Who Coordinates Care For Discharged Patients?

With our current patchwork system of independent providers that includes primary care physicians, specialists, hospitals, home care providers and a host of support services, sometimes the communication between them is lost. When this happens, the patient who is dependent on the coordination of all these services is the one who suffers. This gap seems to be most evident for the newly discharged patient who still must follow a regimen of medication and/or treatment following discharge from the hospital. Where does the hospital's responsibility stop and the primary care physician's responsibility resume? Or is it the job of the specialist? As lengths of stay get shorter and we handle more care on an outpatient basis, this becomes an even bigger issue.

A recent study in the Journal of the American Medical Association highlights this issue relative to heart failure patients. They found that post discharge death rates and readmissions have increased for these patients between 1993 and 2006. At the same time, length of hospital stay has decreased by 2.5 days from 8.8 to 6.3. The study was not conclusive that the shorter length of stay caused the increase in either deaths or readmissions. There may have been other outside factors involved. But the point is that we have a gap in our healthcare system and it seems to be getting worse.

The popular response to this seems to be that we hold the hospital responsible. First we incentivize them to shorten length of stay because we assume they are keeping patients unnecessarily long then we deny payment for readmissions because we assume they are now discharging patients way too early. The fact is that there are many factors that contribute to a patient's readmission. Many of the are out of the control of the hospital. Some of them are out of the control of any of the providers. I have discussed this issue in more detail in a previous post.

The answer is that it involves more than just the hospital. All providers and the patients themselves play a role in this. The key is to have a system where all providers and the patients are involved in their post discharge treatment plan. There are some models being developed as part of the new healthcare reform that show promise for addressing this issue. Let's hope they work.

More on this later.

Mark Brodeur