Submitted by Colleen O’Connor, MD, LMC Campus lead of Hospital Medicine
“Transitions in Care” represents a key feature of hospital medicine — not only within MLH but on a national level. We see it reiterated in many forums via our umbrella organization, the Society of Hospitalist Medicine, as it is rare that any current article on hospital medicine trends does not highlight some aspect of this as a central component of the care we provide. Yet despite this messaging, it is often the piece that is most challenging to coordinate, and most risky if not fully addressed.
Approaching discharges with patient education, assistance with medications, access to post discharge services and coordinated follow up remains a significant challenge for many hospitalized patients. This is all the more paramount as hospitalists continue to gain momentum on a local and national level, with more and more primary care physicians collaborating with hospitalists to care for their admitted patients. In its ideal state, a pristine hand off process with coordinated post discharge care is invaluable: reaching out to PCPs, sharing admission data, helping secure access to medications, preventing medication errors, and ultimately preventing hospital readmission, particularly with our high risk patients. Across all campuses, much work is being done on multiple levels to help improve our “Transitions in Care.”
Hospital Medicine at MLH has already started to partner with MLHC outpatient care management as well as outpatient care management from the DVACO. This connection and ready access to the primary care environment has been invaluable. We look forward to further collaboration with our outpatient partners expanded beyond just our Medicare populations to include all patients and all referring PCPs. We also look forward to developing disease specific care transition pathways.
Many are aware of significant investment in processes to help prevent CHF readmissions – a local and national trend need, addressing this patient population most at risk of readmission.
Here within MLH, and specifically at LMC, collaboration with Nursing, Physician, Care Management, Patient Quality leadership as well Administration is moving us closer and closer to a more comprehensive approach to the care of our CHF patients.
Similarly, our Clinical Operations Committee – composed of physician/nursing dyads on each campus representing Internal Medicine, Surgery, OB-GYN, Emergency Medicine and Critical Care, is addressing multiple aspects of hospital care. Partnering physician and nursing leadership has in this forum helped approach needs and issues in a balanced way. Specifically, our Internal Medicine dyad has prioritized aspects involving transitions of care:
- making “multidisclinary rounds” involving inpatient medicine teams (floor managers, housestaff/attendings, CM, SW, PT) more scripted and efficient
- better anticipating and addressing post discharge care, in close coordination with case management
- reevaluating role of attending supervision in medication reconciliation and electronic discharge process
Our goal is to take the hard work involving both the CHF Readmissions Committee as well as our Clinical Operations Committee to each campus to share in the process of improving Transitions of Care, and ultimately provide safe, expedited, high quality discharges.