SummaryHospitalists at Northwestern Memorial Hospital contact the primary care physicians of patients with complex medication regimens who are about to be discharged from the hospital to their homes to discuss the discharge plan and facilitate the patient's transition to the outpatient setting. The primary care doctor subsequently meets or talks by phone with the patient at or soon after discharge to confirm the postdischarge plan and medication regimen and to identify and clarify any confusion the patient may have about them or other health-related issues. In a small trial, patients who had contact with their primary care doctor were 70 percent less likely to have a medication discrepancy than those who did not. Both hospitalists and primary care physicians expressed high levels of satisfaction with the program.Moderate: The evidence consists primarily of a comparison of the likelihood of a medication discrepancy among recently discharged patients who had contact with their primary care physician within 48 hours of discharge with those who did not.
Developing OrganizationsAligning Forces for Quality; Northwestern Memorial Hospital
Date First Implemented2011
Northwestern Memorial Hospital conducted a small trial of the program beginning in January 2011.
Vulnerable Populations > Frail elderly; Medically or socially complex
Problem AddressedMedication discrepancies are common among recently discharged patients, and these discrepancies increase the risk of subsequent medication errors and readmissions. Traditional efforts to reduce discrepancies through use of transitional care personnel can be expensive and hence possibly difficult to sustain. While primary care physicians (PCPs) may be in a good position to work with patients to identify and address discrepancies, relatively few hospitals engage them in this process.
- A common occurrence: Roughly half of the 3 million older adults who are discharged from the hospital to their home experience a medication discrepancy.1 (A medication discrepancy is defined as a difference between the medications prescribed in the medical record, including dosing and frequency, and the actual regimen being taken as reported by the patient). In many cases, discrepancies may be the result of hospitalized patients with complex medical problems being prescribed new medications with complex dosing and schedules. Adhering to these changed regimens can be particularly difficult for elderly patients with cognitive impairment, low health literacy, and/or limited social and financial support.
- Increased risk of readmission: Patients with medication discrepancies face a significantly higher risk of being readmitted to the hospital than those without such discrepancies.2
- Challenges with traditional strategies: Many programs to improve transitional care for recently discharged patients rely on multiple additional personnel, such as care managers, nurses, pharmacists, and/or transitional care coaches.3,4,5,6 These strategies tend to be expensive and hence can be difficult to maintain.
- Unrealized potential of PCPs: PCPs often have established, trusting relationships with their patients (including those recently discharged from the hospital) and may be in a good position to identify and address medication discrepancies. Yet many hospitals fail to routinely communicate with the PCP after a patient is discharged, leading to incomplete and inaccurate information about medications and missed and/or delayed followup appointments.7,8
Description of the Innovative ActivityHospitalists at Northwestern Memorial Hospital contact the PCPs of patients with complex medication regimens who are about to be discharged from the hospital to their homes to discuss the discharge plan and facilitate the transition to the outpatient setting. The PCP subsequently meets or talks by phone with the patient at or soon after discharge to confirm the discharge plan and medication regimen and to identify and clarify any confusion the patient may have about them or other health-related issues. Key program elements are detailed below:
- Targeted at patients with complex medication regimens: The program serves patients 18 and older being discharged to their homes who were taking 5 or more medications prior to the hospitalization. Made up primarily of elderly patients, this population tends to have difficulties following posthospital medication regimens, which often call for the addition of new medications, the removal of old ones, and/or changes in dosing or frequency. During the initial trial, the program excluded those with severe vision impairment, those reliant on a caregiver or home aide 8 or more hours a day (under the assumption that these individuals assist with the medication regimen), those with very short hospital stays (less than 24 hours), and those who do not speak English or Spanish.9
- Predischarge call from hospitalist to PCP: One or two days before discharge, the hospitalist calls the patient’s PCP to discuss the discharge plan and to facilitate the transition to the outpatient setting. Hospital staff send a text via pager reminding the hospitalist to make the call; the text includes relevant contact information. Aided by a written list of topics prepared by program leaders, the hospitalist reviews the patient’s discharge plan with the PCP and highlights recommended changes in the medication regimen and the rationale for them. This call typically takes 10 minutes or less. During the initial trial, hospitalists successfully reached the vast majority of PCPs.
- At or postdischarge communication between PCP and patient: The PCP either meets with the patient in the hospital before discharge or meets with or calls the patient shortly thereafter, ideally within 24 hours. (The hospital’s automatic paging service notifies the PCP via text when a patient has been discharged.) During this 5–10 minute conversation, the PCP explains to the patient that he or she has talked with the hospitalist about the discharge plan and changes to the medication regimen. The PCP emphasizes his or her approval of the plan and the changes and urges the patient to adhere to them. To assist with this process, participating PCPs receive a laminated card listing key discussion topics, including the reason for the hospitalization, resulting medication changes, scheduled followup appointments, and test results still outstanding that may require followup. While covering these areas, the PCP attempts to identify and clear up any confusion the patient may have. During the trial, 36 percent of patients ended up having inperson or phone contact with the PCP within 48 hours of discharge.9 This relatively low contact rate may stem in part from the lack of a financial incentive for PCPs. During the trial, PCPs received a $5 gift card as compensation for their time.9 (Since the trial ended, Medicare has approved new transition codes that allow outpatient physicians to be reimbursed for this type of activity.)
Context of the InnovationNorthwestern Memorial Hospital is a large, acute care hospital located in downtown Chicago. It serves as the primary teaching hospital for Northwestern University's Feinberg School of Medicine. The initial trial focused on patients who had PCPs from practices in the Research and Education for Academic Achievement (REACH) Practice-Based Research Network, a group of eight academic, private, and community-based provider groups affiliated with the hospital and medical school.
The impetus for this program came from physicians and other clinicians practicing in the outpatient setting at Northwestern who found that recently discharged patients with complex medical problems often did not follow their medication regimens after returning home. Fearing that these patients faced an increased risk of readmission, these physicians wanted to find an efficient, effective way to improve the postdischarge transition. PCPs represented a logical resource to employ, since they often have trusted relationships with patients. In addition, getting PCPs involved did not require the addition of new staff, which can be expensive and add unnecessary complexity by creating more handoffs.
ResultsIn a small trial, patients who had contact with their PCP were 70 percent less likely to have a medication discrepancy than those who did not. Both hospitalists and PCPs expressed high levels of satisfaction with the program.
Moderate: The evidence consists primarily of a comparison of the likelihood of a medication discrepancy among recently discharged patients who had contact with their primary care physician within 48 hours of discharge with those who did not.
- Significantly fewer discrepancies: In a trial involving 75 patients who completed a postdischarge phone interview with researchers, patients who had communicated with their PCP at or within 48 hours of discharge were 70 percent less likely to have a medication discrepancy than those who did not have contact with their PCP.9
- No data on readmissions: The study’s small sample size precluded an evaluation of the program’s impact on readmissions.9
- High satisfaction: Anecdotally, both PCPs and hospitalists expressed high levels of satisfaction with the program. Hospitalists saw value in communicating with and facilitating the patient handoff to the PCP, while PCPs appreciated being made a formal part of the transition process. PCPs also found that talking to patients in advance of the first posthospital visit made these visits go more smoothly and efficiently, because in many cases the patient already understood and was adhering to the postdischarge plan and medication regimen.
Planning and Development ProcessKey steps included the following:
- Meeting with hospitalists: Program leaders attended a weekly meeting of hospitalists to introduce the program and the rationale for it. The hospitalists quickly bought into the idea and expressed their support and willingness to talk to patients' PCPs before discharge.
- Meeting with PCP practices: Program leaders visited each of the practices in the REACH network to give a brief presentation explaining the program and the rationale for it. They also distributed the laminated cards listing the key topics to be covered during communications with patients. In most cases, the PCPs expressed strong support for the idea of getting formally involved in care transitions prior to the first postdischarge visit. In a few instances, practice leaders expressed a desire for a nurse to take responsibility for talking to the hospitalist and the patient, although during the subsequent trial PCPs handled all of these conversations.
Resources Used and Skills Needed
- Staffing: The program requires no new staff, as existing personnel incorporate program-related activities into their regular job responsibilities.
- Costs: Program-related costs are minimal. During the trial, patients received $20 for their participation in the research aspects of the study, but this expenditure is not necessary outside of a research trial. As noted, PCPs received a $5 gift card during the trial as compensation for the time required to call patients. However, such an incentive is no longer necessary now that Medicare has approved transition codes that allow PCPs to be reimbursed for the phone call (most patients who are targeted by the program are Medicare beneficiaries).
Funding SourcesNorthwestern Memorial Hospital
Northwestern’s REACH Network provided an internal grant to support research-related aspects of the trial. As noted, Medicare recently created new transition codes that allow PCPs to be reimbursed for phone consultations with recently discharged patients.
Getting Started with This Innovation
- Reach out to high-admitting PCPs, including education about new codes: Meet with the leaders of primary care practices that admit a lot of patients to the hospital to explain the program and the hospital’s desire to work with them to improve postdischarge transitions. As part of this conversation, explain the new Medicare transition codes that allow them to be reimbursed for telephone communications with patients transitioning from the hospital to the home.
- Target elderly patients with complex medication regimens: The program will be most helpful for elderly patients with multiple chronic conditions who take multiple medications, particularly those with low health literacy and/or cognitive impairment.
- Consider including spouses and/or other caregivers: As noted, the initial trial did not include patients with full-time home aides or caregivers. However, the program likely has high value for these patients, who often have physical limitations and/or cognitive impairments and hence rely on someone else to manage their medications. In these instances, the PCP can clear up any confusion the caregiver may have about the postdischarge plan and medication regimen.
Sustaining This Innovation
- Share information on program’s positive impact: Regularly share data and anecdotes with both hospitalists and PCPs that demonstrate the program’s positive impact, including its ability to reduce medication discrepancies and readmissions.
- Facilitate hospital–PCP networking: Periodically host “meet-and-greet” sessions that bring hospitalists together with local PCPs. These sessions provide an opportunity for the doctors to get to know one another and help to make the predischarge conversation between PCP and hospitalist a routine part of care.
Contact the InnovatorLee Lindquist, MD, MPH, MBA
Associate Professor of Medicine
Associate Division Chief, Division of General Internal Medicine and Geriatrics
Northwestern University Feinberg School of Medicine
750 North Lake Shore Drive, 10th Floor
Chicago, IL 60611
Innovator DisclosuresDr. Lindquist reported having no financial interests or business/professional affiliations relevant to the work described in the profile, other than the funders listed in the Funding Sources section.
References/Related ArticlesLindquist LA, Yamahiro A, Garrett A, et al. Primary care physician communication at hospital discharge reduces medication discrepancies. J Hosp Med. 2013;8(12):672–7. [PubMed]
Forster AJ, Murff HJ, Peterson JF, et al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161-7. [PubMed]
Coleman EA, Smith JD, Raha D, et al. Posthospital medication discrepancies—prevalence and contributing factors. Arch Intern Med. 2005;165(16):1842-7. [PubMed]
Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178-87. [PubMed]
Fitzgerald JF, Smith DM, Martin DK, et al. A case manager intervention to reduce readmissions. Arch Intern Med. 1994;154(15):1721-9. [PubMed]
Coleman EA, Smith JD, Frank JC, et al. Preparing patients and caregivers to participate in care delivered across settings: the Care Transitions Intervention. J Am Geriatr Soc. 2004;52(11):1817-25. [PubMed]
Forster AJ, Clark HD, Menard A, et al. Effect of a nurse team coordinator on outcomes for hospitalized medicine patients. Am J Med. 2005;118(10):1148-53. [PubMed]
Arora VM, Prochaska ML, Farnan JM, et al. Problems after discharge and understanding of communication with their primary care physicians among hospitalized seniors: a mixed methods study. J Hosp Med. 2010;5(7):385-91. [PubMed]
Anderson GF, Steinberg EP. Hospital readmissions in the Medicare population. N Engl J Med. 1984;311(21):1349-53. [PubMed]
Lindquist LA, Yamahiro A, Garrett A, et al. Primary care physician communication at hospital discharge reduces medication discrepancies. J Hosp Med. 2013;8(12):672-7. [PubMed]
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Original publication: August 27, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: August 27, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.