LR18 / Discharge Transfer Intervention

Type of Patient Safety Practice
Clinical Practice (CP)
Related practices from PaSQ database
“Best fit” category of the reported practice


Patient safety theme the SCP/clinical risk management practice is aimed at
Discharge Transfer Intervention is a safe practice aiming to improve communication between inpatient and outpatient care teams and to promptly reconnect discharged patients with their “medical home.”[15]. A Randomized Controlled Study highlights and details intervention and results obtained by implementing this intervention.
Objective of the CRM practice
To integrate the systematic transfer of patient care to the PCP as part of the discharge process. The main goal is to provide seamless medical care during the transition from hospital to home and to formalize communication to ensure that all parties are well-informed about the post-discharge plan.
Short description of the CRM practice, including any references for further information
The discharge–transfer intervention sought to better equip patients to participate in their post-discharge care, to encourage explicit communication among all involved parties, and to improve accountability for patient care. This intervention consists of the following: (1) a comprehensive, user-friendly Patient Discharge Form provided to patients, in one of 3 languages; (2) the electronic transfer of the Patient Discharge Form to the RNs at the patient’s primary care site; (3) telephone contact by a primary care RN (Registred Nurse) to the patient; and (4) PCP review and modification of the discharge–transfer plan. Additional details are provided below. The Patient Discharge Form was prepared by a discharge planning nurse with input from the discharging physician. The form was computer generated either in English, Portuguese, or Spanish. The floor nurse reviewed the information on the Patient Discharge Form with the patient, using an interpreter as needed. The patient was reminded, in writing, to bring the form to the first post-discharge appointment. The information included in the Patient Discharge Form sought to address communication problems that occur frequently during care transitions, including patients’ inability to state their discharge diagnosis or recall revisions to their medication list [16]. The Patient Discharge Form is sent electronically to the RNs at the patient’s primary care site and became part of the permanent medical record. Receipt of the form signaled to the primary care RNs that the patient had been discharged from the hospital and that a nurse should telephone the patient by the next business day. Utilizing a script (available from RB on request), the primary care RN conducted a brief telephone outreach with the patient. The patient’smedical status was assessed, the Patient Discharge Formwas reviewed, patient questions and concernswere elicited, and scheduled follow-up appointments were confirmed. The nurse arranged immediate interventions as needed, including urgent appointments, medication refills or changes. The Patient Discharge Form and the nurse’s telephone notes were then forwarded electronically to the PCP who reviewed the discharge–transfer plan and modified as necessary [p.1229;1]. The overarching design of our intervention is based upon the structure–process–outcome framework for quality of care JGIM Balaban et al.: Redefining and Redesigning Hospital Discharge 1229 established by Donabedian [17].
Innovator of the SCP, country of origin
Somerville Hospital, a 100-bed community teaching hospital affiliated with Harvard Medical School.
Involved health care staff
This four-step intervention did not require the addition of any new personnel [p.1229;1]. Standard medical staff involved is used in this intervention as follows: 1.) the Patient Discharge Form was prepared by a discharge planning nurse with input from the discharging physician; 2.) the floor nurse reviewed the information on the Patient Discharge Form with the patient, using an interpreter as needed; 3.) the Patient Discharge Form was sent electronically to the RNs at the patient’s primary care site; 4.) utilizing a script (available from RB on request), the primary care RN conducted a brief telephone outreach with the patient; 5.) a nurse from primary care should telephone the patient by the next business day.
Tested in which countries/health care systems, health care context(s) and/or clinical specialty/specialties, including references
Tested in one country –USA, respectively in the Somerville Hospital.[1]
Summary of evidence for effectiveness, including references
As the results of this Randomized Controlled Study show, among a culturally and linguistically diverse population, the intervention significantly increased the rates of timely outpatient follow-up and the completion rates of recommended outpatient workups. Subgroup analysis suggested that the intervention may be effective with non-English speakers, weekend discharges, shorter stay and older patients. 1) Less undesirable outcomes: The intervention group had a significantly lower summary outcome rate than the 2 control groups; 25.5% of the patients in the intervention group had 1 or more undesirable outcomes compared to 55.1% of the concurrent controls and 55.0% of the historical controls. 2.) Higher outpatient follow-up rate: The intervention group’s improved outcome rate was attributable primarily to a higher outpatient follow-up rate within 21 days. In the intervention group, only 14.9% of the patients failed to follow-up within 21 days compared to 40.8% of the concurrent and 35.0% of the historical controls. 3.) Better completion of outpatient workups recommended by the Hospitalist: Only 11.5% of recommended workups in the intervention group were incomplete versus 31.3% of the concurrent controls and 31.0% of the historical controls. 4.) Global effectiveness: The intervention was especially effective among weekend discharges, demonstrating a significantly lower outcome rate in the intervention group (8.3%) compared to both the concurrent (85.7%) and historical (60.0%) controls. Finally, the intervention appeared to have had a greater effect on patients with the shortest hospital stays of 1–2 days and patients 60 years and older.[p.1230-1231;1] 5.) Low-cost: The low cost discharge–transfer intervention used in this study improved the rates of outpatient follow-up and of completed outpatient workups [p.1232;1].
Summary of evidence for transferability (transferability across health care systems or health care contexts or clinical specialties), including references
There were a number of limitations to this study that could affect its generalizability [p.1232-1233;1]. 1. First, an underlying clinical assumption is that timely outpatient follow-up after every hospitalization is desirable. There are, however, no published guidelines as towhen or whether a patient should have outpatient follow-up after hospitalization. We selected a 21-day follow-up to accommodate both the seriously ill patients who need rapid follow-up and those patients who can reasonably wait longer. Beyond 21 days, we believe the immediacy and relevancy of the hospitalization diminish. Future studiesmaywish to examine other time periods. 2. Second, the study was conducted within a single safety net hospital system. As all patients had their PCP within this system and most lacked private insurance, it was likely that patients received the majority of their care within this system. Whereas it is possible that patients could have had an ED visit, a readmission, or specialty care at an outside institution, it is unlikely that this would have altered our results given the randomization of the groups. 3. Third, the system where this intervention was implemented serves primarily a lower socioeconomic group of patients. Whether similar benefits would be realized with more affluent patients remains uncertain. However, studies of various populations have reported quality problems during care transitions, indicating that not only low-income patients are at risk in the post discharge period [2-14]. 4. Fourth, this intervention requires that a patient has a PCP and that the PCP’s office conducts a telephone outreach after hospital discharge. Whereas an integrated medical and information system such as CHA’s is ideal, the intervention could readily be implemented with associated independent practices, if these practices were willing and able to carry out the post discharge outreach. Still, some patients do not have a PCP or their PCP’s office may not be prepared to perform such outreach. As evidence accumulates regarding the benefits of coordinated inpatient and outpatient care, medical standards will ideally advance so that more patients have a medical home to actively manage their post-discharge care. 5. Fifth, the study was small in size and was not powered to examine important outcomes such as cost savings, health improvements, or decreased resource utilization. Larger studies could answer these questions.
Summary of available information on feasibility, including references
There is no evidence available on feasibility of implementation of this safe clinical practice. But, at least in USA, thecomprehensive inpatient-to-outpatient communication could become a precondition for discharge, whereas electronic prompts could facilitate telephone contact with patients immediately upon discharge. Such innovations could help to further the goal, advocated by the Institute of Medicine,26 that high-quality medical care be uniformly delivered by failsafe medical systems.[p.1232;1] there is a well-documented imperative to improve care transitions,[18-21] and the present study is one only a few randomized controlled trials to address this issue [22-26].
Existing implementation tools, including references
The Patient Discharge Form included the following:1. Patient demographics 2. Discharge diagnosis 3. Names of hospital physicians (including residents, Hospitalists, and specialists) 4. Vaccinations given 5. New allergies 6. Dietary and activity instructions 7. Home services ordered 8. Scheduled appointments with PCP, specialists, and fordiagnostic studies 9. Pending medical test results 10. Recommended outpatient workup(s) 11. Discharge medications list, which consisted of the following: (a) Continued medications (with dose changes highlighted) (b) New medications (c) Discontinued medications 12. Optional nursing comments 13. Reminder to patients to bring the form to their next PCP appointment
Potential for/description of patient involvement in the CRM practice, including references
This intervention is based on the communication by medical staff involved and patient. But the role of patient within this intervention is mainly an pasive role, he receiving information, being informed, called and asked for new appoitments.
Bibliography (for each reference: author(s), year, title, journal/internet link, page(s))
1.Richard B. Balaban at all; „Redefining and Redesigning Hospital Discharge to Enhance Patient Care: A Randomized Controlled Study”; May 2, 2008;Journal of General Internal Medicine; J Gen Intern Med. 2008 August; 23(8): pp. 1228–1233; Published online 2008 May 2. doi:  10.1007/s11606-008-0618-9 2. Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18(8):646–51. 3. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161–7. 4. Forster AJ, Clark HD, Menard A, et al. Adverse events among medical patients after discharge from hospital. CMAJ. 2004;170(3):345–9. 5. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297(8):831–41. 6. Schoen C, Davis Km, How SK, Schoenbaum SC. U.S. health system performance: a national scorecard. Health Aff (Millwood). 2006;25(6):w457– 75. 7. Makaryus AN, Friedman EA. Patients’ understanding of their treatment plans and diagnosis at discharge. Mayo Clin Proc. 2005;80(8): 991–4. 8. Beers MH, Sliwkowski J, Brooks J. Compliance with medication orders among the elderly after hospital discharge. Hosp Formul. 1992;27(7):720–4. 9. van Walraven C, Mamdani M, Fang J, Austin PC. Continuity of care and patient outcomes after hospital discharge. J Gen Intern Med. 2004;19(6): 624–31. 10. van Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med. 2002;17(3):186–92. 11. van Walraven C, Seth R, Laupacis A. Dissemination of discharge summaries. Not reaching follow-up physicians. Can Fam Physician. 2002;48:737–42. 12. Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005;143(2):121–8. 13. Coleman EA, Min SJ, Chomiak A, Kramer AM. Posthospital care transitions: patterns, complications, and risk identification. Health Serv Res. 2004;39(5):1449–65. 14. Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;165(4):424–9. 15. Beal AC, Doty MM, Hernadez SE, Shea KK, Davis K. Closing the divide: how medical homes promote equity in health care: results from the Commonwealth Fund 2006 Health Care Quality Survey. The Commonwealth Fund. 2007;62. 16. Makaryus AN, Friedman EA. Patients’ understanding of their treatment plans and diagnosis at discharge. Mayo Clin Proc. 2005;80(8): 991–4. 17. Donabedian A. The quality of care. How can it be assessed? JAMA. 1988;260(12):1743–8. 18. Schoen C, Davis Km, How SK, Schoenbaum SC. U.S. health system performance: a national scorecard. Health Aff (Millwood). 2006;25(6):w457– 75. 19. Coleman EA, Berenson RA. Lost in transition: challenges and opportunities for improving the quality of transitional care. Ann Intern Med. 2004;141(7):533–6. 20. Naylor MD. Transitional care: a critical dimension of the home healthcare quality agenda. J Healthc Qual. 2006;28(1):48–54. 21. SUTTP-Alliance. Principles and Standards forManaging Transitions in Care. 2007. 22. Dudas V, Bookwalter T, Kerr KM, Pantilat SZ. The impact of follow-up telephone calls to patients after hospitalization. Am J Med. 2001;111 (9B):26S–30S. 23. Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822–8. 24. Phillips CO, Wright SM, Kern DE, Singa RM, Shepperd S, Rubin HR. Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis. JAMA. 2004;291 (11):1358–67. 25. Naylor MD, McCauley KM. The effects of a discharge planning and home follow-up intervention on elders hospitalized with common medical and surgical cardiac conditions. J Cardiovasc Nurs. 1999;14 (1):44–54. 26. Shepperd S, Parkes J, McClaren J, Phillips C. Discharge planning from hospital to home. Cochrane Database Syst Rev. 2004;(1):CD000313.
Dr. Marius Ciutan, National School of Public Health and Management, Romania
National School of Public Health and Management, Romania
Any additional information on the CRM (e.g. implementation barriers and drivers)