exposure (8.8%) at the time of the survey. Although 31% had considering starting a PDC, only 3% were starting in the next year. Of responding hospitalists with exposure to a PDC, 70% were satisfied with the experience and 85% felt their patients were satisfied. Responses did not vary by type of practice (academic vs nonacademic), group size, geographic location, or by exposure to a PDC except as above.

DISCUSSION

Responding hospitalists reported encountering significant difficulty arranging appropriate postdischarge appointments with primary care providers and feel this contributes to postdischarge complications. Nearly 75% of those surveyed felt a hospitalist‐run PDC would be effective in reducing postdischarge emergency department visits, presumably in part due to improved access to postdischarge care. However, 62% of responding hospitalists opposed providing this type of care, though those who had experienced a PDC were somewhat more likely to view providing care in a PDC favorably. Survey responses largely reflect attitudes rather than experience with PDCs, because very few respondents had ever worked in a PDC.

The juxtaposition of the confidence expressed in PDCs to reduce postdischarge emergency department visits with the less enthusiastic views of respondents about providing care in a PDC was surprising. Several explanations are possible. First, providing such care is outside the usual scope of practice of most hospitalists, and preliminary reports indicate hospitalists, as self‐selected inpatient providers, may not initially welcome this opportunity.[12] Second, responding hospitalists identified the need for extra compensation for providing this care, suggesting they would see staffing a PDC as a burden requiring extra payment. Third, only 12% of respondents felt their responsibility to their discharged patients extended to 1 month following discharge. Given this, hospitalists may not feel enough personal ownership over 30‐day readmission rates to justify the additional clinical demand of staffing a PDC.[13]

In fact, 29% of responding hospitalists felt their responsibility to the patient ended at the time of discharge. Respondents may have interpreted responsibility differently, and we cannot rule out response bias given our lower‐than‐expected response rate. However, we had anticipated many fewer hospitalists would respond this way given professional hospitalist societies have endorsed guidelines for improved transitions of care, which clearly delineate the key role hospitalists play in care transitions.[14]

Although fewer than 10% of respondents had worked in a PDC, nearly one‐third reported considering starting such a practice in the future, underscoring the importance of understanding hospitalist attitudes and experiences when creating a PDC and the significant barriers to arranging appropriate postdischarge care identified by survey respondents. The barriers to establishing a PDC may explain why few planned to start a PDC in the next year.

This study should be interpreted in the context of its design. Due to limitations in survey delivery, more rigorous sampling designs could not be used, and efforts were instead made to deliver the survey to a diverse group of hospitalists. The survey response rate was lower than anticipated and this increases the risk of response bias. Though this response rate is characteristic of other surveys of hospitalists, responses may have been from a selected population and therefore not representative of all hospitalists.[15] We sampled from a variety of practice venues, locations, academic and community practices, and practice group sizes to try to minimize this bias. Due to the low exposure rate to PDCs, hospitalist responses to experiences with PDCs should be considered exploratory.

We asked about similar content areas in the survey in multiple questions to maximize content validity; this resulted in variations in the degree of agreement or disagreement to similar prompts. For example, 62% of hospitalists opposed seeing patients in the clinic after discharge when directly asked, but nearly 50% said they would welcome the opportunity to work in a PDC if their employer required it. In another example, 50% of respondents said their responsibility for the patient ended at time of discharge, but when asked about duration of responsibility, 30% identified time of discharge as the limit. When reporting and interpreting results, we have tried to highlight responses to questions that ask most clearly and directly about the content of interest (rather than general themes), but this interpretation may also be subject to bias.

The time after hospital discharge is one of heightened risk for adverse events for the recently discharged patient. Hospitalist‐run postdischarge clinics may offer improved postdischarge care access and continuity; more research is needed on the effects of such clinics on patient outcomes, including postdischarge utilization. Until then, physicians and hospitals considering establishing PDCs should consider the barriers responding hospitalists identified to working in such a clinic, as well as the confidence they expressed in PDCs to reduce subsequent utilization.

Disclosures: Dr. Burke had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. Dr. Burke was supported by grant funding from the Colorado Research Enhancement Award Program to Improve Care Coordination for Veterans. Dr. Ryan has no conflicts of interest to disclose.

Transitions of care, which encompass the patient experience of hospital discharge to the community, are frequently associated with clinically and financially costly adverse events.[1, 2] One important element for reducing the risk of postdischarge adverse events is provision of timely follow‐up by a clinician familiar with the patient and hospital course.[3, 4]

However, achieving this ideal is becoming more difficult because of an increased demand for primary care services (due to expanding coverage of Medicare and Medicaid) and the decreased supply of primary care physicians.[5, 6] When a timely visit with a clinician is available postdischarge, the widening discontinuity between inpatient and outpatient care providers often means this clinician is lacking essential details of the hospitalization.[7, 8]

One increasingly common innovation to improve postdischarge care access and continuity is to extend the role of inpatient providers (usually hospitalists) to provide care after discharge in a postdischarge clinic (PDC).[9, 10, 11] These clinics require an expansion of a hospitalist's duties to the outpatient setting, a requirement that has met with hospitalist resistance in initial reports.[12] However, little is known about hospitalists' experience with PDCs or attitudes toward postdischarge care. We aimed to explore these attitudes and experiences surrounding postdischarge care and PDCs.

METHODS

We conducted a cross‐sectional 17‐question Web‐based survey of hospitalists at 20 academic and 17 VA medical centers across the United States. Hospital medicine faculty at each site were identified by their group leader; members of each group then received an email survey up to 3 times. To collect responses from nonacademic hospitalists, the survey was also distributed to a large national private hospitalist employer. Due to internal limitations at the employer site, sampling was not feasible, and thus a convenience sample was obtained. Hospitalists who were not clinically active or did not have computer access to complete the survey were excluded. Responses were initially gathered on a 4‐point Likert scale; for comparisons between groups the scale was collapsed to a binary comparison using Fisher exact or ² tests. We included questions answered in partially completed surveys in both the numerator and denominator; questions not answered were excluded from both numerator and denominator. The denominator of all responses was noted. All analyses were conducted using SAS 9.3 (SAS Institute, Inc., Cary, NC). The study was approved by the Colorado Multiple Institutional Review Board.

RESULTS

Of 814 hospitalists, 228 responded to the survey (28.3%). Table 1 illustrates characteristics of responding hospitalists, who were divided between university hospitals, community teaching hospitals, and community nonteaching hospitals in diverse practices in terms of location and group size.

Sixty‐one percent of responding hospitalists believed most patient problems after discharge were due to poor follow‐up with primary care providers, and 55% found it difficult to arrange timely primary care follow up (Table 2). Despite this, 87% thought patient problems after discharge should be cared for by primary care physicians, and 62% opposed the idea of hospitalists seeing patients in the clinic after discharge.

When asked if hospitalists were responsible for patients after discharge from the hospital, only 50% responded positively. However, when asked how long hospitalists were responsible for patients after discharge, 71% gave a response longer than hospital discharge, including 60% who believed this responsibility ended at 1 week or less following discharge. A minority (12%) felt it extended to 1 month following discharge (Table 3).

Responding hospitalists expressed confidence in a PDC to reduce postdischarge emergency department visits (74%). However, most felt they would require extra compensation to staff a PDC (77%). They were divided on whether they would discharge patients from the hospital earlier if they could see those patients in postdischarge follow‐up (51% would discharge patients earlier).

Compared to those who had not experienced a PDC, responding hospitalists who had provided care in a PDC trended toward responding more positively that hospitalists should provide postdischarge care (P = 0.054). Few responding hospitalists had such exposure (8.8%) at the time of the survey. Although 31% had considering starting a PDC, only 3% were starting in the next year. Of responding hospitalists with exposure to a PDC, 70% were satisfied with the experience and 85% felt their patients were satisfied. Responses did not vary by type of practice (academic vs nonacademic), group size, geographic location, or by exposure to a PDC except as above.

DISCUSSION

Responding hospitalists reported encountering significant difficulty arranging appropriate postdischarge appointments with primary care providers and feel this contributes to postdischarge complications. Nearly 75% of those surveyed felt a hospitalist‐run PDC would be effective in reducing postdischarge emergency department visits, presumably in part due to improved access to postdischarge care. However, 62% of responding hospitalists opposed providing this type of care, though those who had experienced a PDC were somewhat more likely to view providing care in a PDC favorably. Survey responses largely reflect attitudes rather than experience with PDCs, because very few respondents had ever worked in a PDC.

The juxtaposition of the confidence expressed in PDCs to reduce postdischarge emergency department visits with the less enthusiastic views of respondents about providing care in a PDC was surprising. Several explanations are possible. First, providing such care is outside the usual scope of practice of most hospitalists, and preliminary reports indicate hospitalists, as self‐selected inpatient providers, may not initially welcome this opportunity.[12] Second, responding hospitalists identified the need for extra compensation for providing this care, suggesting they would see staffing a PDC as a burden requiring extra payment. Third, only 12% of respondents felt their responsibility to their discharged patients extended to 1 month following discharge. Given this, hospitalists may not feel enough personal ownership over 30‐day readmission rates to justify the additional clinical demand of staffing a PDC.[13]

In fact, 29% of responding hospitalists felt their responsibility to the patient ended at the time of discharge. Respondents may have interpreted responsibility differently, and we cannot rule out response bias given our lower‐than‐expected response rate. However, we had anticipated many fewer hospitalists would respond this way given professional hospitalist societies have endorsed guidelines for improved transitions of care, which clearly delineate the key role hospitalists play in care transitions.[14]

Although fewer than 10% of respondents had worked in a PDC, nearly one‐third reported considering starting such a practice in the future, underscoring the importance of understanding hospitalist attitudes and experiences when creating a PDC and the significant barriers to arranging appropriate postdischarge care identified by survey respondents. The barriers to establishing a PDC may explain why few planned to start a PDC in the next year.

This study should be interpreted in the context of its design. Due to limitations in survey delivery, more rigorous sampling designs could not be used, and efforts were instead made to deliver the survey to a diverse group of hospitalists. The survey response rate was lower than anticipated and this increases the risk of response bias. Though this response rate is characteristic of other surveys of hospitalists, responses may have been from a selected population and therefore not representative of all hospitalists.[15] We sampled from a variety of practice venues, locations, academic and community practices, and practice group sizes to try to minimize this bias. Due to the low exposure rate to PDCs, hospitalist responses to experiences with PDCs should be considered exploratory.

We asked about similar content areas in the survey in multiple questions to maximize content validity; this resulted in variations in the degree of agreement or disagreement to similar prompts. For example, 62% of hospitalists opposed seeing patients in the clinic after discharge when directly asked, but nearly 50% said they would welcome the opportunity to work in a PDC if their employer required it. In another example, 50% of respondents said their responsibility for the patient ended at time of discharge, but when asked about duration of responsibility, 30% identified time of discharge as the limit. When reporting and interpreting results, we have tried to highlight responses to questions that ask most clearly and directly about the content of interest (rather than general themes), but this interpretation may also be subject to bias.

The time after hospital discharge is one of heightened risk for adverse events for the recently discharged patient. Hospitalist‐run postdischarge clinics may offer improved postdischarge care access and continuity; more research is needed on the effects of such clinics on patient outcomes, including postdischarge utilization. Until then, physicians and hospitals considering establishing PDCs should consider the barriers responding hospitalists identified to working in such a clinic, as well as the confidence they expressed in PDCs to reduce subsequent utilization.

Disclosures: Dr. Burke had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. Dr. Burke was supported by grant funding from the Colorado Research Enhancement Award Program to Improve Care Coordination for Veterans. Dr. Ryan has no conflicts of interest to disclose.

Transitions of care, which encompass the patient experience of hospital discharge to the community, are frequently associated with clinically and financially costly adverse events.[1, 2] One important element for reducing the risk of postdischarge adverse events is provision of timely follow‐up by a clinician familiar with the patient and hospital course.[3, 4]

However, achieving this ideal is becoming more difficult because of an increased demand for primary care services (due to expanding coverage of Medicare and Medicaid) and the decreased supply of primary care physicians.[5, 6] When a timely visit with a clinician is available postdischarge, the widening discontinuity between inpatient and outpatient care providers often means this clinician is lacking essential details of the hospitalization.[7, 8]

One increasingly common innovation to improve postdischarge care access and continuity is to extend the role of inpatient providers (usually hospitalists) to provide care after discharge in a postdischarge clinic (PDC).[9, 10, 11] These clinics require an expansion of a hospitalist's duties to the outpatient setting, a requirement that has met with hospitalist resistance in initial reports.[12] However, little is known about hospitalists' experience with PDCs or attitudes toward postdischarge care. We aimed to explore these attitudes and experiences surrounding postdischarge care and PDCs.

METHODS

We conducted a cross‐sectional 17‐question Web‐based survey of hospitalists at 20 academic and 17 VA medical centers across the United States. Hospital medicine faculty at each site were identified by their group leader; members of each group then received an email survey up to 3 times. To collect responses from nonacademic hospitalists, the survey was also distributed to a large national private hospitalist employer. Due to internal limitations at the employer site, sampling was not feasible, and thus a convenience sample was obtained. Hospitalists who were not clinically active or did not have computer access to complete the survey were excluded. Responses were initially gathered on a 4‐point Likert scale; for comparisons between groups the scale was collapsed to a binary comparison using Fisher exact or ² tests. We included questions answered in partially completed surveys in both the numerator and denominator; questions not answered were excluded from both numerator and denominator. The denominator of all responses was noted. All analyses were conducted using SAS 9.3 (SAS Institute, Inc., Cary, NC). The study was approved by the Colorado Multiple Institutional Review Board.

RESULTS

Of 814 hospitalists, 228 responded to the survey (28.3%). Table 1 illustrates characteristics of responding hospitalists, who were divided between university hospitals, community teaching hospitals, and community nonteaching hospitals in diverse practices in terms of location and group size.

Sixty‐one percent of responding hospitalists believed most patient problems after discharge were due to poor follow‐up with primary care providers, and 55% found it difficult to arrange timely primary care follow up (Table 2). Despite this, 87% thought patient problems after discharge should be cared for by primary care physicians, and 62% opposed the idea of hospitalists seeing patients in the clinic after discharge.

When asked if hospitalists were responsible for patients after discharge from the hospital, only 50% responded positively. However, when asked how long hospitalists were responsible for patients after discharge, 71% gave a response longer than hospital discharge, including 60% who believed this responsibility ended at 1 week or less following discharge. A minority (12%) felt it extended to 1 month following discharge (Table 3).

Responding hospitalists expressed confidence in a PDC to reduce postdischarge emergency department visits (74%). However, most felt they would require extra compensation to staff a PDC (77%). They were divided on whether they would discharge patients from the hospital earlier if they could see those patients in postdischarge follow‐up (51% would discharge patients earlier).

Compared to those who had not experienced a PDC, responding hospitalists who had provided care in a PDC trended toward responding more positively that hospitalists should provide postdischarge care (P = 0.054). Few responding hospitalists had such exposure (8.8%) at the time of the survey. Although 31% had considering starting a PDC, only 3% were starting in the next year. Of responding hospitalists with exposure to a PDC, 70% were satisfied with the experience and 85% felt their patients were satisfied. Responses did not vary by type of practice (academic vs nonacademic), group size, geographic location, or by exposure to a PDC except as above.

DISCUSSION

Responding hospitalists reported encountering significant difficulty arranging appropriate postdischarge appointments with primary care providers and feel this contributes to postdischarge complications. Nearly 75% of those surveyed felt a hospitalist‐run PDC would be effective in reducing postdischarge emergency department visits, presumably in part due to improved access to postdischarge care. However, 62% of responding hospitalists opposed providing this type of care, though those who had experienced a PDC were somewhat more likely to view providing care in a PDC favorably. Survey responses largely reflect attitudes rather than experience with PDCs, because very few respondents had ever worked in a PDC.

The juxtaposition of the confidence expressed in PDCs to reduce postdischarge emergency department visits with the less enthusiastic views of respondents about providing care in a PDC was surprising. Several explanations are possible. First, providing such care is outside the usual scope of practice of most hospitalists, and preliminary reports indicate hospitalists, as self‐selected inpatient providers, may not initially welcome this opportunity.[12] Second, responding hospitalists identified the need for extra compensation for providing this care, suggesting they would see staffing a PDC as a burden requiring extra payment. Third, only 12% of respondents felt their responsibility to their discharged patients extended to 1 month following discharge. Given this, hospitalists may not feel enough personal ownership over 30‐day readmission rates to justify the additional clinical demand of staffing a PDC.[13]

In fact, 29% of responding hospitalists felt their responsibility to the patient ended at the time of discharge. Respondents may have interpreted responsibility differently, and we cannot rule out response bias given our lower‐than‐expected response rate. However, we had anticipated many fewer hospitalists would respond this way given professional hospitalist societies have endorsed guidelines for improved transitions of care, which clearly delineate the key role hospitalists play in care transitions.[14]

Although fewer than 10% of respondents had worked in a PDC, nearly one‐third reported considering starting such a practice in the future, underscoring the importance of understanding hospitalist attitudes and experiences when creating a PDC and the significant barriers to arranging appropriate postdischarge care identified by survey respondents. The barriers to establishing a PDC may explain why few planned to start a PDC in the next year.

This study should be interpreted in the context of its design. Due to limitations in survey delivery, more rigorous sampling designs could not be used, and efforts were instead made to deliver the survey to a diverse group of hospitalists. The survey response rate was lower than anticipated and this increases the risk of response bias. Though this response rate is characteristic of other surveys of hospitalists, responses may have been from a selected population and therefore not representative of all hospitalists.[15] We sampled from a variety of practice venues, locations, academic and community practices, and practice group sizes to try to minimize this bias. Due to the low exposure rate to PDCs, hospitalist responses to experiences with PDCs should be considered exploratory.

We asked about similar content areas in the survey in multiple questions to maximize content validity; this resulted in variations in the degree of agreement or disagreement to similar prompts. For example, 62% of hospitalists opposed seeing patients in the clinic after discharge when directly asked, but nearly 50% said they would welcome the opportunity to work in a PDC if their employer required it. In another example, 50% of respondents said their responsibility for the patient ended at time of discharge, but when asked about duration of responsibility, 30% identified time of discharge as the limit. When reporting and interpreting results, we have tried to highlight responses to questions that ask most clearly and directly about the content of interest (rather than general themes), but this interpretation may also be subject to bias.

The time after hospital discharge is one of heightened risk for adverse events for the recently discharged patient. Hospitalist‐run postdischarge clinics may offer improved postdischarge care access and continuity; more research is needed on the effects of such clinics on patient outcomes, including postdischarge utilization. Until then, physicians and hospitals considering establishing PDCs should consider the barriers responding hospitalists identified to working in such a clinic, as well as the confidence they expressed in PDCs to reduce subsequent utilization.

Disclosures: Dr. Burke had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. Dr. Burke was supported by grant funding from the Colorado Research Enhancement Award Program to Improve Care Coordination for Veterans. Dr. Ryan has no conflicts of interest to disclose.

Readmissions to the hospital are common and costly.[1] However, identifying patients prospectively who are likely to be readmitted and who may benefit from interventions to reduce readmission risk has proven challenging, with published risk scores having only moderate ability to discriminate between patients likely and unlikely to be readmitted.[2] One reason for this may be that published studies have not typically focused on patients who are cognitively impaired, psychiatrically ill, have low health or English literacy, or have poor social supports, all of whom may represent a substantial fraction of readmitted patients.[2, 3, 4, 5]

Psychiatric disease, in particular, may contribute to increased readmission risk for nonpsychiatric (medical) illness, and is associated with increased utilization of healthcare resources.[6, 7, 8, 9, 10, 11] For example, patients with mental illness who were discharged from New York hospitals were more likely to be rehospitalized and had more costly readmissions than patients without these comorbidities, including a length of stay nearly 1 day longer on average.[7] An unmet need for treatment of substance abuse was projected to cost Tennessee $772 million of excess healthcare costs in 2000, mostly incurred through repeat hospitalizations and emergency department (ED) visits.[10]

Despite this, few investigators have considered the role of psychiatric disease and/or substance abuse in medical readmission risk. The purpose of the current study was to evaluate the role of psychiatric illness and substance abuse in unselected medical patients to determine their relative contributions to 30‐day all‐cause readmissions (ACR) and potentially avoidable readmissions (PAR).

METHODS

RESULTS

There were 7984 unique patients discharged during the study period. Patients were generally white and English speaking; just over half of admissions came from the ED (Table 1). Of note, nearly all patients were insured, as are almost all patients in Massachusetts. They had high degrees of comorbid illness and large numbers of prescribed medications. Nearly 30% had at least 1 hospital admission within the prior year.

DISCUSSION

Comorbid psychiatric illness was common among patients admitted to the medicine wards. Patients with documented discharge diagnoses of depression or schizophrenia were at highest risk for a potentially avoidable 30‐day readmission, whereas those prescribed more psychiatric medications were at increased risk for ACR. These findings were independent of a comprehensive set of risk factors among medicine inpatients in this retrospective cohort study.

This study extends prior work indicating patients with psychiatric disease have increased healthcare utilization,[6, 7, 8, 9, 10, 11] by identifying at least 2 subpopulations of the psychiatrically ill (those with depression and schizophrenia) at particularly high risk for 30‐day PAR. To our knowledge, this is the first study to identify schizophrenia as a predictor of hospital readmission for medical illnesses. One prior study prospectively identified depression as increasing the 90‐day risk of readmission 3‐fold, although medication usage was not assessed,[6] and our report strengthens this association.

There are several possible explanations why these two subpopulations in particular would be more predisposed to readmissions that are potentially avoidable. It is known that patients with schizophrenia, for example, live on average 20 years less than the general population, and most of this excess mortality is due to medical illnesses.[20, 21] Reasons for this may include poor healthcare access, adverse effects of medication, and socioeconomic factors among others.[21, 22] All of these reasons may contribute to the increased PAR risk in this population, mediated, for example, by decreased ability to adhere to postdischarge care plans. Successful community‐based interventions to decrease these inequities have been described and could serve as a model for addressing the increased readmission risk in this population.[23]

Our finding that patients with a greater number of prescribed psychiatric medications are at increased risk for ACR may be expected, given other studies that have highlighted the crucial importance of medications in postdischarge adverse events, including readmissions.[24] Indeed, medication‐related errors and toxicities are the most common postdischarge adverse events experienced by patients.[25] Whether psychiatric medications are particularly prone to causing postdischarge adverse events or whether these medications represent greater psychiatric comorbidity cannot be answered by this study.

It was surprising but reassuring that substance abuse was not a predictor of short‐term readmissions as identified using our measures; in fact, a discharge diagnosis of substance abuse was associated with lower risk of ACR than comparator patients. It seems unlikely that we would have inadequate power to find such a result, as we found a statistically significant negative association in the ACR population, and 17% of our population overall was considered likely to have a substance abuse comorbidity. However, it is likely the burden of disease was underestimated given that we did not try to determine the contribution of long‐term substance abuse to medical diseases that may increase readmission risk (eg, liver cirrhosis from alcohol use). Unlike other conditions in our study, patients with substance abuse diagnoses at BWH can be seen by a dedicated multidisciplinary team while an inpatient to start treatment and plan for postdischarge follow‐up; this may have played a role in our findings.

A discharge diagnosis of anxiety was also somewhat protective against readmission, whereas a prescription of an anxiolytic (predominantly benzodiazepines) increased risk; many patients prescribed a benzodiazepine do not have a Diagnostic and Statistical Manual of Mental Disorders4th Edition (DSM‐IV) diagnosis of anxiety disorder, and thus these findings may reflect different patient populations. Discharging physicians may have used anxiety as a discharge diagnosis in patients in whom they suspected somatic complaints without organic basis; these patients may be at lower risk of readmission.

Discharge diagnoses of psychiatric illnesses were associated with ACR and PAR in our study, but outpatient diagnoses were not. This likely reflects greater severity of illness (documentation as a treated diagnosis on discharge indicates the illness was relevant during the hospitalization), but may also reflect inaccuracies of diagnosis and lack of assessment of severity in outpatient coding, which would bias toward null findings. Although many of the patients in our study were seen by primary care doctors within the Partners system, some patients had outside primary care physicians and we did not have access to these records. This may also have decreased our ability to find associations.

The findings of our study should be interpreted in the context of the study design. Our study was retrospective, which limited our ability to conclusively diagnose psychiatric disease presence or severity (as is true of most institutions, validated psychiatric screening was not routinely used at our institutions on hospital admission or discharge). However, we used a conservative scale to classify the likelihood of patients having psychiatric or substance abuse disorders, and we used other metrics to establish the presence of illness, such as the number of prescribed medications, inpatient consultation with a substance abuse service, and hospital discharge diagnoses. This approach also allowed us to quickly identify a large cohort unaffected by selection bias. Our study was single center, potentially limiting generalizability. Although we capture at least 80% of readmissions, we were not able to capture all readmissions, and we cannot rule out that patients readmitted elsewhere are different than those readmitted within the Partners system. Last, the SQLape algorithm is not perfectly sensitive or specific in identifying avoidable readmissions,[13] but it does eliminate many readmissions that are clearly unavoidable, creating an enriched cohort of patients whose readmissions are more likely to be avoidable and therefore potentially actionable.

We suggest that our study findings first be considered when risk stratifying patients before hospital discharge in terms of readmission risk. Patients with depression and schizophrenia would seem to merit postdischarge interventions to decrease their potentially avoidable readmissions. Compulsory community treatment (a feature of treatment in Canada and Australia that is ordered by clinicians) has been shown to decrease mortality due to medical illness in patients who have been hospitalized and are psychiatrically ill, and addition of these services to postdischarge care may be useful.[23] Inpatient physicians could work to ensure follow‐up not just with medical providers but with robust outpatient mental health programs to decrease potentially avoidable readmission risk, and administrators could work to ensure close linkages with these community resources. Studies evaluating the impact of these types of interventions would need to be conducted. Patients with polypharmacy, including psychiatric medications, may benefit from interventions to improve medication safety, such as enhanced medication reconciliation and pharmacist counseling.[26]

Our study suggests that patients with depression, those with schizophrenia, and those who have increased numbers of prescribed psychiatric medications should be considered at high risk for readmission for medical illnesses. Targeting interventions to these patients may be fruitful in preventing avoidable readmissions.

Readmissions to the hospital are common and costly.[1] However, identifying patients prospectively who are likely to be readmitted and who may benefit from interventions to reduce readmission risk has proven challenging, with published risk scores having only moderate ability to discriminate between patients likely and unlikely to be readmitted.[2] One reason for this may be that published studies have not typically focused on patients who are cognitively impaired, psychiatrically ill, have low health or English literacy, or have poor social supports, all of whom may represent a substantial fraction of readmitted patients.[2, 3, 4, 5]

Psychiatric disease, in particular, may contribute to increased readmission risk for nonpsychiatric (medical) illness, and is associated with increased utilization of healthcare resources.[6, 7, 8, 9, 10, 11] For example, patients with mental illness who were discharged from New York hospitals were more likely to be rehospitalized and had more costly readmissions than patients without these comorbidities, including a length of stay nearly 1 day longer on average.[7] An unmet need for treatment of substance abuse was projected to cost Tennessee $772 million of excess healthcare costs in 2000, mostly incurred through repeat hospitalizations and emergency department (ED) visits.[10]

Despite this, few investigators have considered the role of psychiatric disease and/or substance abuse in medical readmission risk. The purpose of the current study was to evaluate the role of psychiatric illness and substance abuse in unselected medical patients to determine their relative contributions to 30‐day all‐cause readmissions (ACR) and potentially avoidable readmissions (PAR).

METHODS

RESULTS

There were 7984 unique patients discharged during the study period. Patients were generally white and English speaking; just over half of admissions came from the ED (Table 1). Of note, nearly all patients were insured, as are almost all patients in Massachusetts. They had high degrees of comorbid illness and large numbers of prescribed medications. Nearly 30% had at least 1 hospital admission within the prior year.

DISCUSSION

Comorbid psychiatric illness was common among patients admitted to the medicine wards. Patients with documented discharge diagnoses of depression or schizophrenia were at highest risk for a potentially avoidable 30‐day readmission, whereas those prescribed more psychiatric medications were at increased risk for ACR. These findings were independent of a comprehensive set of risk factors among medicine inpatients in this retrospective cohort study.

This study extends prior work indicating patients with psychiatric disease have increased healthcare utilization,[6, 7, 8, 9, 10, 11] by identifying at least 2 subpopulations of the psychiatrically ill (those with depression and schizophrenia) at particularly high risk for 30‐day PAR. To our knowledge, this is the first study to identify schizophrenia as a predictor of hospital readmission for medical illnesses. One prior study prospectively identified depression as increasing the 90‐day risk of readmission 3‐fold, although medication usage was not assessed,[6] and our report strengthens this association.

There are several possible explanations why these two subpopulations in particular would be more predisposed to readmissions that are potentially avoidable. It is known that patients with schizophrenia, for example, live on average 20 years less than the general population, and most of this excess mortality is due to medical illnesses.[20, 21] Reasons for this may include poor healthcare access, adverse effects of medication, and socioeconomic factors among others.[21, 22] All of these reasons may contribute to the increased PAR risk in this population, mediated, for example, by decreased ability to adhere to postdischarge care plans. Successful community‐based interventions to decrease these inequities have been described and could serve as a model for addressing the increased readmission risk in this population.[23]

Our finding that patients with a greater number of prescribed psychiatric medications are at increased risk for ACR may be expected, given other studies that have highlighted the crucial importance of medications in postdischarge adverse events, including readmissions.[24] Indeed, medication‐related errors and toxicities are the most common postdischarge adverse events experienced by patients.[25] Whether psychiatric medications are particularly prone to causing postdischarge adverse events or whether these medications represent greater psychiatric comorbidity cannot be answered by this study.

It was surprising but reassuring that substance abuse was not a predictor of short‐term readmissions as identified using our measures; in fact, a discharge diagnosis of substance abuse was associated with lower risk of ACR than comparator patients. It seems unlikely that we would have inadequate power to find such a result, as we found a statistically significant negative association in the ACR population, and 17% of our population overall was considered likely to have a substance abuse comorbidity. However, it is likely the burden of disease was underestimated given that we did not try to determine the contribution of long‐term substance abuse to medical diseases that may increase readmission risk (eg, liver cirrhosis from alcohol use). Unlike other conditions in our study, patients with substance abuse diagnoses at BWH can be seen by a dedicated multidisciplinary team while an inpatient to start treatment and plan for postdischarge follow‐up; this may have played a role in our findings.

A discharge diagnosis of anxiety was also somewhat protective against readmission, whereas a prescription of an anxiolytic (predominantly benzodiazepines) increased risk; many patients prescribed a benzodiazepine do not have a Diagnostic and Statistical Manual of Mental Disorders4th Edition (DSM‐IV) diagnosis of anxiety disorder, and thus these findings may reflect different patient populations. Discharging physicians may have used anxiety as a discharge diagnosis in patients in whom they suspected somatic complaints without organic basis; these patients may be at lower risk of readmission.

Discharge diagnoses of psychiatric illnesses were associated with ACR and PAR in our study, but outpatient diagnoses were not. This likely reflects greater severity of illness (documentation as a treated diagnosis on discharge indicates the illness was relevant during the hospitalization), but may also reflect inaccuracies of diagnosis and lack of assessment of severity in outpatient coding, which would bias toward null findings. Although many of the patients in our study were seen by primary care doctors within the Partners system, some patients had outside primary care physicians and we did not have access to these records. This may also have decreased our ability to find associations.

The findings of our study should be interpreted in the context of the study design. Our study was retrospective, which limited our ability to conclusively diagnose psychiatric disease presence or severity (as is true of most institutions, validated psychiatric screening was not routinely used at our institutions on hospital admission or discharge). However, we used a conservative scale to classify the likelihood of patients having psychiatric or substance abuse disorders, and we used other metrics to establish the presence of illness, such as the number of prescribed medications, inpatient consultation with a substance abuse service, and hospital discharge diagnoses. This approach also allowed us to quickly identify a large cohort unaffected by selection bias. Our study was single center, potentially limiting generalizability. Although we capture at least 80% of readmissions, we were not able to capture all readmissions, and we cannot rule out that patients readmitted elsewhere are different than those readmitted within the Partners system. Last, the SQLape algorithm is not perfectly sensitive or specific in identifying avoidable readmissions,[13] but it does eliminate many readmissions that are clearly unavoidable, creating an enriched cohort of patients whose readmissions are more likely to be avoidable and therefore potentially actionable.

We suggest that our study findings first be considered when risk stratifying patients before hospital discharge in terms of readmission risk. Patients with depression and schizophrenia would seem to merit postdischarge interventions to decrease their potentially avoidable readmissions. Compulsory community treatment (a feature of treatment in Canada and Australia that is ordered by clinicians) has been shown to decrease mortality due to medical illness in patients who have been hospitalized and are psychiatrically ill, and addition of these services to postdischarge care may be useful.[23] Inpatient physicians could work to ensure follow‐up not just with medical providers but with robust outpatient mental health programs to decrease potentially avoidable readmission risk, and administrators could work to ensure close linkages with these community resources. Studies evaluating the impact of these types of interventions would need to be conducted. Patients with polypharmacy, including psychiatric medications, may benefit from interventions to improve medication safety, such as enhanced medication reconciliation and pharmacist counseling.[26]

Our study suggests that patients with depression, those with schizophrenia, and those who have increased numbers of prescribed psychiatric medications should be considered at high risk for readmission for medical illnesses. Targeting interventions to these patients may be fruitful in preventing avoidable readmissions.

Readmissions to the hospital are common and costly.[1] However, identifying patients prospectively who are likely to be readmitted and who may benefit from interventions to reduce readmission risk has proven challenging, with published risk scores having only moderate ability to discriminate between patients likely and unlikely to be readmitted.[2] One reason for this may be that published studies have not typically focused on patients who are cognitively impaired, psychiatrically ill, have low health or English literacy, or have poor social supports, all of whom may represent a substantial fraction of readmitted patients.[2, 3, 4, 5]

Psychiatric disease, in particular, may contribute to increased readmission risk for nonpsychiatric (medical) illness, and is associated with increased utilization of healthcare resources.[6, 7, 8, 9, 10, 11] For example, patients with mental illness who were discharged from New York hospitals were more likely to be rehospitalized and had more costly readmissions than patients without these comorbidities, including a length of stay nearly 1 day longer on average.[7] An unmet need for treatment of substance abuse was projected to cost Tennessee $772 million of excess healthcare costs in 2000, mostly incurred through repeat hospitalizations and emergency department (ED) visits.[10]

Despite this, few investigators have considered the role of psychiatric disease and/or substance abuse in medical readmission risk. The purpose of the current study was to evaluate the role of psychiatric illness and substance abuse in unselected medical patients to determine their relative contributions to 30‐day all‐cause readmissions (ACR) and potentially avoidable readmissions (PAR).

METHODS

RESULTS

There were 7984 unique patients discharged during the study period. Patients were generally white and English speaking; just over half of admissions came from the ED (Table 1). Of note, nearly all patients were insured, as are almost all patients in Massachusetts. They had high degrees of comorbid illness and large numbers of prescribed medications. Nearly 30% had at least 1 hospital admission within the prior year.

DISCUSSION

Comorbid psychiatric illness was common among patients admitted to the medicine wards. Patients with documented discharge diagnoses of depression or schizophrenia were at highest risk for a potentially avoidable 30‐day readmission, whereas those prescribed more psychiatric medications were at increased risk for ACR. These findings were independent of a comprehensive set of risk factors among medicine inpatients in this retrospective cohort study.

This study extends prior work indicating patients with psychiatric disease have increased healthcare utilization,[6, 7, 8, 9, 10, 11] by identifying at least 2 subpopulations of the psychiatrically ill (those with depression and schizophrenia) at particularly high risk for 30‐day PAR. To our knowledge, this is the first study to identify schizophrenia as a predictor of hospital readmission for medical illnesses. One prior study prospectively identified depression as increasing the 90‐day risk of readmission 3‐fold, although medication usage was not assessed,[6] and our report strengthens this association.

There are several possible explanations why these two subpopulations in particular would be more predisposed to readmissions that are potentially avoidable. It is known that patients with schizophrenia, for example, live on average 20 years less than the general population, and most of this excess mortality is due to medical illnesses.[20, 21] Reasons for this may include poor healthcare access, adverse effects of medication, and socioeconomic factors among others.[21, 22] All of these reasons may contribute to the increased PAR risk in this population, mediated, for example, by decreased ability to adhere to postdischarge care plans. Successful community‐based interventions to decrease these inequities have been described and could serve as a model for addressing the increased readmission risk in this population.[23]

Our finding that patients with a greater number of prescribed psychiatric medications are at increased risk for ACR may be expected, given other studies that have highlighted the crucial importance of medications in postdischarge adverse events, including readmissions.[24] Indeed, medication‐related errors and toxicities are the most common postdischarge adverse events experienced by patients.[25] Whether psychiatric medications are particularly prone to causing postdischarge adverse events or whether these medications represent greater psychiatric comorbidity cannot be answered by this study.

It was surprising but reassuring that substance abuse was not a predictor of short‐term readmissions as identified using our measures; in fact, a discharge diagnosis of substance abuse was associated with lower risk of ACR than comparator patients. It seems unlikely that we would have inadequate power to find such a result, as we found a statistically significant negative association in the ACR population, and 17% of our population overall was considered likely to have a substance abuse comorbidity. However, it is likely the burden of disease was underestimated given that we did not try to determine the contribution of long‐term substance abuse to medical diseases that may increase readmission risk (eg, liver cirrhosis from alcohol use). Unlike other conditions in our study, patients with substance abuse diagnoses at BWH can be seen by a dedicated multidisciplinary team while an inpatient to start treatment and plan for postdischarge follow‐up; this may have played a role in our findings.

A discharge diagnosis of anxiety was also somewhat protective against readmission, whereas a prescription of an anxiolytic (predominantly benzodiazepines) increased risk; many patients prescribed a benzodiazepine do not have a Diagnostic and Statistical Manual of Mental Disorders4th Edition (DSM‐IV) diagnosis of anxiety disorder, and thus these findings may reflect different patient populations. Discharging physicians may have used anxiety as a discharge diagnosis in patients in whom they suspected somatic complaints without organic basis; these patients may be at lower risk of readmission.

Discharge diagnoses of psychiatric illnesses were associated with ACR and PAR in our study, but outpatient diagnoses were not. This likely reflects greater severity of illness (documentation as a treated diagnosis on discharge indicates the illness was relevant during the hospitalization), but may also reflect inaccuracies of diagnosis and lack of assessment of severity in outpatient coding, which would bias toward null findings. Although many of the patients in our study were seen by primary care doctors within the Partners system, some patients had outside primary care physicians and we did not have access to these records. This may also have decreased our ability to find associations.

The findings of our study should be interpreted in the context of the study design. Our study was retrospective, which limited our ability to conclusively diagnose psychiatric disease presence or severity (as is true of most institutions, validated psychiatric screening was not routinely used at our institutions on hospital admission or discharge). However, we used a conservative scale to classify the likelihood of patients having psychiatric or substance abuse disorders, and we used other metrics to establish the presence of illness, such as the number of prescribed medications, inpatient consultation with a substance abuse service, and hospital discharge diagnoses. This approach also allowed us to quickly identify a large cohort unaffected by selection bias. Our study was single center, potentially limiting generalizability. Although we capture at least 80% of readmissions, we were not able to capture all readmissions, and we cannot rule out that patients readmitted elsewhere are different than those readmitted within the Partners system. Last, the SQLape algorithm is not perfectly sensitive or specific in identifying avoidable readmissions,[13] but it does eliminate many readmissions that are clearly unavoidable, creating an enriched cohort of patients whose readmissions are more likely to be avoidable and therefore potentially actionable.

We suggest that our study findings first be considered when risk stratifying patients before hospital discharge in terms of readmission risk. Patients with depression and schizophrenia would seem to merit postdischarge interventions to decrease their potentially avoidable readmissions. Compulsory community treatment (a feature of treatment in Canada and Australia that is ordered by clinicians) has been shown to decrease mortality due to medical illness in patients who have been hospitalized and are psychiatrically ill, and addition of these services to postdischarge care may be useful.[23] Inpatient physicians could work to ensure follow‐up not just with medical providers but with robust outpatient mental health programs to decrease potentially avoidable readmission risk, and administrators could work to ensure close linkages with these community resources. Studies evaluating the impact of these types of interventions would need to be conducted. Patients with polypharmacy, including psychiatric medications, may benefit from interventions to improve medication safety, such as enhanced medication reconciliation and pharmacist counseling.[26]

Our study suggests that patients with depression, those with schizophrenia, and those who have increased numbers of prescribed psychiatric medications should be considered at high risk for readmission for medical illnesses. Targeting interventions to these patients may be fruitful in preventing avoidable readmissions.

Containing the rise of healthcare costs has taken on a new sense of urgency in the wake of the recent economic recession and continued growth in the cost of healthcare. Accordingly, many stakeholders seek solutions to improve value (reducing costs while improving care)[1]; hospital readmissions, which are common and costly,[2] have emerged as a key target. The Centers for Medicare and Medicaid Services (CMS) have instituted several programs intended to reduce readmissions, including funding for community‐based, care‐transition programs; penalties for hospitals with elevated risk‐adjusted readmission rates for selected diagnoses; pioneer Accountable Care Organizations (ACOs) with incentives to reduce global costs of care; and Hospital Engagement Networks (HENs) through the Partnership for Patients.[3] A primary aim of these initiatives is to enhance the quality of care transitions as patients are discharged from the hospital.

Though the recent focus on hospital readmissions has appropriately drawn attention to transitions in care, some have expressed concerns. Among these are questions about: 1) the extent to which readmissions truly reflect the quality of hospital care[4]; 2) the preventability of readmissions[5]; 3) limitations in risk‐adjustment techniques[6]; and 4) best practices for preventing readmissions.[7] We believe these concerns stem in part from deficiencies in the state of the science of transitional care, and that future efforts in this area will be hindered without a clear vision of an ideal transition in care. We propose the key components of an ideal transition in care and discuss the implications of this concept as it pertains to hospital readmissions.

THE IDEAL TRANSITION IN CARE

We propose the key components of an ideal transition in care in Figure 1 and Table 1. Figure 1 represents 10 domains described more fully below as structural supports of the bridge patients must cross from one care environment to another during a care transition. This figure highlights key domains and suggests that lack of a domain makes the bridge weaker and more prone to gaps in care and poor outcomes. It also implies that the more components are missing, the less safe is the bridge or transition. Those domains that mainly take place prior to discharge are placed closer to the hospital side of the bridge, those that mainly take place after discharge are placed closer to the community side of the bridge, while those that take place both prior to and after discharge are in the middle. Table 1 provides descriptions of the key content for each of these domains, as well as guidance about which personnel might be involved and where in the transition process that domain should be implemented. We support these domains with supporting evidence where available.

Figure 1

Our concept of an ideal transition in care began with work by Naylor, who described several important components of a safe transition in care, including complete communication of information, patient education, enlisting the help of social and community supports, ensuring continuity of care, and coordinating care among team members.[8] It is supplemented by the Transitions of Care Consensus Policy Statement proposed by representatives from hospital medicine, primary care, and emergency medicine, which emphasized aspects of timeliness and content of communication between providers.[9] Our present articulation of these key components includes 10 organizing domains.

The Discharge Planning domain highlights the important principle of planning ahead for hospital discharge while the patient is still being treated in the hospital, a paradigm espoused by Project RED[10] and other successful care transitions interventions.[11, 12] Collaborating with the outpatient provider and taking the patient and caregiver's preferences for appointment scheduling into account can help ensure optimal outpatient follow‐up.

Complete Communication of Information refers to the content that should be included in discharge summaries and other means of information transfer from hospital to postdischarge care. The specific content areas are based on the Society of Hospital Medicine and Society of General Internal Medicine Continuity of Care Task Force systematic review and recommendations,[13] which takes into account information requested by primary care physicians after discharge.

Availability, Timeliness, Clarity, and Organization of that information is as important as the content because postdischarge providers must be able to access and quickly understand the information they have been provided before assuming care of the patient.[14, 15]

The Medication Safety domain is of central importance because medications are responsible for most postdischarge adverse events.[16] Taking an accurate medication history,[17] reconciling changes throughout the hospitalization,[18] and communicating the reconciled medication regimen to patients and providers across transitions of care can reduce medication errors and improve patient safety.[19, 20, 21, 22]

The Patient Education and Promotion of Self‐Management domain involves teaching patients and their caregivers about the main hospital diagnoses and instructions for self‐care, including medication changes, appointments, and whom to contact if issues arise. Confirming comprehension of instructions through assessments of acute (delirium) and chronic (dementia) cognitive impairments[23, 24, 25, 26] and teach‐back from the patient (or caregiver) is an important aspect of such counseling, as is providing patients and caregivers with educational materials that are appropriate for their level of health literacy and preferred language.[14] High‐risk patients may benefit from patient coaching to improve their self‐management skills.[12] These recommendations are based on years of health literacy research,[27, 28, 29] and such elements are generally included in effective interventions (including Project RED,[10] Naylor and colleagues' Transitional Care Model,[11] and Coleman and colleagues' Care Transitions Intervention[12]).