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December 12, 2011

To Avoid Readmissions, Hospitals Trying Post-Discharge Clinics

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In recent years, hospitals have been under increasing pressure to keep their readmission rates low. The next bump in the road comes in October 2012, when Medicare will begin cutting back on reimbursement for facilities whose readmit rates are too high.

Hospitals are already hard at work at preventing readmissions due to preventable medical errors, which may not be reimbursed at all by Medicare at all. But it seems like they’re still far behind in the care coordination department.

In fact, research suggests that they’re facing an uphill battle, in part because patients often don’t get the kind of follow-up care they need.

In theory, fragile patients  should move smoothly from inpatient care to their PCP, ideally a medical home equipped to coordinate whatever follow-up care needs they have. Few primary care practices are up to speed yet, however.  In fact, some aren’t even sure when their patients are discharged.

How bad is the problem? According to one study quoted in The Hospitalist, only 42 percent of hospitalized Medicare patients had any contact with a primary care physician within 14 days of being discharged.

One solution to this problem might be a “post-discharge” or transitional care clinic offering primary care on or near a hospital’s campus, the article notes. This makes sense. After all, it’s more likely a patient will follow through and get follow-up care if it’s convenient to do so.

The idea behind these clinics isn’t to replace the patient’s existing PCP; instead, the clinic’s hospitalists, advance-practice nurses or PCPs are there to make sure patients absorbed their post-discharge instructions and are compliant with the meds prescribed during their stay.

Some hospitals have invested significant resources in building out transitional clinics, including Beth Israel Deaconess Medical Center, Seattle-based Harborview Medical Center and Tallahassee (Fla.) Memorial Hospital, which partnered with a local health plan to kick off the effort.

That being said, the idea is a new one and few other hospitals have taken the plunge as of yet. It will be interesting to see whether this approach actually works, and particularly, whether one model of transitional care stands out.

P.S.  I’d particularly like to know whether hospitals can accomplish some of these objectives by monitoring patients remotely after they’re discharged. After attending last week’s mHealth show, I’m betting remote monitoring would be cheaper than setting up a new clinic. Can’t wait to see whether hospitals try that route!





July 9, 2010

Passing the buck, or, why PCPs *are* the problem

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Look, let me say up front that I’m very sympathetic to primary care practices.  I mean, truly.  My family is lucky enough to have access to a small, intimate primary care practice, and I kid you not, I love those folks.

All that being said, I just had an experience which tells me that changing PCP business models are creating a very, very large problem.

What of my experience?  Well, in theory, it was no big deal.  I called in after hours to ask about a family medical problem which worried me, and asked for a bit of guidance.   I was just concerned enough about a family member’s health to see a bit of extra help.

The response I got was another matter. Rather than asking why I had called after regular practice hours, and what my concerns were, the clinician taking call said (more or less verbatim): “Well, I didn’t see (Jill) yesterday when you brought her in, so I have no idea what’s going on with her. Take her to the ED if you want, but I can’t help you.”  I was silent for a bit, shocked by her rudeness (she’s usually very helpful), then said “If that’s what you think” and hung up.

Because I know enough to avoid the ED whenever possible, I held off, and things turned out fine. But this encounter raised a few questions which trouble me deeply:

*  Let me get this straight: Are patients supposed to go to the ED first these days so as not to inconvenience their PCP?

*  If they do contact an on-call PCP, should they be afraid that their call will be “unsuitable” or not worth addressing?

*  Has the whole notion of taking call deteriorated so much that PCPs covering the night shift will only talk to patients they’ve seen recently?  If so, they’re nudging many, many patients to the ED who might otherwise just need a word or two.

For many years, the ED was the pressure point in the whole health system, with ED administrators secretly hoping to avoid uninsured GOMER (Get out of My Emergency Room) patients. (Yes, not very sensitive terminology.)

Now, the problem seems DCAHs (Don’t Call After Hours).  Greviously-stressed care practices just aren’t prepared to absorb the costs of after-hours care or even telephone advice, and it’s throwing the system out of balance in a new way.

As things stand, the exploding primary care clinician shortage just keeps getting worse and the need for patients to have medical homes is climbing. Pile these issues on top of the already overloaded primary care business — in which margins are so bad that practices are adding day spas, for heaven’s sake — and you’ve got real trouble.

Ultimately, I think all of these problems are going to be resolved, and I’m very clear that PCP practices want to help. In the mean time, someone’s going to have to do a better job of fielding the 5PM to 9AM gap in care.  Telemedicine, urgent care centers and retail clinics are making a dent, but they can only make a dent in the problem.   This is a very big deal, and it’s only going to get bigger.