The hospital, which is the "gold standard" for the delivery of acute medical care, is not an ideal care environment for many patients. Iatrogenic events such as nosocomial infections, pressure sores, falls and delirium are common. New functional impairment commonly occurs during hospital stay. Suboptimal transitions in care at the time of hospital discharge also occur, contributing, ironically, to readmission to hospital. Furthermore, hospital care is very expensive. In this issue, Shepperd and colleagues present a meta-analysis of the effectiveness of "hospital-at-home programs."

Peikes D, Chen A, Schore J, Brown R. Effects of Care Coordination on Hospitalization, Quality of Care, and Health Care Expenditures Among Medicare Beneficiaries. JAMA. 2009;301(6). Http://jama.jamanetwork.com/article.aspx?articleid=183370 Accessed 7/9/14. Medicare expenditures of patients with chronic illnesses might be reduced through improvements in care, patient adherence, and communication.

Transitions between healthcare settings are associated with errors in communication of information and treatment plans for frail older patients, but strategies to improve transitional care are lacking. A systematic review was conducted to identify and evaluate interventions to improve communication of accurate and appropriate medication lists and advance directives for elderly patients who transition between nursing homes and hospitals. MEDLINE, ISIWeb, and EBSCO Host (from inception to June 2008) were searched for original, English-language research articles reporting interventions to improve communication of medication lists and advance directives. Five studies ultimately met all inclusion criteria. Two described interventions that enhanced transmission of advance directives, two described interventions that improved communication of medication lists, and one intervention addressed both goals. One study was a randomized controlled trial, whereas the remaining studies used historical or no controls. Study results indicate that a standardized patient transfer form may assist with the communication of advance directives and medication lists and that pharmacist-led review of medication lists may help identify omitted or indicated medications on transfer. Although preliminary evidence supports adoption of these methods to improve transitions between nursing home and hospital, further research is needed to define target populations and outcomes measures for high-quality transitional care.

An emerging consortium of nine leading medical specialty societies – with the support of the ABIM Foundation, AHRQ, IHI, NCQA and others – has recently begun developing principles and initial standards to enhance care transitions. By defining ways to change medical culture, establishing agreed–upon practices, and eventually identifying related measures, this consortium – the Stepping Up to the Plate (SUTTP) Alliance – is focused on designing a system of coordination between sites of care with the goal of reducing errors, gaps in care and waste.

In the United States, 125 million people are living with chronic illness, disability, or functional limitation.1 The nature of modern medicine requires that these patients receive assistance from a number of different care provi ders. Between 2000 and 2002, the typical Medicare beneficiary saw a median of two primary care physicians and five specialists each year, in addition to accessing diagnostic, pharmacy, and other services. Patients with several chronic conditions may visit up to 16 physicians in a year.2 Care among multiple providers must be coordinated to avoid wasteful duplication of diagnostic testing, perilous polypharmacy, and confusion about conflicting care plans.

Background: The exchange of information is an integral component of continuity of health care and may limit or prevent costly duplication of tests and treatments. This study determined the probability that patient information from previous visits with other physicians was available for a current physician visit. Methods: We conducted a multicentre prospective cohort study including patients discharged from the medical or surgical services of 11 community and academic hospitals in Ontario. Patients included in the study saw at least 2 different physicians during the 6 months after discharge. The primary outcome was whether information from a previous visit with another physician was available at the current visit. We determined the availability of previous information using surveys of or interviews with the physicians seen during current visits. Results: A total of 3250 patients, with a total of 39 469 previous–current visit combinations, met the inclusion criteria. Overall, information about the previous visit was available 22.0% of the time. Information was more likely to be available if the current doctor was a family physician (odds ratio [OR] 1.75, 95% confidence interval [CI] 1.54–1.98) or a physician who had treated the patient before the hospital admission (OR 1.33, 95% CI 1.21–1.46). Conversely, information was less likely to be available if the previous doctor was a family physician (OR 0.38, 95% CI 0.32–0.44) or a physician who had treated the patient before the admission (OR 0.72, 95% CI 0.60–0.86). The strongest predictor of information exchange was the current physician having previously received information about the patient from the previous physician (OR 7.72, 95% CI 6.92–8.63).

Older patients with multiple chronic health conditions and complex health care needs often receive care that is fragmented, incomplete, inefficient, and ineffective. This article describes the case of an older woman whose case cannot be managed effectively through the customary approach of simply diagnosing and treating her individual diseases. Based on expert consensus about the available evidence, this article identifies 4 proactive, continuous processes that can substantially improve the primary care of community-dwelling older patients who have multiple chronic conditions: comprehensive assessment, evidence-based care planning and monitoring, promotion of patients' and (family caregivers’) active engagement in care, and coordination of professionals in care of the patient—all tailored to the patient's goals and preferences. Three models of chronic care that include these processes and that appear to improve some aspects of the effectiveness and the efficiency of complex primary care—the Geriatric Resources for Assessment and Care of Elders (GRACE) model, Guided Care, and the Program of All-inclusive Care for the Elderly (PACE)—are described briefly, and steps toward their implementation are discussed.

BACKGROUND: Hospital readmissions are common and costly. A recent previous hospitalization preceding the index admission is a marker of increased risk of future readmission. OBJECTIVES: To identify factors associated with an increased risk of recurrent readmission in medical patients with 2 or more hospitalizations in the past 6 months. DESIGN: Prospective cohort study. SETTING: Australian teaching hospital acute medical wards, February 2006-February 2007. PARTICIPANTS: 142 inpatients aged =50 years with a previous hospitalization =6 months preceding the index admission. Patients from residential care, with terminal illness, or with serious cognitive or language difficulties were excluded. VARIABLES OF INTEREST: Demographics, previous hospitalizations, diagnosis, comorbidities and nutritional status were recorded in hospital. Participants were assessed at home within 2 weeks of hospital discharge using validated questionnaires for cognition, literacy, activities of daily living (ADL)/instrumental activities of daily living (IADL) function, depression, anxiety, alcohol use, medication adherence, social support, and financial status. MAIN OUTCOME MEASURE: Unplanned readmission to the study hospital within 6 months. RESULTS: A total of 55 participants (38.7%) had a further unplanned hospital admission within 6 months. In multivariate analysis, chronic disease (adjusted odds ratio [OR] 3.4; 95% confidence interval [CI], 1.3-9.3, P = 0.002), depressive symptoms (adjusted OR, 3.0; 95% CI, 1.3-6.8, P = 0.01), and underweight (adjusted OR, 12.7; 95% CI, 2.3-70.7, P = 0.004) were significant predictors of readmission after adjusting for age, length of stay and functional status. CONCLUSIONS: In this high-risk patient group, multiple chronic conditions are common and predict increased risk of readmission. Post-hospital interventions should consider targeting nutritional and mood status in this population. Journal of Hospital Medicine 2010. © 2010 Society of Hospital Medicine.

A lack of communication and accountability among healthcare professionals in general and physicians in particular, jeopardizes quality and safety for our patients who are transitioning across sites of care. Our patients, their family caregivers, and our health care professional colleagues on the receiving end of these transfers are often left “flying blind” without adequate information or direction to make sound clinical decisions.

Background: Acutely ill older persons often experience adverse events when cared for in the acute care hospital. Objective: To assess the clinical feasibility and efficacy of providing acute hospital-level care in a patient's home in a hospital at home. Design: Prospective quasi-experiment. Setting: 3 Medicare-managed care (Medicare + Choice) health systems at 2 sites and a Veterans Administration medical center. Participants: 455 community-dwelling elderly patients who required admission to an acute care hospital for community-acquired pneumonia, exacerbation of chronic heart failure, exacerbation of chronic obstructive pulmonary disease, or cellulitis. Intervention: Treatment in a hospital-at-home model of care that substitutes for treatment in an acute care hospital. Measurements: Clinical process measures, standards of care, clinical complications, satisfaction with care, functional status, and costs of care. Results: Hospital-at-home care was feasible and efficacious in delivering hospital-level care to patients at home. In 2 of 3 sites studied, 69% of patients who were offered hospital-at-home care chose it over acute hospital care; in the third site, 29% of patients chose hospital-at-home care. Although less procedurally oriented than acute hospital care, hospital-at-home care met quality standards at rates similar to those of acute hospital care. On an intention-to-treat basis, patients treated in hospital-at-home had a shorter length of stay (3.2 vs. 4.9 days) (P?= 0.004), and there was some evidence that they also had fewer complications. The mean cost was lower for hospital-at-home care than for acute hospital care ($5081 vs. $7480) (P?< 0.001). Limitations: Possible selection bias because of the quasi-experimental design and missing data, modest sample size, and study site differences. Conclusions: The hospital-at-home care model is feasible, safe, and efficacious for certain older patients with selected acute medical illnesses who require acute hospital-level care.

Rehospitalizations that occur soon after hospital discharge are drawing increasing attention. About 2.5 million Medicare beneficiaries and about 2 million other patients are rehospitalized within 30 days of discharge, with total hospital costs (not including physician services) of about $44 billion (1; Steiner C, Jiang J. Personal communication). From the perspectives of payers, purchasers, and policymakers, avoidable rehospitalizations represent massive and remediable waste. However, most rehospitalization is the result of clinical deterioration, occurs emergently, and is often necessary by the time the patient reaches the emergency department. Some emergency department visits might be prevented from turning into hospitalizations. However, compelling evidence from a series of controlled studies (2–4), in which interventions to improve the transition from hospital to posthospital care have reduced rehospitalizations by 30% to 50%, suggests that the rehospitalization problem represents a failure of those transitions rather than willful overuse of hospital services. It is a symptom of fragmented care

With hospitalists playing key roles in improving transitions in care, a new study has tested a low-cost process that shows increases in outpatient follow-up and completed workups soon after hospital discharge. The improvements potentially could lead to better patient outcomes and lower readmission rates, according to Richard B. Balaban, MD, who as the medical director of Cambridge Health Alliance’s (CHA) Somerville, Mass., primary-care center and a hospitalist at CHA’s Cambridge Hospital has a unique, dual perspective on the discharge process. Dr. Balaban’s team’s discharge-transfer intervention process, tested in one of the few randomized controlled studies on the subject of transitions of care, is intended to improve communication between hospitalists and primary-care providers, as well as promptly connect inpatients to outpatient providers. It’s also designed to better equip patients to participate in their care and to improve accountability within the medical team.

BACKGROUND: Patients are routinely ill-prepared for the transition from hospital to home. Inadequate communication between Hospitalists and primary care providers can further compromise post-discharge care. Redesigning the discharge processmay improve the continuity and the quality of patient care. OBJECTIVES: To evaluate a low-cost intervention designed to promptly reconnect patients to their “medical home” after hospital discharge. DESIGN: Randomized controlled study. Intervention patients received a “user-friendly” Patient Discharge Form, and upon arrival at home, a telephone outreach from a nurse at their primary care site. PARTICIPANTS: A culturally and linguistically diverse group of patients admitted to a small community teaching hospital. MEASUREMENTS: Four undesirable outcomes were measured after hospital discharge: (1) no outpatient follow-up within 21 days; (2) readmission within 31 days; (3) emergency department visit within 31 days; and (4) failure by the primary care provider to complete an outpatient workup recommended by the hospital doctors. Outcomes of the intervention group were compared to concurrent and historical controls. RESULTS: Only 25.5% of intervention patients had 1 or more undesirable outcomes compared to 55.1% of the concurrent and 55.0% of the historical controls. Notably, only 14.9% of the intervention patients failed to follow-up within 21 days compared to 40.8% of the concurrent and 35.0% of the historical controls. Only 11.5% of recommended outpatient workups in the intervention group were incomplete versus 31.3% in the concurrent and 31.0% in the historical controls. CONCLUSIONS: A low-cost discharge–transfer intervention may improve the rates of outpatient follow-up and of completed workups after hospital discharge.

After patients are discharged from U.S. hospitals, 13 percent require rehospitalization and one in five patients suffers an adverse event. Many of these problems are due to inadequate postdischarge followup of patients' unresolved medical problems. More patients with unresolved problems would receive outpatient workups if their primary care doctors received the hospital doctors' discharge summary recommendations, concludes a study supported by the Agency for Healthcare Research and Quality (HS14020). A second AHRQ-supported study (HS14289 and HS15905) describes 11 factors that could be modified during the hospital discharge process to reduce posthospital adverse events and rehospitalizations. Both studies are briefly discussed here.

Context: Readmission after hospitalization for heart failure is common. Early outpatient follow-up after hospitalization has been proposed as a means of reducing readmission rates. However, there are limited data describing patterns of follow-up after heart failure hospitalization and its association with readmission rates. Objective: To examine associations between outpatient follow-up within 7 days after discharge from a heart failure hospitalization and readmission within 30 days. Design, Setting, and Patients: Observational analysis of patients 65 years or older with heart failure and discharged to home from hospitals participating in the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure and the Get With the Guidelines-Heart Failure quality improvement program from January 1, 2003, through December 31, 2006. Main Outcome Measure: All-cause readmission within 30 days after discharge. Results: The study population included 30 136 patients from 225 hospitals. Median length of stay was 4 days (interquartile range, 2-6) and 21.3% of patients were readmitted within 30 days. At the hospital level, the median percentage of patients who had early follow-up after discharge from the index hospitalization was 38.3% (interquartile range, 32.4%-44.5%). Compared with patients whose index admission was in a hospital in the lowest quartile of early follow-up (30-day readmission rate, 23.3%), the rates of 30-day readmission were 20.5% among patients in the second quartile (risk-adjusted hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.78-0.93), 20.5% among patients in the third quartile (risk-adjusted HR, 0.87; 95% CI, 0.78-0.96), and 20.9% among patients in the fourth quartile (risk-adjusted HR, 0.91; 95% CI, 0.83-1.00). Conclusions: Among patients who are hospitalized for heart failure, substantial variation exists in hospital-level rates of early outpatient follow-up after discharge. Patients who are discharged from hospitals that have higher early follow-up rates have a lower risk of 30-day readmission.

Sharma G, Fletcher K, Zhang D, et.al. JAMA. 2009;301(16):1671-1680. http://jama.jamanetwork.com/article.aspx?articleid=183797 . Accessed August 1, 2014. Continuity of Outpatient and Inpatient Care by Primary Care Physicians for Hospitalized Older Adults. Context Little is known about the extent of continuity of care across the transition from outpatient care to hospitalization. Objectives To describe continuity of care in older hospitalized patients, change in continuity over time, and factors associated with discontinuity.

Schnipper J, Roumie C, Cawthon C, et.al. Rationale and Design of the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) Study. Circulation: Cardiovascular Quality and Outcomes. 2010; 3: 212-219. http://circoutcomes.ahajournals.org/content/3/2/212.abstract . Accessed August 1, 2014. Background— Medication errors and adverse drug events are common after hospital discharge due to changes in medication regimens, suboptimal discharge instructions, and prolonged time to follow-up. Pharmacist-based interventions may be effective in promoting the safe and effective use of medications, especially among high-risk patients such as those with low health literacy.