Perfecting the post-discharge visit

Intuitively, the benefit of a physician visit soon after hospital discharge seems obvious. But doctors and researchers are still grappling with how to best assess and confirm its effectiveness. Among the questions they're addressing are when should that visit happen, which patient groups should be targeted, and what should occur during the visit itself?

Getting a recently discharged patient to see a doctor quickly has become a focus as doctors and hospital leaders strive to limit preventable 30-day readmissions, in order to improve care and avoid Medicare penalties. Several studies published in the last few years, though, have presented a mixed picture, showing that fast-tracking that first appointment is not necessarily beneficial, or at least not for all types of patients.

One study, published in March in Annals of Family Medicine, found little change in readmissions from early follow-up among patients with 1 or fewer medical conditions but a significant effect—a 19.1% reduction—among patients with multiple conditions. Meanwhile, another recent study, published in the May 2015 Journal of General Internal Medicine (JGIM), didn't find any protective effect among patients ages 65 and older who saw a doctor within 7 days after discharge.

“Since we did not find a difference, my conclusion and what others have told me is that the major issue is targeting the right patient,” said Jerry Gurwitz, MD, FACP, senior author on the JGIM study, as well as executive director of the Meyers Primary Care Institute. The institute is a joint endeavor of the University of Massachusetts Medical School, Reliant Medical Group, and the Fallon Community Health Plan.

“And then the second issue is that there is no evidence-based approach or protocol that a primary care physician is expected to follow in seeing the patient who presents following hospital discharge,” Dr. Gurwitz said. “Everybody is doing whatever they think is the right thing to do. The reality is we don't even know what's happening in the context of that visit. There is just no way everyone is doing it the same.”

Visit timing and target

The study that Dr. Gurwitz led, involving 3,661 patients, found that 49.4% visited some type of doctor within 7 days of hospital discharge and 27.3% specifically saw a primary care physician. But the 19.3% of the patients who were rehospitalized within 30 days were no more or less likely to have seen a primary care doctor (or any doctor) in that first week than the patients who stayed out of the hospital.

Dr. Gurwitz is now trying to figure out whether subgroups of patients should be the focus of special attention by the primary care doctor during the immediate post-discharge period, based on various factors, such as social support, use of high-risk medications, or functional status.

He is not alone in struggling to nail down what works in terms of post-discharge interventions, according to several review articles cited in his study. In 1 systematic review, involving 47 studies and published in the March 5, 2013, Annals of Internal Medicine, researchers wrote that the “strategies that an individual hospital can implement to improve transitional care remain largely undefined.”

Plus, with limited resources and tight appointment scheduling, clinicians must strive to maximize effectiveness, said Annette DuBard, MD, MPH, an author on the recent Annals of Family Medicine study. She's also a senior vice president for informatics and evaluation at Community Care of North Carolina, a public-private partnership that links Medicaid recipients to primary care medical homes and other support services, including a transitional care program.

“We recognized that we needed to be intelligent about targeting our efforts to assure that the patients who needed that appointment the most were the ones who got it,” Dr. DuBard said. “So we set out to really test whether clinical complexity was indeed associated with the likelihood of benefiting from early outpatient follow-up.”

The researchers analyzed North Carolina Medicaid data involving 44,473 recently hospitalized beneficiaries and stratified them based not only on the number and complexity of their medical conditions but also by when they first visited their medical clinician, ranging from 3 days to 30 days after discharge.

Less complex patients—those with 1 or fewer chronic conditions—did not meaningfully benefit from having that visit sooner after discharge, the study found. But among higher-risk patients with at least 3 chronic conditions, 1 readmission was prevented for every 5 patients who had a follow-up visit within the first 14 days, according to the analysis.

It's clinically intuitive that those vulnerable patients “need to be at the top of the list” for an early visit, Dr. DuBard said. But the researchers also determined that only half of the patients who met the high-risk criteria were seen within 14 days.

“In truth, it may be that our highest-risk, most vulnerable patients are less equipped to really navigate—make that appointment, keep that appointment—and so may be being edged out by more capable patients,” Dr. DuBard said.

On the heels of those findings, the nurse care managers at Raleigh-based Community Care of North Carolina are now told how soon a newly discharged patient needs to be seen by an outpatient clinician based on that patient's risk profile, Dr. DuBard said. The care managers also are working even harder these days to find an appointment slot for those at-risk patients, along with making sure that there aren't any transportation problems or other hurdles to getting them in, she said.

Which physician?

In a survey of hospitalists reported in the October 2013 Journal of Hospital Medicine, slightly more than half, 55%, reported difficulties in arranging an outpatient referral. Nearly two-thirds of the 228 hospitalists asked attributed most post-discharge patient difficulties to this lack of access.

But nearly two-thirds, 62%, also stated that providing post-discharge care was not part of their responsibility, and 77% believed that additional compensation should be involved to work in a post-discharge clinic. “There was not a lot of enthusiasm for it without more pay and more time,” said Robert Burke, MD, one of the authors on the paper and an assistant chief of hospital medicine at the Denver Veterans Affairs (VA) Medical Center.

Since the Denver VA has already had a hospitalist-run post-discharge clinic for more a decade, Dr. Burke wanted to get a better sense of whether that model of post-discharge care reduces readmissions.

The retrospective study, which looked at a composite 30-day outcomes measure that included mortality and hospital and emergency department readmissions, found no significant reductions in adverse outcomes among patients seen in the hospitalist-led clinic versus those seen by primary care, according to the findings, published in the January 2014 Journal of Hospital Medicine.

It could be that the hospitalist-led model makes no significant difference, Dr. Burke said. But he also noted that the Denver VA facility's 30-day readmission rate is already low, just under 11%, making it one of the lowest in the system. “So it's just hard at our particular VA to show any difference in outcomes,” he said.

A notable finding of the study, however, was that patients seen at the hospitalist-led clinic had spent an average of 2.4 fewer days in the hospital. One possible explanation is that the hospitalists are more comfortable with sending those patients home, as they know where they will return, Dr. Burke said.

“It is very reassuring for me to be able to say, ‘Come back and see us within 48 hours,’” he said. “It lends some confidence that you're not going to lose this patient, and you're going to go follow up very short term and you will see them yourself with this clinic.”

To date, a lot of the transitional care research has involved patients admitted for medical reasons, such as for heart failure, said Benjamin Brooke, MD, PhD, assistant professor of surgery at the University of Utah. But post-surgical patients may have other medical issues, either related to the operation or ongoing, that are better treated in primary care.

Dr. Brooke was lead author of a study, published in the August 2014 JAMA Surgery, that assessed readmissions after 2 types of surgeries—a higher-risk open thoracic aortic repair and a more routine hernia procedure. In the hernia repair group, early follow-up with a primary care clinician didn't make any difference in 30-day readmissions.

But for the patients in the aneurysm repair group, a primary care visit did appear to help those patients—36.6% of the total—who had experienced some type of complication during their hospital stay. The 30-day readmission rate was 20.4% among those with complications who saw a primary care clinician after discharge, compared with 35% among patients who did not.

Designing the visit

Still, getting more than 1 doctor involved in post-discharge care can potentially raise a new set of coordination headaches, said Dr. Gurwitz. “Who is responsible for what? Who is changing what? Who is monitoring or following up on what? Is there good communication between these physicians even in a high-functioning system?”

Another issue is that some of these efforts to push to get a patient into a doctor's office might present a catch-22 in terms of readmission rates. “If someone is presenting themselves to their doctor, there is a greater chance of finding something that might lead to more rehospitalizations, which could be a good thing or a bad thing,” Dr. Gurwitz said.

Even if a patient's health benefited from returning to the hospital (which would depend upon the individual scenario, Dr. Gurwitz noted), the readmission would confound efforts that try to measure and understand the benefits of post-discharge visits using only readmission rates.

An additional challenge in crafting the post-discharge visit is deciding what should occur during it, said Jing Li, MD, lead author on an editorial that accompanied Dr. Gurwitz's research in JGIM. In addition to specifics, such as whether medication reconciliation happens, success might rely more broadly on how well the hospital physician and the outpatient physician are communicating about any psychosocial dynamics, such as mental health difficulties, gaps in caregiver support, and other factors that that might influence readmission, she said.

“I think more and more people realize that it's not just initiating the intervention,” said Dr. Li, an assistant professor of medicine at the University of Kentucky in Lexington.

To help close this patient discharge gap, researchers and doctors will have to keep pursuing innovative ideas in the years ahead, according to Dr. Burke. The data remain in flux regarding the timing, focus, and specifics of that first post-discharge visit, he said.

“But I think the preponderance of evidence is that it is important that you follow up with someone,” he said. “And it's important that that someone knows what happened and who you are as a patient, as a person.”