Organizers and Facilitators: Jeffrey Schnipper, Himali Weerahandi, Mark Williams, Safa Farag, Eva Angeli, Sonia Dalal, Tim Anderson, Aaron Fisher, Angela Keniston

Background: Discharge from the hospital is an inherently vulnerable period for patients, and suboptimal discharges too frequently have unintended consequences for patients and their family caregivers. Many programs have been designed, implemented, and studied to improve care transitions, but, despite promising results in carefully constructed trials, it has been notoriously difficult to spread and sustain these programs more broadly.



During this HOMERuN Collaborative session, we delved into our collective experiences with transitions of care programs at our hospitals, what has worked and not worked, and barriers and facilitators of implementation. We will use this as background and preparation for a potential multi-site pragmatic trial, involving interested HOMERuN sites, of transitional care programs.

Programs in place to improve care transitions out of the hospital or to reduce readmission rates

Wide variation in types of programs, including:

• Interdisciplinary rounds/huddle with the attending, nurses, and other staff: to identify high-risk patients, assess readiness for discharge, schedule follow-up appointments, arrange home health, durable medical equipment, medication delivery, rides for follow-up, obtain a primary care provider (PCP) for the patient if they don't have one
• Pharmacist-led programs focused on discharge medication reconciliation: to call patients up afterwards to ensure they understand the medication list, obtained their medications, are taking them, and are not having side effects
• Post-discharge phone calls, often by nurses: to assess for adherence to discharge plan, new or worsening symptoms
• Remote monitoring programs, telehealth programs: to track patients after discharge
• Transitions of care call centers: for patients to call with questions
• After-care clinics and bridge clinics, especially for patients who do not have a PCP, uninsured or under-insured patients
• Hospital at home programs; many hospitals have found that these patients have lower readmission rates
• Discharge navigators, peer support, community health workers: to help high-risk patients with social needs (e.g., substance use disorders, Medicaid managed care)
• Disease-focused programs, e.g., for patients with heart failure, COPD, and certain cancers
• Geriatric-focused programs, advance care planning programs
• Resources for homeless patients after discharge

Often, these programs are reserved for certain patient subgroups (e.g., by insurance, housing status, disease, age, readmission risk, PCP within system, part of a research study), the programs are often fragmented, and are not run by Hospital Medicine clinicians.

"One of the top priorities of our institution is to reduce readmissions broadly across the board. They are finding higher risk patients and following up with them after discharge via phone and to make sure they have what they need."

What works in transitions of care programs

• Support from leadership and institution
• Interdisciplinary teamwork
• Central person to coordinate activities of the team
• Bedside medication delivery
• Isolated programs at individual sites (e.g., QI program for patients with drains; Social Work support for homeless patients, Remote monitoring via text, Attending nurse program)
• Specialty-specific programs, e.g., heart failure, oncology

"Affordable housing for some of our homeless population, sick patients that need a lot of medical care. Now there are 20 plus beds that can be used for discharge of patients who have complex medical issues that are unhoused or have housing insecurity."

What is not working in transitions of care programs

• Lack of access to programs for uninsured patients, outside or no PCP
• Inconsistency in which patients have access to which programs, lack of awareness of all the programs that are available
• Institutional focus on length of stay, early discharge rather than readmissions and patient safety/experience during care transitions
• High staff turnover, chronic understaffing of programs
• Social determinants of health issues (e.g., food deserts)
• Scheduling prompt follow-up appointments, limited access to appointments
• Lack of measurement, measurement by non-clinical personnel, lack of data to know whether there is Return on Investment
• Difficulty of communication with PCPs outside the admission hospital's health system
• Difficulty scaling up and sustaining programs due to staffing issues
• Low response rates when trying to contact patients after discharge, high no-show rates for follow-up appointments

"Inability to measure. Are you actually having an impact? Are you actually having a return on investment? The cost of a readmission? If you don't have those things, it's often hard to get leadership to sustain programs like that."

How the transitions of care program could be better

• Discharge clinics for the uninsured
• Resources that start in the hospital and continue after discharge — continuity of care and personnel
• Focusing on health literacy, language barriers, patient and family education and coaching
• More resources for personnel, transitional clinics, medications, etc.
• Sooner appointments, access to primary care and specialty clinics
• Better data on whether the programs are working
• Better testing of patient communication tools, better understanding of why patients don’t respond or no-show, better assessment of patient needs (e.g., for digital health)
• Greater emphasis on social infrastructure, social determinants of health
• More structured guidelines and better targeting of interventions
• Getting more input from patients and families on how we could improve transitions

"There are ways for Epic to help with the appointment scheduling process. It's a lot of just humans calling other humans for appointments that could be improved with better technology."

Barriers to implementing these programs

• Limited resources, staff shortages, staff turnover
• Culture focused on discharge but not care after patients leave; focus on readmission rates only rather than other metrics of quality of transitional care
• Changes in leadership; non-clinical leadership who lack clinical perspective
• Lack of programs for patients outside the health care system or without insurance
• Lack of programs for patients with multi-morbidity
• Lack of single entity taking ownership for these programs
• Lack of clear communication of benefits of programs
• Challenges balancing core elements with adaptability of programs
• Misconceptions about what actually happens in the outpatient setting

"Our own specialists don't take their insurance, o we can't follow up with the same specialist who saw them in the hospital."

Facilitators to implementing these programs

• Buy-in from various stakeholders e.g., nursing, case management, physicians
• Clear leadership structure and accountability
• When multiple people make the case for TOC programs
• Multidisciplinary teamwork
• Patient engagement and feedback
• Local champions, executive sponsors
• Sufficient resources and funding (e.g., initial influx of funding from CMMI)
• Business model, case for Return on Investment
• Focus on equity and access, patient-centered outcomes, overall health
• Community collaboration
• Single mechanism for triggering all TOC programs
• Outpatient services that have sense of ownership for their patients

"We have dedicated transitions of care; we have case managers, social work, transfer of care, pharmacists, and a pilot of a group that is supposed to help with making post discharge appointments."

Key Takeaways

1. Many transitions of care programs exist, but they are often fragmented, restricted to patients with certain diseases, certain insurance types, or within network PCPs.
2. Challenges include a lack of post-discharge follow-up appointments, limited resources, staff shortages and turnover, and lack of coordination of the various programs.
3. Many programs do not measure the impact of their programs on outcomes important to leadership (e.g., ROI) and important to patients and families (post-discharge safety, anxiety).
4. Facilitators of implementation include stakeholder buy-in, support from leadership, clinical champions, sufficient resources, and a focus on patient-centered outcomes.
5. Hospitalists could play more of a role in leading these programs.

Our next meeting will be on October 11, 2024.