SAN DIEGO – The way Dr. Michael Kedansky sees it, a hospitalist’s responsibility to a patient doesn’t end when that person is discharged.

“What happens beyond the walls of the hospital matters to us as clinicians,” he said at the annual meeting of the Society of Hospital Medicine. “Readmission is both an undesirable clinical outcome for our patients and a significant cost to the hospital.”

He defined a successful hospital discharge as one in which the patient is not readmitted and transitions to his or her home with an eventual recovery of function. This means that they’re taking the correct medications, follow-up visits are scheduled and honored, and that they feel safe in their home environment, said Dr. Kedansky, chief medical officer of transitional care services for Sound Physicians, which has more than 2,000 physicians in more than 180 hospitals and postacute facilities in the United States. Common barriers that prevent successful care transitions, he said, include the patient not understanding discharge instructions, ineffective medication reconciliation, lack of follow-up appointment availability, need for caregiver training/education, poor continuity of care and transfer of information, and psychosocial factors.

Dr. Kedansky defined effective transitional care as “a set of actions designed to ensure the coordination and continuity of health care as patients move one from one health care setting to another or home. It’s a way to address the current gaps in care, so patients can move safely from hospital to home and back to their PCP.” The problem is, transitional care sometimes takes a back seat to competing demands in the health care landscape. For example, one study found that only 50% of Medicare patients readmitted to the hospital within 30 days of discharge were seen by a follow-up provider (N Engl J Med. 2009;360:1418-28).

One novel care transitions intervention is the so-called Coleman model, in which a “transitions coach” works with patients for 30 days after discharge to help them understand and manage their complex postdischarge needs and ensure continuity of care across settings. Developed by Dr. Eric Coleman, four key aspects of the model include medication self-management, use of a patient-centered record, primary care and specialist follow-up, and knowledge of “red flags.” The process includes an initial visit in the hospital, telephone contact, and a home visit. A randomized trial of 750 community-dwelling adults aged 65 and older showed that those who received the intervention had 20%-40% lower overall hospital readmission rates, compared with controls (Arch Intern Med. 2006;166[17]:1822-8). In addition, they were about 50% less likely to be readmitted at 30, 90, and 180 days for the same condition that caused the initial hospitalization. Barriers to implementing the intervention, Dr. Kedansky said, include costs of startup, training staff, and the question of exactly who sees the savings.

Three more common models of delivering care transitions involve the following:

Traditional internist or family physician. Advantages of this model, he said, include better continuity of care, “both in relationships and transfer of information,” no additional resources required, and a high potential for patient satisfaction. Limitations of this model include a reduction in the physician presence, a high workload, and risk for burnout.

Extensivist. Advantages of this model, which was outlined in a recent JAMA article based on the experience of CareMore Health System (JAMA. 2016;315[1]:23-4), include improved continuity at the time of high-risk transitions, and evidence which demonstrates a reduction in readmission rates and lower costs of care. Drawbacks include the fact that it’s a high-cost model that has not been scaled beyond health plan settings. “There is no model to use extensivists in the fee-for-service world,” Dr. Kedansky said.

Hospitalist + post–acute care provider + PCP. Advantages of this model, he said, are that it’s easier to scale, physicians can develop an area of expertise, and they have a presence in the hospital or skilled nursing facility. One limitation is that it can lead to reduced continuity of care. “Until recently, this has been a volume-based model of care,” he added.

According to Dr. Kedansky, postacute expenses account for 65% of spending during a 90-day acute episode of care. The Bundled Payments for Care Improvement Initiative (BPCI), developed by the Centers for Medicare & Medicaid Services, is a shared savings model aimed at reducing post–acute care spending. Creative components of initiative, he said, include waivers for telemedicine and home health, waiver of the 3-night stay rule, and sharing and using data to define preferred, high performance networks. “I see BPCI as a game changer, as it turbocharges our physician-based models and incentivizes the right behavior,” he said. “The key to working in a bundled payment world is to teach hospitalists and other providers how to think differently, while managing patients across a full 90-day episode of care. Care redesign to improve clinical outcomes for patients leads to success and shared savings in this type of payment model.”

He concluded his remarks by advising physicians to “work through the list of items that ensure a successful care transition: patient education, caregiver training, medication reconciliation, and warm hand-offs of information.”

Dr. Kedansky reported having no financial disclosures.

dbrunk@frontlinemedcom.com

Transition of care plans crucial to cutting readmissions