The delivery of safe, high‐quality care to hospitalized patients depends on effective communication among providers.1, 2 Inpatients may receive care from a number of specialists in addition to their primary hospital physicians, and each provider may practice in a group that transfers care of individual patients among its members. This issue is exacerbated in teaching hospitals because fellows, residents, and interns make frequent transfers of care because of work‐hour rules.3, 4 Finally, teams of physician providers making management decisions must effectively communicate with other members of the care team, such as nurses, dieticians, and social workers, who also may be part of a group practice involving transfers. A patient hospitalized for just a few days in a modern hospital may receive care from dozens of providers and be the subject of multiple transfers of care, or handoffs, that require effective communication. Therefore, as part of its 2006 National Patient Safety Goals,5 the Joint Commission on Accreditation of Health Care Organizations (JCAHO) now requires that each hospital implement a standardized, structured approach to transfers of care.

Transfers of care have been shown to be a source of medical errors and adverse patient outcomes.2, 6, 7 In many cases, the critical information necessary to avert medical errors exists but is not available in real time to providers.6

Traditionally, provider teams have relied on the patient chart, in concert with direct patient evaluation, to provide the information to guide decision making during a hospitalization. Unfortunately, the structure of the chart in most hospitals has evolved little over the past 80 years810 and remains organized so that information is more easily filed than retrieved, read, or summarized.811 Typically, electronic medical records (EMRs) mimic the appearance of paper records and include similar organizational flaws.12 As a result, many providers have created ad hoc informational systems, separate from the chart, designed to track a patient's progress over time and to facilitate transfers of care. These sign‐out systems, which are intended to complement verbal sign‐out between providers,1315 range in complexity from simple handwritten index cards16 to adapted spreadsheets, PDA systems,17, 18 and more complex data systems (eg, FileMaker Pro)19 and often contain crucial information not found elsewhere in the medical record.20, 21

Although sign‐out systems are crucial to patient safety, they have several drawbacks. First, ad‐hoc informational systems may not be standardized, resulting in content and accuracy that vary among providers.22 These systems may fail to identify critical elements of a patient's condition, promoting ineffective communication and placing the patient at increased risk of adverse events.7, 13, 23

These observations underscore the need for a standardized patient‐tracking instrument that can distill crucial patient information, enhance communication, support transfers, improve efficiency, and enhance continuity of patient care.

We aimed to develop an integrated, problem‐based patient‐tracking tool as part of our hospital's EMR. The tool, SynopSIS, supports patient tracking, transfers of care (ie, sign‐outs), and daily rounds.

METHODS

PROGRAM DESCRIPTION

Conceptual Model

We developed this conceptual model by integrating existing scholarship and input from stakeholders at our institution. First, we reviewed existing literature on documentation and transfers of care. Next, we conducted several focus group sessions with our EMR Residents' Advisory Group to conceptualize work flow and handoff needs for hospital physicians across specialties. We arrived at this model after several iterations of feedback from providers.

SynopSIS maps patient data available in the EMR to each of the 3 main functions according to type of clinical decisions supported by that function (Fig. 1). For example, data needed for effective patient tracking, such as likely functional status, are required to make decisions over the course of a patient's hospitalization. Similarly, data needed for sign‐out are used to make decisions over the course of a shift, typically overnight; and data needed for morning rounds are used to make decisions for the day. Although the information required for each function overlaps considerably, there are specialized data elements unique to each function.

Figure 1

Description of Functionality

SynopSIS is integrated with our hospital's EMR, General Electric (GE) Centricity Enterprise. The physician interface for SynopSIS is shown in Figure 2. After selecting a patient from a list corresponding to a given inpatient service (eg, Medicine Team B), the user selects the menu option to view the SynopSIS screen, which provides an at a glance overview of the patient's current condition. Different fields on the screen support each of SynopSIS's 3 main functions. At the top, the patient's demographic and registration information is displayed, including name, location, age, medical record number, and attending physician. Below are fields viewable and editable by users of the EMR. The Admission Diagnosis/Course and Problem List fields support patient tracking and allow a receiving physician to understand the reason for the patient's admission, the overall course of the illness, and the current active problems. The problem list is entered by the primary hospital physician. The Anticipated Problems/To Do List field supports the sign‐out function from which providers can coordinate care‐related activities and make contingency plans for anticipated events. The patients' most recent laboratory results and vital signs are displayed on the lower left of the screen for easy reference during face‐to‐face physician sign‐outs. Finally, the CODE status, Allergies, and Medications fields allow efficient tracking of information. Temporarily, until the pharmacy component of the EMR goes into use, the primary hospital physician will enter and update the medications. When the pharmacy is linked to the EMR, medications will be added directly from the inpatient pharmacy records to the EMR‐linked sign‐out tool.

Figure 2

This on‐screen SynopSIS view is distinct from the summary screen typically seen in EMRs, including vendor‐based and the Veterans' Affairs systems. For instance, the Veterans' Affairs summary screen incorporates clinical and nonclinical data, including demographic and payment information, upcoming appointments, and patient‐specific information such as allergies. Moreover, it is not editable by primary hospital physicians. Unlike a summary screen, which collates select patient information from other parts of the EMR, SynopSIS is specific to the current acute hospitalization and includes information not found elsewhere in the medical record.

To support rounding, SynopSIS gathers and presents data from the EMR in a printed Rounds Report (Fig. 3). The report is generated for all patients assigned to an inpatient service (eg, Medicine Team B) and emphasizes clarity and brevity using a format validated in the medical literature.24, 25 Each patient's report covers one fourth of a standard 8‐by‐11‐inch landscape‐printed page. The top half of each of these quarter‐page patient reports displays data stored in SynopSIS's interface and summarizes the patient's illness and the course of that illness. The lower half displays vital signs, intake/output, and laboratory data over the 24 hours from the time of printing. The most recent value and the range over the previous 24 hours of all vital signs are displayed. Intake/output totals are listed together with a structured breakdown. Laboratory results for the past 24 hours are listed with the most immediate prior values, allowing providers to discern trends. We envision providers obtaining a rounds report on arrival each day before examining their patients.

Figure 3

Importantly, although SynopSIS is part of the patient's medical record, physician users may change or overwrite the data in any field. This ability is a critical feature of the toolthe focus is on providing an interpretable snapshot of the patient. Data may be removed as their importance lessens or as the patient's condition changes, which contrasts with unchangeable documentation geared for alternative purposes, such as billing or medical‐legal requirements. Deleted data are saved in the medical record and are viewable by audit.

DISCUSSION

Several systems have been developed to enhance communication among providers and to support the transfer of care of hospitalized patients.13, 14, 16, 19, 24, 25 We have developed a tool to support patient tracking, sign‐out, and rounding that incorporates key elements of previously designed systems and may improve communication among providers. SynopSIS helps to fulfill the 2006 JCAHO accreditation requirement for standardized communication for transfers of care when used with appropriate verbal communication, including an opportunity to ask and respond to questions.5 Research from other safety‐oriented industries recommends standardized information transfer, which SynopSIS will provide.20 What is innovative about SynopSIS is that it is not a stand‐alone system, but an integrated part of the EMR.

Currently, fewer than 5% of hospitals have an electronic sign‐out tool linked to hospital information systems27; therefore, SynopSIS has great potential for dissemination. In technical terms, this tool was coded by GE and could be readily adopted by any other GE Centricity Enterprise customer. Moreover, the conceptual model, the design strategy, and the critical system elements should be relevant to effective patient tracking, sign‐out, and rounding across different IT platforms.

Despite its strengths, the SynopSIS system has several limitations. First, appropriate transfer of care is a learned process that incorporates well‐described provider and system elements.15, 21, 2830 This tool cannot perform sign‐out; it makes up one part of an effective sign‐out process. As our institution implements SynopSIS, we will also proceed with educational efforts and infrastructure to improve the sign‐out process. Second, although data can be overwritten, prior screen versions are archived in the database. Because SynopSIS is part of the medical record, users may omit sensitive or clinically useful information because of medical‐legal concerns, such as sensitive family dynamics or patient behavioral issues that providers may be reluctant to document in the patient chart. Currently, such information is conveyed verbally during sign‐out. Third, as information gathering and transfer become more automated, informal person‐to‐person interactions among providers (eg, physicians and nurses) may erode. However, we expect that SynopSIS actually will enhance the quality of this communication because it places them on the same page. Finally, SynopSIS generates paper reports that must be disposed of in accordance with standards of patient confidentiality.

We believe that SynopSIS will improve the quality of care through several mechanisms. Because this single‐screen summary will be available to all members of a patients' care team, it is possible that SynopSIS will enable providers to share management plans more readily. Although nursing and care management do not use SynopSIS for their own handoffs, they have clamored for the ability to view it. In addition, rotating providers can readily assume care of an unfamiliar patient. By automating data‐gathering tasks, SynopSIS may foster efficiency and increase time with patients during rounds. For trainee providers in particular, such increased efficiency should allow more time for education and alleviate some of the pressures of duty‐hour compliance. Most important, SynopSIS frees the EMR from emulating the historic paper chart as its method of supporting clinical work flow and communication. That paradigm does not harness the power of today's EMR databases and integration capabilities31 and creates extra work through interruptive work flow and redundant effort.32 With SynopSIS reengineering, instead of providers having to serve the needs of the chart, the chart serves the needs of providers and patients.

Future clinical documentation and EMR systems should focus on provider work flow to improve quality and efficiency in patient care. Moreover, involving providers, including residents, in system design fosters innovation and optimally applies information technology to supporting clinical practice.

The delivery of safe, high‐quality care to hospitalized patients depends on effective communication among providers.1, 2 Inpatients may receive care from a number of specialists in addition to their primary hospital physicians, and each provider may practice in a group that transfers care of individual patients among its members. This issue is exacerbated in teaching hospitals because fellows, residents, and interns make frequent transfers of care because of work‐hour rules.3, 4 Finally, teams of physician providers making management decisions must effectively communicate with other members of the care team, such as nurses, dieticians, and social workers, who also may be part of a group practice involving transfers. A patient hospitalized for just a few days in a modern hospital may receive care from dozens of providers and be the subject of multiple transfers of care, or handoffs, that require effective communication. Therefore, as part of its 2006 National Patient Safety Goals,5 the Joint Commission on Accreditation of Health Care Organizations (JCAHO) now requires that each hospital implement a standardized, structured approach to transfers of care.

Transfers of care have been shown to be a source of medical errors and adverse patient outcomes.2, 6, 7 In many cases, the critical information necessary to avert medical errors exists but is not available in real time to providers.6

Traditionally, provider teams have relied on the patient chart, in concert with direct patient evaluation, to provide the information to guide decision making during a hospitalization. Unfortunately, the structure of the chart in most hospitals has evolved little over the past 80 years810 and remains organized so that information is more easily filed than retrieved, read, or summarized.811 Typically, electronic medical records (EMRs) mimic the appearance of paper records and include similar organizational flaws.12 As a result, many providers have created ad hoc informational systems, separate from the chart, designed to track a patient's progress over time and to facilitate transfers of care. These sign‐out systems, which are intended to complement verbal sign‐out between providers,1315 range in complexity from simple handwritten index cards16 to adapted spreadsheets, PDA systems,17, 18 and more complex data systems (eg, FileMaker Pro)19 and often contain crucial information not found elsewhere in the medical record.20, 21

Although sign‐out systems are crucial to patient safety, they have several drawbacks. First, ad‐hoc informational systems may not be standardized, resulting in content and accuracy that vary among providers.22 These systems may fail to identify critical elements of a patient's condition, promoting ineffective communication and placing the patient at increased risk of adverse events.7, 13, 23

These observations underscore the need for a standardized patient‐tracking instrument that can distill crucial patient information, enhance communication, support transfers, improve efficiency, and enhance continuity of patient care.

We aimed to develop an integrated, problem‐based patient‐tracking tool as part of our hospital's EMR. The tool, SynopSIS, supports patient tracking, transfers of care (ie, sign‐outs), and daily rounds.

METHODS

PROGRAM DESCRIPTION

Conceptual Model

We developed this conceptual model by integrating existing scholarship and input from stakeholders at our institution. First, we reviewed existing literature on documentation and transfers of care. Next, we conducted several focus group sessions with our EMR Residents' Advisory Group to conceptualize work flow and handoff needs for hospital physicians across specialties. We arrived at this model after several iterations of feedback from providers.

SynopSIS maps patient data available in the EMR to each of the 3 main functions according to type of clinical decisions supported by that function (Fig. 1). For example, data needed for effective patient tracking, such as likely functional status, are required to make decisions over the course of a patient's hospitalization. Similarly, data needed for sign‐out are used to make decisions over the course of a shift, typically overnight; and data needed for morning rounds are used to make decisions for the day. Although the information required for each function overlaps considerably, there are specialized data elements unique to each function.

Figure 1

Description of Functionality

SynopSIS is integrated with our hospital's EMR, General Electric (GE) Centricity Enterprise. The physician interface for SynopSIS is shown in Figure 2. After selecting a patient from a list corresponding to a given inpatient service (eg, Medicine Team B), the user selects the menu option to view the SynopSIS screen, which provides an at a glance overview of the patient's current condition. Different fields on the screen support each of SynopSIS's 3 main functions. At the top, the patient's demographic and registration information is displayed, including name, location, age, medical record number, and attending physician. Below are fields viewable and editable by users of the EMR. The Admission Diagnosis/Course and Problem List fields support patient tracking and allow a receiving physician to understand the reason for the patient's admission, the overall course of the illness, and the current active problems. The problem list is entered by the primary hospital physician. The Anticipated Problems/To Do List field supports the sign‐out function from which providers can coordinate care‐related activities and make contingency plans for anticipated events. The patients' most recent laboratory results and vital signs are displayed on the lower left of the screen for easy reference during face‐to‐face physician sign‐outs. Finally, the CODE status, Allergies, and Medications fields allow efficient tracking of information. Temporarily, until the pharmacy component of the EMR goes into use, the primary hospital physician will enter and update the medications. When the pharmacy is linked to the EMR, medications will be added directly from the inpatient pharmacy records to the EMR‐linked sign‐out tool.

Figure 2

This on‐screen SynopSIS view is distinct from the summary screen typically seen in EMRs, including vendor‐based and the Veterans' Affairs systems. For instance, the Veterans' Affairs summary screen incorporates clinical and nonclinical data, including demographic and payment information, upcoming appointments, and patient‐specific information such as allergies. Moreover, it is not editable by primary hospital physicians. Unlike a summary screen, which collates select patient information from other parts of the EMR, SynopSIS is specific to the current acute hospitalization and includes information not found elsewhere in the medical record.

To support rounding, SynopSIS gathers and presents data from the EMR in a printed Rounds Report (Fig. 3). The report is generated for all patients assigned to an inpatient service (eg, Medicine Team B) and emphasizes clarity and brevity using a format validated in the medical literature.24, 25 Each patient's report covers one fourth of a standard 8‐by‐11‐inch landscape‐printed page. The top half of each of these quarter‐page patient reports displays data stored in SynopSIS's interface and summarizes the patient's illness and the course of that illness. The lower half displays vital signs, intake/output, and laboratory data over the 24 hours from the time of printing. The most recent value and the range over the previous 24 hours of all vital signs are displayed. Intake/output totals are listed together with a structured breakdown. Laboratory results for the past 24 hours are listed with the most immediate prior values, allowing providers to discern trends. We envision providers obtaining a rounds report on arrival each day before examining their patients.

Figure 3

Importantly, although SynopSIS is part of the patient's medical record, physician users may change or overwrite the data in any field. This ability is a critical feature of the toolthe focus is on providing an interpretable snapshot of the patient. Data may be removed as their importance lessens or as the patient's condition changes, which contrasts with unchangeable documentation geared for alternative purposes, such as billing or medical‐legal requirements. Deleted data are saved in the medical record and are viewable by audit.

DISCUSSION

Several systems have been developed to enhance communication among providers and to support the transfer of care of hospitalized patients.13, 14, 16, 19, 24, 25 We have developed a tool to support patient tracking, sign‐out, and rounding that incorporates key elements of previously designed systems and may improve communication among providers. SynopSIS helps to fulfill the 2006 JCAHO accreditation requirement for standardized communication for transfers of care when used with appropriate verbal communication, including an opportunity to ask and respond to questions.5 Research from other safety‐oriented industries recommends standardized information transfer, which SynopSIS will provide.20 What is innovative about SynopSIS is that it is not a stand‐alone system, but an integrated part of the EMR.

Currently, fewer than 5% of hospitals have an electronic sign‐out tool linked to hospital information systems27; therefore, SynopSIS has great potential for dissemination. In technical terms, this tool was coded by GE and could be readily adopted by any other GE Centricity Enterprise customer. Moreover, the conceptual model, the design strategy, and the critical system elements should be relevant to effective patient tracking, sign‐out, and rounding across different IT platforms.

Despite its strengths, the SynopSIS system has several limitations. First, appropriate transfer of care is a learned process that incorporates well‐described provider and system elements.15, 21, 2830 This tool cannot perform sign‐out; it makes up one part of an effective sign‐out process. As our institution implements SynopSIS, we will also proceed with educational efforts and infrastructure to improve the sign‐out process. Second, although data can be overwritten, prior screen versions are archived in the database. Because SynopSIS is part of the medical record, users may omit sensitive or clinically useful information because of medical‐legal concerns, such as sensitive family dynamics or patient behavioral issues that providers may be reluctant to document in the patient chart. Currently, such information is conveyed verbally during sign‐out. Third, as information gathering and transfer become more automated, informal person‐to‐person interactions among providers (eg, physicians and nurses) may erode. However, we expect that SynopSIS actually will enhance the quality of this communication because it places them on the same page. Finally, SynopSIS generates paper reports that must be disposed of in accordance with standards of patient confidentiality.

We believe that SynopSIS will improve the quality of care through several mechanisms. Because this single‐screen summary will be available to all members of a patients' care team, it is possible that SynopSIS will enable providers to share management plans more readily. Although nursing and care management do not use SynopSIS for their own handoffs, they have clamored for the ability to view it. In addition, rotating providers can readily assume care of an unfamiliar patient. By automating data‐gathering tasks, SynopSIS may foster efficiency and increase time with patients during rounds. For trainee providers in particular, such increased efficiency should allow more time for education and alleviate some of the pressures of duty‐hour compliance. Most important, SynopSIS frees the EMR from emulating the historic paper chart as its method of supporting clinical work flow and communication. That paradigm does not harness the power of today's EMR databases and integration capabilities31 and creates extra work through interruptive work flow and redundant effort.32 With SynopSIS reengineering, instead of providers having to serve the needs of the chart, the chart serves the needs of providers and patients.

Future clinical documentation and EMR systems should focus on provider work flow to improve quality and efficiency in patient care. Moreover, involving providers, including residents, in system design fosters innovation and optimally applies information technology to supporting clinical practice.

The delivery of safe, high‐quality care to hospitalized patients depends on effective communication among providers.1, 2 Inpatients may receive care from a number of specialists in addition to their primary hospital physicians, and each provider may practice in a group that transfers care of individual patients among its members. This issue is exacerbated in teaching hospitals because fellows, residents, and interns make frequent transfers of care because of work‐hour rules.3, 4 Finally, teams of physician providers making management decisions must effectively communicate with other members of the care team, such as nurses, dieticians, and social workers, who also may be part of a group practice involving transfers. A patient hospitalized for just a few days in a modern hospital may receive care from dozens of providers and be the subject of multiple transfers of care, or handoffs, that require effective communication. Therefore, as part of its 2006 National Patient Safety Goals,5 the Joint Commission on Accreditation of Health Care Organizations (JCAHO) now requires that each hospital implement a standardized, structured approach to transfers of care.

Transfers of care have been shown to be a source of medical errors and adverse patient outcomes.2, 6, 7 In many cases, the critical information necessary to avert medical errors exists but is not available in real time to providers.6

Traditionally, provider teams have relied on the patient chart, in concert with direct patient evaluation, to provide the information to guide decision making during a hospitalization. Unfortunately, the structure of the chart in most hospitals has evolved little over the past 80 years810 and remains organized so that information is more easily filed than retrieved, read, or summarized.811 Typically, electronic medical records (EMRs) mimic the appearance of paper records and include similar organizational flaws.12 As a result, many providers have created ad hoc informational systems, separate from the chart, designed to track a patient's progress over time and to facilitate transfers of care. These sign‐out systems, which are intended to complement verbal sign‐out between providers,1315 range in complexity from simple handwritten index cards16 to adapted spreadsheets, PDA systems,17, 18 and more complex data systems (eg, FileMaker Pro)19 and often contain crucial information not found elsewhere in the medical record.20, 21

Although sign‐out systems are crucial to patient safety, they have several drawbacks. First, ad‐hoc informational systems may not be standardized, resulting in content and accuracy that vary among providers.22 These systems may fail to identify critical elements of a patient's condition, promoting ineffective communication and placing the patient at increased risk of adverse events.7, 13, 23

These observations underscore the need for a standardized patient‐tracking instrument that can distill crucial patient information, enhance communication, support transfers, improve efficiency, and enhance continuity of patient care.

We aimed to develop an integrated, problem‐based patient‐tracking tool as part of our hospital's EMR. The tool, SynopSIS, supports patient tracking, transfers of care (ie, sign‐outs), and daily rounds.

METHODS

PROGRAM DESCRIPTION

Conceptual Model

We developed this conceptual model by integrating existing scholarship and input from stakeholders at our institution. First, we reviewed existing literature on documentation and transfers of care. Next, we conducted several focus group sessions with our EMR Residents' Advisory Group to conceptualize work flow and handoff needs for hospital physicians across specialties. We arrived at this model after several iterations of feedback from providers.

SynopSIS maps patient data available in the EMR to each of the 3 main functions according to type of clinical decisions supported by that function (Fig. 1). For example, data needed for effective patient tracking, such as likely functional status, are required to make decisions over the course of a patient's hospitalization. Similarly, data needed for sign‐out are used to make decisions over the course of a shift, typically overnight; and data needed for morning rounds are used to make decisions for the day. Although the information required for each function overlaps considerably, there are specialized data elements unique to each function.

Figure 1

Description of Functionality

SynopSIS is integrated with our hospital's EMR, General Electric (GE) Centricity Enterprise. The physician interface for SynopSIS is shown in Figure 2. After selecting a patient from a list corresponding to a given inpatient service (eg, Medicine Team B), the user selects the menu option to view the SynopSIS screen, which provides an at a glance overview of the patient's current condition. Different fields on the screen support each of SynopSIS's 3 main functions. At the top, the patient's demographic and registration information is displayed, including name, location, age, medical record number, and attending physician. Below are fields viewable and editable by users of the EMR. The Admission Diagnosis/Course and Problem List fields support patient tracking and allow a receiving physician to understand the reason for the patient's admission, the overall course of the illness, and the current active problems. The problem list is entered by the primary hospital physician. The Anticipated Problems/To Do List field supports the sign‐out function from which providers can coordinate care‐related activities and make contingency plans for anticipated events. The patients' most recent laboratory results and vital signs are displayed on the lower left of the screen for easy reference during face‐to‐face physician sign‐outs. Finally, the CODE status, Allergies, and Medications fields allow efficient tracking of information. Temporarily, until the pharmacy component of the EMR goes into use, the primary hospital physician will enter and update the medications. When the pharmacy is linked to the EMR, medications will be added directly from the inpatient pharmacy records to the EMR‐linked sign‐out tool.

Figure 2

This on‐screen SynopSIS view is distinct from the summary screen typically seen in EMRs, including vendor‐based and the Veterans' Affairs systems. For instance, the Veterans' Affairs summary screen incorporates clinical and nonclinical data, including demographic and payment information, upcoming appointments, and patient‐specific information such as allergies. Moreover, it is not editable by primary hospital physicians. Unlike a summary screen, which collates select patient information from other parts of the EMR, SynopSIS is specific to the current acute hospitalization and includes information not found elsewhere in the medical record.

To support rounding, SynopSIS gathers and presents data from the EMR in a printed Rounds Report (Fig. 3). The report is generated for all patients assigned to an inpatient service (eg, Medicine Team B) and emphasizes clarity and brevity using a format validated in the medical literature.24, 25 Each patient's report covers one fourth of a standard 8‐by‐11‐inch landscape‐printed page. The top half of each of these quarter‐page patient reports displays data stored in SynopSIS's interface and summarizes the patient's illness and the course of that illness. The lower half displays vital signs, intake/output, and laboratory data over the 24 hours from the time of printing. The most recent value and the range over the previous 24 hours of all vital signs are displayed. Intake/output totals are listed together with a structured breakdown. Laboratory results for the past 24 hours are listed with the most immediate prior values, allowing providers to discern trends. We envision providers obtaining a rounds report on arrival each day before examining their patients.

Figure 3

Importantly, although SynopSIS is part of the patient's medical record, physician users may change or overwrite the data in any field. This ability is a critical feature of the toolthe focus is on providing an interpretable snapshot of the patient. Data may be removed as their importance lessens or as the patient's condition changes, which contrasts with unchangeable documentation geared for alternative purposes, such as billing or medical‐legal requirements. Deleted data are saved in the medical record and are viewable by audit.

DISCUSSION

Several systems have been developed to enhance communication among providers and to support the transfer of care of hospitalized patients.13, 14, 16, 19, 24, 25 We have developed a tool to support patient tracking, sign‐out, and rounding that incorporates key elements of previously designed systems and may improve communication among providers. SynopSIS helps to fulfill the 2006 JCAHO accreditation requirement for standardized communication for transfers of care when used with appropriate verbal communication, including an opportunity to ask and respond to questions.5 Research from other safety‐oriented industries recommends standardized information transfer, which SynopSIS will provide.20 What is innovative about SynopSIS is that it is not a stand‐alone system, but an integrated part of the EMR.

Currently, fewer than 5% of hospitals have an electronic sign‐out tool linked to hospital information systems27; therefore, SynopSIS has great potential for dissemination. In technical terms, this tool was coded by GE and could be readily adopted by any other GE Centricity Enterprise customer. Moreover, the conceptual model, the design strategy, and the critical system elements should be relevant to effective patient tracking, sign‐out, and rounding across different IT platforms.

Despite its strengths, the SynopSIS system has several limitations. First, appropriate transfer of care is a learned process that incorporates well‐described provider and system elements.15, 21, 2830 This tool cannot perform sign‐out; it makes up one part of an effective sign‐out process. As our institution implements SynopSIS, we will also proceed with educational efforts and infrastructure to improve the sign‐out process. Second, although data can be overwritten, prior screen versions are archived in the database. Because SynopSIS is part of the medical record, users may omit sensitive or clinically useful information because of medical‐legal concerns, such as sensitive family dynamics or patient behavioral issues that providers may be reluctant to document in the patient chart. Currently, such information is conveyed verbally during sign‐out. Third, as information gathering and transfer become more automated, informal person‐to‐person interactions among providers (eg, physicians and nurses) may erode. However, we expect that SynopSIS actually will enhance the quality of this communication because it places them on the same page. Finally, SynopSIS generates paper reports that must be disposed of in accordance with standards of patient confidentiality.

We believe that SynopSIS will improve the quality of care through several mechanisms. Because this single‐screen summary will be available to all members of a patients' care team, it is possible that SynopSIS will enable providers to share management plans more readily. Although nursing and care management do not use SynopSIS for their own handoffs, they have clamored for the ability to view it. In addition, rotating providers can readily assume care of an unfamiliar patient. By automating data‐gathering tasks, SynopSIS may foster efficiency and increase time with patients during rounds. For trainee providers in particular, such increased efficiency should allow more time for education and alleviate some of the pressures of duty‐hour compliance. Most important, SynopSIS frees the EMR from emulating the historic paper chart as its method of supporting clinical work flow and communication. That paradigm does not harness the power of today's EMR databases and integration capabilities31 and creates extra work through interruptive work flow and redundant effort.32 With SynopSIS reengineering, instead of providers having to serve the needs of the chart, the chart serves the needs of providers and patients.

Future clinical documentation and EMR systems should focus on provider work flow to improve quality and efficiency in patient care. Moreover, involving providers, including residents, in system design fosters innovation and optimally applies information technology to supporting clinical practice.

Institute of Medicine (IOM) reports1, 2 have estimated that between 44,000 and 98,000 patients die every year in hospitals because of iatrogenic errors of omission and commission. More people die in a year from medical errors than from car accidents (43,458), breast cancer (42,297), or AIDS (16,515).3 The IOM report recommended a goal of a 50% reduction in errors over the next 5 years.4 Since publication of these reports, a great deal of interest has been focused on how to make our hospitals safer.5, 6 Times of transitions in care (eg, from home to hospital, from emergency department to hospital, from the intensive care unit to the general ward) have been identified as opportune times to improve continuity and thus to decrease errors.

The hospital discharge process is often nonstandardized and frequently marked by poor quality.7 One in five hospital discharges is complicated by adverse events within 30 days, many of which lead to visits to emergency departments (EDs) and rehospitalization.810 Nationally, approximately 25% of hospitalized patients are readmitted within 90 days, often because of errors resulting from discontinuity and fragmentation of care at discharge, which exposes patients to iatrogenic risk and raises costs.11, 12 Low health literacy rates, lack of coordination in the handoff from the hospital to community care, gaps in social supports, and the absence of physician follow‐up after discharge place patients at high risk of rehospitalization.1315 Increasingly, as hospitalists provide more inpatient care, it is difficult for primary care physicians to be aware of all the complexities of a hospitalization.16

Studying the hospital discharge process provides an opportunity to learn more about its complexities,17 which could then be used to standardize the process and focus on those interventions that reduce the number of medical errors and resulting adverse events. However, to date, few studies have described the essential components of the discharge process, and no studies have focused on the discharge process from the point of view of the hospitalized patient. Therefore, a qualitative study was conducted in order to understand the phenomenon of frequent rehospitalization from the perspective of the discharged patient and to determine if activities at the time of discharge could be designed to reduce the number of adverse events and rehospitalizations.

METHODS

The larger study of which this work is a part examined the transition from inpatient service at a large inner‐city hospital to community care in order to lead to the development of an intervention to improve the discharge process. Qualitative research stresses the socially constructed nature of reality, and qualitative researchers seek to answer questions that stress how social experience is created and given meaning.18 Qualitative interviewing permits the researcher to understand the world as seen by the respondent within the context of the respondent's everyday life.19 Learning from the experiences of patients hospitalized more than once in a 6‐month period will help to identify their perceptions and beliefs about their disease and discharge instructions and assist additional interventions that could prevent rehospitalization.

RESULTS

All the patients who participated in this study were able to describe their medical condition and the reasons they were admitted to the hospital. Almost all, 20 of the 21 participants, were rehospitalized for the same primary diagnosis. For 5 of these 20 participants, length of time since the last hospitalization was 5‐6 months (4 for diabetes control, 1 for a lupus erythematosus flare); for 4 participants time since last hospitalization was between 6 weeks and 2 months (1 because of a fall, 1 because of seizures, 1 with hypertension, and 1 with SOB); for 8 participants time since last hospitalization was between 3 weeks and 1 month (2 with kidney disease, 2 with seizures, and 1 each with chronic obstructive pulmonary disease, sickle cell disease, PVD, and alcoholic gastritis), and for 3 participants time since last hospitalization was 1‐2 weeks (1 each with abdominal pain, alcohol intoxication, and lower gastrointestinal bleed). The principal diagnosis in a patient's discharge records matched that participant's description. Participants also described the discharge instructions they received. Although some did not report the brand names of the medications they were taking, all reports of the types of medications being taken or the conditions for which the medications were prescribed were consistent with discharge summaries. Although none of the participants incorrectly reported a medication or condition to the interviewer, a few did not provide information about every medication or condition. In 1 case the discharge summary noted medications for bipolar disorder and mental illness; in 2 cases medications were prescribed for depression. None of these participants mentioned these conditions or medications to the interviewer. One patient talked about stress and depression, but nothing was written about these issues in the discharge record.

For participants in this study, difficult life circumstances posed a greater barrier to recuperation than did lack of medical knowledge. The interviews conducted in this study illustrate the personal and social impact of disease that resulted in rehospitalization.

DISCUSSION AND CONCLUSIONS

The hospital discharge process has been identified as a time when sources of error occur that result in rehospitalization. Many factors that adversely affect care transitions apply to the hospital discharge process, including preparation of the patient and caregiver, communication of the care plan, changes in the medication regimen, transportation of the patient, scheduling of follow‐up care, and availability of advance care directives.20 Patients with low socioeconomic status have been found to be especially vulnerable after discharge. A 1989 telephone survey of 6455 patients recently discharged from hospitals in the United States found that low socioeconomic status and poor patient health were independent predictors of patient problems after discharge.21 A nationwide telephone survey of 1800 recently discharged patients and their care partners also revealed that low socioeconomic status and poor patient health status were associated with problems experienced by care partners.22

High rates of unnecessary rehospitalization have been shown to be related to poorly managed discharge processes.23 Although some factors identified in other studies of care transition did influence the rehospitalization of participants in this study; others did not. Transportation and follow‐up care greatly affected rehospitalization, whereas health literacy had a minimal effect. Fifteen of 20 participants were readmitted within weeks up to 2 months for the same primary diagnosis, yet they understood their medical conditions and knew the procedures to be followed. Having a chronic illness may have affected their understanding of their disease because they had received teaching over time. However, for most participants in this studyinner‐city, minority, low‐income patientsfactors beyond the discharge process affected their rehospitalization. Difficult life circumstances and gaps in ongoing care or support resulted in distress and behavior that exacerbated their conditions. Participants lacked social and emotional support that would have enabled them to prioritize maintaining their health.

Although there is not a universally accepted definition of the concept of social support, it is generally understood that it involves emotional connection and caring24 and occurs in a relationship in which the person providing the support is equipped to respond to a wide variety of needs ranging from practical assistance to counseling and encouragement based on the concerns or life circumstances of the patient. Qualitative studies of social support interventions demonstrate the ways in which having a dependable person to whom a patient can turn for encouragement, information, and practical assistance improves the patient's ability to maintain health regimens and manage chronic pain. An intervention in which nurses made weekly telephone contact with low‐income pregnant smokers helped these patients manage numerous stressors and, in some cases, reduce their tobacco use.25 A support group for women with chronic pain helped participants learn practical strategies for reducing pain and reduced isolation and emotional distress about their conditions.26 A study of consumer experiences of transition care27 found that the most valued institutions were those in which providers from one facility thoroughly communicated a patient's medical and treatment history to providers in another; also important was involving the consumer in medical decision making, preparing the consumer to actively participate in his or her own care, and attending to individual needs and preferences.

This study had several limitations, including reliance on participants' reports of their conditions and experiences with medical staff at a time when they were rehospitalized. In the vulnerable position of being hospitalized, participants may have been reluctant to have complaints about their hospital experiences tape‐recorded. All participants reported positive experiences with hospital staff during the formal interview. Two participants reported negative experiences with hospital staff after the audio‐recorder was turned off and the interview concluded. Other limitations of the hospital setting include limited privacy. Either a roommate was present during the interview or the interview was interrupted by a visit from a hospital staff person or a telephone call. Participants were asked to recall events that for some had occurred several months before the interview, introducing the possibility of inaccurate recall. To address these limitations, we compared interview transcripts to discharge summaries in order to assess any inconsistencies that may have resulted from this lack of privacy. The differences between summaries and patient self‐reports were that 2 participants did not report illicit substance use and 2 did not report psychiatric conditions. Despite these limitations, conducting this study in a hospital setting allowed investigators access to a highly vulnerable population that would be most affected by improvements in the discharge process. Given the difficulties many participants reported in getting to appointments, it is unlikely that a study conducted outside the hospital setting would have effectively reached this population.

These results support the findings in this study that life circumstances outside the hospital can be as important to recovery as institutional coordination of medical care. Although the stresses described by the low‐income patients in this study may not directly cause subsequent illness, their experiences clearly demonstrate the ways in which stresses make it difficult or impossible to attain sufficient rest to heal, maintain the behavioral change necessary to improve health, and follow instructions given by clinicians at the time of discharge. Interventions targeting low‐income patients thus are more likely to succeed if they include provisions for social support and assist patients in easing the burden of daily responsibilities. Effective transition care includes support that may not be explicitly medical, but without which participants lack the stability to fully recuperate. Without the possibility of taking a break from household or parenting responsibilities, it is difficult to rest enough to truly recover. The descriptions of extreme measures taken in order to obtain needed support illustrate how recuperation was compromised by both family responsibilities and lack of flexibility in caregiver work schedules. Distress, particularly depression, further contributed to poor health and undermined the ability to follow doctors' recommendations and discharge plans.

Discharge interventions that explicitly assess requirements for social support and connect patients with agencies or volunteer groups that call or visit those recuperating, provide meals on wheels, or offer other services such as light cleaning or shopping can address the complex circumstances that result in poor health and chronic rehospitalization. This study has identified the crucial role social support plays in getting and staying well.

Institute of Medicine (IOM) reports1, 2 have estimated that between 44,000 and 98,000 patients die every year in hospitals because of iatrogenic errors of omission and commission. More people die in a year from medical errors than from car accidents (43,458), breast cancer (42,297), or AIDS (16,515).3 The IOM report recommended a goal of a 50% reduction in errors over the next 5 years.4 Since publication of these reports, a great deal of interest has been focused on how to make our hospitals safer.5, 6 Times of transitions in care (eg, from home to hospital, from emergency department to hospital, from the intensive care unit to the general ward) have been identified as opportune times to improve continuity and thus to decrease errors.

The hospital discharge process is often nonstandardized and frequently marked by poor quality.7 One in five hospital discharges is complicated by adverse events within 30 days, many of which lead to visits to emergency departments (EDs) and rehospitalization.810 Nationally, approximately 25% of hospitalized patients are readmitted within 90 days, often because of errors resulting from discontinuity and fragmentation of care at discharge, which exposes patients to iatrogenic risk and raises costs.11, 12 Low health literacy rates, lack of coordination in the handoff from the hospital to community care, gaps in social supports, and the absence of physician follow‐up after discharge place patients at high risk of rehospitalization.1315 Increasingly, as hospitalists provide more inpatient care, it is difficult for primary care physicians to be aware of all the complexities of a hospitalization.16

Studying the hospital discharge process provides an opportunity to learn more about its complexities,17 which could then be used to standardize the process and focus on those interventions that reduce the number of medical errors and resulting adverse events. However, to date, few studies have described the essential components of the discharge process, and no studies have focused on the discharge process from the point of view of the hospitalized patient. Therefore, a qualitative study was conducted in order to understand the phenomenon of frequent rehospitalization from the perspective of the discharged patient and to determine if activities at the time of discharge could be designed to reduce the number of adverse events and rehospitalizations.

METHODS

The larger study of which this work is a part examined the transition from inpatient service at a large inner‐city hospital to community care in order to lead to the development of an intervention to improve the discharge process. Qualitative research stresses the socially constructed nature of reality, and qualitative researchers seek to answer questions that stress how social experience is created and given meaning.18 Qualitative interviewing permits the researcher to understand the world as seen by the respondent within the context of the respondent's everyday life.19 Learning from the experiences of patients hospitalized more than once in a 6‐month period will help to identify their perceptions and beliefs about their disease and discharge instructions and assist additional interventions that could prevent rehospitalization.

RESULTS

All the patients who participated in this study were able to describe their medical condition and the reasons they were admitted to the hospital. Almost all, 20 of the 21 participants, were rehospitalized for the same primary diagnosis. For 5 of these 20 participants, length of time since the last hospitalization was 5‐6 months (4 for diabetes control, 1 for a lupus erythematosus flare); for 4 participants time since last hospitalization was between 6 weeks and 2 months (1 because of a fall, 1 because of seizures, 1 with hypertension, and 1 with SOB); for 8 participants time since last hospitalization was between 3 weeks and 1 month (2 with kidney disease, 2 with seizures, and 1 each with chronic obstructive pulmonary disease, sickle cell disease, PVD, and alcoholic gastritis), and for 3 participants time since last hospitalization was 1‐2 weeks (1 each with abdominal pain, alcohol intoxication, and lower gastrointestinal bleed). The principal diagnosis in a patient's discharge records matched that participant's description. Participants also described the discharge instructions they received. Although some did not report the brand names of the medications they were taking, all reports of the types of medications being taken or the conditions for which the medications were prescribed were consistent with discharge summaries. Although none of the participants incorrectly reported a medication or condition to the interviewer, a few did not provide information about every medication or condition. In 1 case the discharge summary noted medications for bipolar disorder and mental illness; in 2 cases medications were prescribed for depression. None of these participants mentioned these conditions or medications to the interviewer. One patient talked about stress and depression, but nothing was written about these issues in the discharge record.

For participants in this study, difficult life circumstances posed a greater barrier to recuperation than did lack of medical knowledge. The interviews conducted in this study illustrate the personal and social impact of disease that resulted in rehospitalization.

DISCUSSION AND CONCLUSIONS

The hospital discharge process has been identified as a time when sources of error occur that result in rehospitalization. Many factors that adversely affect care transitions apply to the hospital discharge process, including preparation of the patient and caregiver, communication of the care plan, changes in the medication regimen, transportation of the patient, scheduling of follow‐up care, and availability of advance care directives.20 Patients with low socioeconomic status have been found to be especially vulnerable after discharge. A 1989 telephone survey of 6455 patients recently discharged from hospitals in the United States found that low socioeconomic status and poor patient health were independent predictors of patient problems after discharge.21 A nationwide telephone survey of 1800 recently discharged patients and their care partners also revealed that low socioeconomic status and poor patient health status were associated with problems experienced by care partners.22

High rates of unnecessary rehospitalization have been shown to be related to poorly managed discharge processes.23 Although some factors identified in other studies of care transition did influence the rehospitalization of participants in this study; others did not. Transportation and follow‐up care greatly affected rehospitalization, whereas health literacy had a minimal effect. Fifteen of 20 participants were readmitted within weeks up to 2 months for the same primary diagnosis, yet they understood their medical conditions and knew the procedures to be followed. Having a chronic illness may have affected their understanding of their disease because they had received teaching over time. However, for most participants in this studyinner‐city, minority, low‐income patientsfactors beyond the discharge process affected their rehospitalization. Difficult life circumstances and gaps in ongoing care or support resulted in distress and behavior that exacerbated their conditions. Participants lacked social and emotional support that would have enabled them to prioritize maintaining their health.

Although there is not a universally accepted definition of the concept of social support, it is generally understood that it involves emotional connection and caring24 and occurs in a relationship in which the person providing the support is equipped to respond to a wide variety of needs ranging from practical assistance to counseling and encouragement based on the concerns or life circumstances of the patient. Qualitative studies of social support interventions demonstrate the ways in which having a dependable person to whom a patient can turn for encouragement, information, and practical assistance improves the patient's ability to maintain health regimens and manage chronic pain. An intervention in which nurses made weekly telephone contact with low‐income pregnant smokers helped these patients manage numerous stressors and, in some cases, reduce their tobacco use.25 A support group for women with chronic pain helped participants learn practical strategies for reducing pain and reduced isolation and emotional distress about their conditions.26 A study of consumer experiences of transition care27 found that the most valued institutions were those in which providers from one facility thoroughly communicated a patient's medical and treatment history to providers in another; also important was involving the consumer in medical decision making, preparing the consumer to actively participate in his or her own care, and attending to individual needs and preferences.

This study had several limitations, including reliance on participants' reports of their conditions and experiences with medical staff at a time when they were rehospitalized. In the vulnerable position of being hospitalized, participants may have been reluctant to have complaints about their hospital experiences tape‐recorded. All participants reported positive experiences with hospital staff during the formal interview. Two participants reported negative experiences with hospital staff after the audio‐recorder was turned off and the interview concluded. Other limitations of the hospital setting include limited privacy. Either a roommate was present during the interview or the interview was interrupted by a visit from a hospital staff person or a telephone call. Participants were asked to recall events that for some had occurred several months before the interview, introducing the possibility of inaccurate recall. To address these limitations, we compared interview transcripts to discharge summaries in order to assess any inconsistencies that may have resulted from this lack of privacy. The differences between summaries and patient self‐reports were that 2 participants did not report illicit substance use and 2 did not report psychiatric conditions. Despite these limitations, conducting this study in a hospital setting allowed investigators access to a highly vulnerable population that would be most affected by improvements in the discharge process. Given the difficulties many participants reported in getting to appointments, it is unlikely that a study conducted outside the hospital setting would have effectively reached this population.

These results support the findings in this study that life circumstances outside the hospital can be as important to recovery as institutional coordination of medical care. Although the stresses described by the low‐income patients in this study may not directly cause subsequent illness, their experiences clearly demonstrate the ways in which stresses make it difficult or impossible to attain sufficient rest to heal, maintain the behavioral change necessary to improve health, and follow instructions given by clinicians at the time of discharge. Interventions targeting low‐income patients thus are more likely to succeed if they include provisions for social support and assist patients in easing the burden of daily responsibilities. Effective transition care includes support that may not be explicitly medical, but without which participants lack the stability to fully recuperate. Without the possibility of taking a break from household or parenting responsibilities, it is difficult to rest enough to truly recover. The descriptions of extreme measures taken in order to obtain needed support illustrate how recuperation was compromised by both family responsibilities and lack of flexibility in caregiver work schedules. Distress, particularly depression, further contributed to poor health and undermined the ability to follow doctors' recommendations and discharge plans.

Discharge interventions that explicitly assess requirements for social support and connect patients with agencies or volunteer groups that call or visit those recuperating, provide meals on wheels, or offer other services such as light cleaning or shopping can address the complex circumstances that result in poor health and chronic rehospitalization. This study has identified the crucial role social support plays in getting and staying well.

Institute of Medicine (IOM) reports1, 2 have estimated that between 44,000 and 98,000 patients die every year in hospitals because of iatrogenic errors of omission and commission. More people die in a year from medical errors than from car accidents (43,458), breast cancer (42,297), or AIDS (16,515).3 The IOM report recommended a goal of a 50% reduction in errors over the next 5 years.4 Since publication of these reports, a great deal of interest has been focused on how to make our hospitals safer.5, 6 Times of transitions in care (eg, from home to hospital, from emergency department to hospital, from the intensive care unit to the general ward) have been identified as opportune times to improve continuity and thus to decrease errors.

The hospital discharge process is often nonstandardized and frequently marked by poor quality.7 One in five hospital discharges is complicated by adverse events within 30 days, many of which lead to visits to emergency departments (EDs) and rehospitalization.810 Nationally, approximately 25% of hospitalized patients are readmitted within 90 days, often because of errors resulting from discontinuity and fragmentation of care at discharge, which exposes patients to iatrogenic risk and raises costs.11, 12 Low health literacy rates, lack of coordination in the handoff from the hospital to community care, gaps in social supports, and the absence of physician follow‐up after discharge place patients at high risk of rehospitalization.1315 Increasingly, as hospitalists provide more inpatient care, it is difficult for primary care physicians to be aware of all the complexities of a hospitalization.16

Studying the hospital discharge process provides an opportunity to learn more about its complexities,17 which could then be used to standardize the process and focus on those interventions that reduce the number of medical errors and resulting adverse events. However, to date, few studies have described the essential components of the discharge process, and no studies have focused on the discharge process from the point of view of the hospitalized patient. Therefore, a qualitative study was conducted in order to understand the phenomenon of frequent rehospitalization from the perspective of the discharged patient and to determine if activities at the time of discharge could be designed to reduce the number of adverse events and rehospitalizations.

METHODS

The larger study of which this work is a part examined the transition from inpatient service at a large inner‐city hospital to community care in order to lead to the development of an intervention to improve the discharge process. Qualitative research stresses the socially constructed nature of reality, and qualitative researchers seek to answer questions that stress how social experience is created and given meaning.18 Qualitative interviewing permits the researcher to understand the world as seen by the respondent within the context of the respondent's everyday life.19 Learning from the experiences of patients hospitalized more than once in a 6‐month period will help to identify their perceptions and beliefs about their disease and discharge instructions and assist additional interventions that could prevent rehospitalization.

RESULTS

All the patients who participated in this study were able to describe their medical condition and the reasons they were admitted to the hospital. Almost all, 20 of the 21 participants, were rehospitalized for the same primary diagnosis. For 5 of these 20 participants, length of time since the last hospitalization was 5‐6 months (4 for diabetes control, 1 for a lupus erythematosus flare); for 4 participants time since last hospitalization was between 6 weeks and 2 months (1 because of a fall, 1 because of seizures, 1 with hypertension, and 1 with SOB); for 8 participants time since last hospitalization was between 3 weeks and 1 month (2 with kidney disease, 2 with seizures, and 1 each with chronic obstructive pulmonary disease, sickle cell disease, PVD, and alcoholic gastritis), and for 3 participants time since last hospitalization was 1‐2 weeks (1 each with abdominal pain, alcohol intoxication, and lower gastrointestinal bleed). The principal diagnosis in a patient's discharge records matched that participant's description. Participants also described the discharge instructions they received. Although some did not report the brand names of the medications they were taking, all reports of the types of medications being taken or the conditions for which the medications were prescribed were consistent with discharge summaries. Although none of the participants incorrectly reported a medication or condition to the interviewer, a few did not provide information about every medication or condition. In 1 case the discharge summary noted medications for bipolar disorder and mental illness; in 2 cases medications were prescribed for depression. None of these participants mentioned these conditions or medications to the interviewer. One patient talked about stress and depression, but nothing was written about these issues in the discharge record.

For participants in this study, difficult life circumstances posed a greater barrier to recuperation than did lack of medical knowledge. The interviews conducted in this study illustrate the personal and social impact of disease that resulted in rehospitalization.

DISCUSSION AND CONCLUSIONS

The hospital discharge process has been identified as a time when sources of error occur that result in rehospitalization. Many factors that adversely affect care transitions apply to the hospital discharge process, including preparation of the patient and caregiver, communication of the care plan, changes in the medication regimen, transportation of the patient, scheduling of follow‐up care, and availability of advance care directives.20 Patients with low socioeconomic status have been found to be especially vulnerable after discharge. A 1989 telephone survey of 6455 patients recently discharged from hospitals in the United States found that low socioeconomic status and poor patient health were independent predictors of patient problems after discharge.21 A nationwide telephone survey of 1800 recently discharged patients and their care partners also revealed that low socioeconomic status and poor patient health status were associated with problems experienced by care partners.22

High rates of unnecessary rehospitalization have been shown to be related to poorly managed discharge processes.23 Although some factors identified in other studies of care transition did influence the rehospitalization of participants in this study; others did not. Transportation and follow‐up care greatly affected rehospitalization, whereas health literacy had a minimal effect. Fifteen of 20 participants were readmitted within weeks up to 2 months for the same primary diagnosis, yet they understood their medical conditions and knew the procedures to be followed. Having a chronic illness may have affected their understanding of their disease because they had received teaching over time. However, for most participants in this studyinner‐city, minority, low‐income patientsfactors beyond the discharge process affected their rehospitalization. Difficult life circumstances and gaps in ongoing care or support resulted in distress and behavior that exacerbated their conditions. Participants lacked social and emotional support that would have enabled them to prioritize maintaining their health.

Although there is not a universally accepted definition of the concept of social support, it is generally understood that it involves emotional connection and caring24 and occurs in a relationship in which the person providing the support is equipped to respond to a wide variety of needs ranging from practical assistance to counseling and encouragement based on the concerns or life circumstances of the patient. Qualitative studies of social support interventions demonstrate the ways in which having a dependable person to whom a patient can turn for encouragement, information, and practical assistance improves the patient's ability to maintain health regimens and manage chronic pain. An intervention in which nurses made weekly telephone contact with low‐income pregnant smokers helped these patients manage numerous stressors and, in some cases, reduce their tobacco use.25 A support group for women with chronic pain helped participants learn practical strategies for reducing pain and reduced isolation and emotional distress about their conditions.26 A study of consumer experiences of transition care27 found that the most valued institutions were those in which providers from one facility thoroughly communicated a patient's medical and treatment history to providers in another; also important was involving the consumer in medical decision making, preparing the consumer to actively participate in his or her own care, and attending to individual needs and preferences.

This study had several limitations, including reliance on participants' reports of their conditions and experiences with medical staff at a time when they were rehospitalized. In the vulnerable position of being hospitalized, participants may have been reluctant to have complaints about their hospital experiences tape‐recorded. All participants reported positive experiences with hospital staff during the formal interview. Two participants reported negative experiences with hospital staff after the audio‐recorder was turned off and the interview concluded. Other limitations of the hospital setting include limited privacy. Either a roommate was present during the interview or the interview was interrupted by a visit from a hospital staff person or a telephone call. Participants were asked to recall events that for some had occurred several months before the interview, introducing the possibility of inaccurate recall. To address these limitations, we compared interview transcripts to discharge summaries in order to assess any inconsistencies that may have resulted from this lack of privacy. The differences between summaries and patient self‐reports were that 2 participants did not report illicit substance use and 2 did not report psychiatric conditions. Despite these limitations, conducting this study in a hospital setting allowed investigators access to a highly vulnerable population that would be most affected by improvements in the discharge process. Given the difficulties many participants reported in getting to appointments, it is unlikely that a study conducted outside the hospital setting would have effectively reached this population.

These results support the findings in this study that life circumstances outside the hospital can be as important to recovery as institutional coordination of medical care. Although the stresses described by the low‐income patients in this study may not directly cause subsequent illness, their experiences clearly demonstrate the ways in which stresses make it difficult or impossible to attain sufficient rest to heal, maintain the behavioral change necessary to improve health, and follow instructions given by clinicians at the time of discharge. Interventions targeting low‐income patients thus are more likely to succeed if they include provisions for social support and assist patients in easing the burden of daily responsibilities. Effective transition care includes support that may not be explicitly medical, but without which participants lack the stability to fully recuperate. Without the possibility of taking a break from household or parenting responsibilities, it is difficult to rest enough to truly recover. The descriptions of extreme measures taken in order to obtain needed support illustrate how recuperation was compromised by both family responsibilities and lack of flexibility in caregiver work schedules. Distress, particularly depression, further contributed to poor health and undermined the ability to follow doctors' recommendations and discharge plans.

Discharge interventions that explicitly assess requirements for social support and connect patients with agencies or volunteer groups that call or visit those recuperating, provide meals on wheels, or offer other services such as light cleaning or shopping can address the complex circumstances that result in poor health and chronic rehospitalization. This study has identified the crucial role social support plays in getting and staying well.

As the counterpart to hospital admission, hospital discharge is a necessary process experienced by each living patient. For all patients except those being transferred to a continuing care facility, discharge is a period of transition from hospital to home that involves a transfer in responsibility from the inpatient provider or hospitalist to the patient and primary care physician (PCP).1 Prescription medications are commonly altered at this transition point, with patients asked to discontinue some medications, switch to a new dosage schedule of others, or begin new treatments.2, 3 Self‐care responsibilities also increase in number and importance, presenting new challenges for patients and their families as they return home.4 Under these circumstances, ineffective planning and coordination of care can undermine patient satisfaction, facilitate adverse events, and contribute to more frequent hospital readmissions.58

Following hospital discharge nearly half (49%) of hospitalized patients experience at least 1 medical error in medication continuity, diagnostic workup, or test follow‐up.7 It has been reported that 19%23% of patients suffer an adverse event, most frequently an adverse drug event (ADE).911 Half of ADEs are considered preventable or ameliorable (ie, their severity or duration could have been decreased). Most errors and adverse events in this setting result from a breakdown in communication between the hospital team and the patient or primary care physician.10

To promote more effective care transitions, The Joint Commission now requires accredited facilities to accurately and completely reconcile medications across the continuum of care.12 The Society of Hospital Medicine recently published recommendations for the discharge of elderly patients.13 The joint Society of Hospital MedicineSociety of General Internal Medicine Continuity of Care Task Force also recently published a systematic review with recommendations for improving the handoff of patient information at discharge.14 Apart from these reports, however, it is uncommon to find evidence‐based recommendations for hospital discharge applicable to a broad range of patients.15 This review highlights several important challenges for physicians who seek to provide high‐quality care during hospital discharge and the subsequent period of transition. Based on the best available evidence, recommendations are also provided for how to improve communication and facilitate the care transition for adult inpatients returning home.

INPATIENTOUTPATIENT PHYSICIAN DISCONTINUITY

Traditionally, primary care physicians have admitted their own patients, provided hospital care (in addition to seeing outpatients during the day), and followed patients after discharge. Under this model, continuity of care has been preserved; however, this method of care has faltered under the weight of inpatients and outpatients with more severe illnesses, rapid technological advancements, managed care pressuring outpatient physicians to see more patients, and a thrust toward reduced hospital costs and length of stay.16 Increases in the efficiency and quality of hospital care have accompanied a new reliance on the field of hospital medicine, while allowing PCPs to focus on outpatient care.1719 With more than 14,000 hospitalists currently practicing in the United States and 25,000 anticipated to be practicing by 2010, transfer of care from hospital‐based providers to PCPs has become increasingly common at discharge.20

Patient discharge summaries are the most common means of communication between inpatient and outpatient providers. However, numerous studies have shown that discharge summaries often fail to provide important administrative and medical information, such as the primary diagnosis, results of abnormal diagnostics, details about the hospital course, follow‐up plans, whether laboratory test results are pending, and patient or family counseling.14 Summaries also may not arrive in a timely manner and sometimes may not reach the PCP at all.2123

At the time patients first follow up with their PCPs after hospitalization, discharge summaries have not yet arrived about 75% of the time,22, 24, 25 restricting the PCPs' ability to provide adequate follow‐up care in 24% of hospital follow‐up visits, according to one study.26 In another investigation, PCPs reported being unaware of 62% of the pending test results that returned after discharge, of which 37% were considered actionable.27

CHANGES AND DISCREPANCIES IN THE MEDICATION REGIMEN

Medication errors make up a large portion of the adverse events patients may experience in the period following hospital discharge.7 In fact, errors during the ordering of admission or discharge medications make up almost half of all hospital medication errors.4043 At transition points such as admission and discharge, errors are often associated with changes in the medication regimen, including discrepancies between the new set of medication orders and what the patient was taking previously. In 2 recent studies, 54% of patients experienced at least 1 unintended medication discrepancy on admission to the hospital, and 39%‐45% of these discrepancies were considered a potential threat to the patient.44, 45

At discharge, differences between the prescribed medication regimen and the prehospital regimen may exist for several reasons. First, physicians may not obtain a comprehensive and accurate medication history at the time of admission.46 The medication history elicited from the patient at hospital admission is often affected by health literacy, language barriers, current health status, medication‐history interviewing skills, and time constraints.47 Physicians may not consult other important sources of medication information, including family members, prescription lists or bottles, and community pharmacy records. The most common error in the admission medication history is omitting a medication taken at home.46 Additionally, several providers, including a physician, a nurse, and an inpatient pharmacist, may independently take medication histories for the same patient. These multiple accounts lead to discrepancies that are rarely recognized or corrected.

Second, a patient's medication regimen can be significantly altered several times during a hospitalization. Acute illness may cause physicians to hold certain medications, discontinue others, or change prescribed doses during hospitalization.48 In addition, at most hospitals closed drug formularies necessitate automatic substitution of 1 medication for another drug in the same class during the patient's hospital stay.49 Changes from long‐acting to short‐acting medications are also routinely made in the name of tighter control (eg, of blood pressure). One study of hospitalized elders found that 40% of all admission medications had been discontinued by discharge and that 45% of all discharge medications were newly started during the hospitalization.3

Finally, at discharge, the current medication regimen needs to be reconciled with the preadmission medication regimen in a thoughtful manner.2 This includes resuming medications held or modified at admission for clinical reasons, resuming medications that were substituted in the hospital for formulary or pharmacokinetic reasons, and stopping newly started medications that were only required during the hospitalization (eg, for prevention of venous thromboembolism or stress ulcers).50 It is difficult, even in hospitals with advanced electronic health information systems, to prompt physicians to make these necessary changes. In a recent study, unexplained discrepancies between the preadmission medication list and discharge medication orders were noted in 49% of hospital discharges.51 Errors in discharge medication reconciliation may subsequently increase the risk of postdischarge ADEs.51

SELF‐CARE RESPONSIBILITIES AND SOCIAL SUPPORT

Compounding the difficulties at discharge are the economic pressures on our health care system, causing patients to be released from the hospital quicker and sicker than ever before.68 The scope of care provided to patients also undergoes a major shift at discharge. Multidisciplinary providers no longer continually review the health status and needs of patients; instead, patients must follow up with their outpatient physician over a period of days to weeks. In the interim, the patients themselves are responsible for administering new medications, participating in physical therapy, and tracking their own symptoms to see if they are worsening. For many patients, sufficient social and family support is not available to help perform these activities effectively. Unfortunately, hospital personnel often inaccurately assess patients' functional status and overestimate patients' knowledge of required self‐care activities.69

INEFFECTIVE PHYSICIANPATIENT COMMUNICATION

Physicianpatient communication is fundamental to the practice of medicine and is crucially important at discharge. However, several studies have demonstrated a disconnect between physician information giving and patient understanding.76, 9690 When providing instructions, physicians commonly use medical jargon and attempt to cover a wealth of information in a limited amount of time.69, 87 They also tend to rely on verbal instructions and fail to provide supplementary audiovisual materials (eg, educational handouts or videos) that could aid patient comprehension. Physicians may not point out important self‐care tasks that patients should carry out at home. The entire interaction may be rushed or seem rushed. Moreover, when physicians solicit questions from patients, they may only allow for yes/no responses by using statements like Any questions? or Do you have any questions? that make it easy for patients to simply respond, No. The encounter usually comes to an end without true confirmation of a patient's level of understanding or assessment of a patient's ability to perform the self‐care activities and medication management required on returning home.81

Adding to the challenges of effective physicianpatient communication is the large number of adult Americans (more than 90 million) who have limited functional literacy skills.91, 92 Such patients typically have difficulty reading and understanding medical instructions, medication labels, and appointment slips.9396 Not surprisingly, patients with limited literacy skills know less about their chronic illnesses and how to manage their diseases.97 Having low literacy is also linked to increased use of emergency department services, a higher risk of hospitalization, and higher health care costs.9799 Patients with limited English proficiency have similar or even greater challenges and also have longer stays in the hospital.100

CONCLUSIONS

The transition from hospital to home is a vulnerable period of discontinuity and potential adverse events. Hospitalists and other inpatient providers should not view discharge as an end to their obligation to patients but rather should attempt to promote a safe and efficient transition of care. Hospitalists can play an important role in bridging the gap between inpatient and outpatient care through appropriate discharge planning and effective communication with patients, their family members, and outpatient physicians.

As the counterpart to hospital admission, hospital discharge is a necessary process experienced by each living patient. For all patients except those being transferred to a continuing care facility, discharge is a period of transition from hospital to home that involves a transfer in responsibility from the inpatient provider or hospitalist to the patient and primary care physician (PCP).1 Prescription medications are commonly altered at this transition point, with patients asked to discontinue some medications, switch to a new dosage schedule of others, or begin new treatments.2, 3 Self‐care responsibilities also increase in number and importance, presenting new challenges for patients and their families as they return home.4 Under these circumstances, ineffective planning and coordination of care can undermine patient satisfaction, facilitate adverse events, and contribute to more frequent hospital readmissions.58

Following hospital discharge nearly half (49%) of hospitalized patients experience at least 1 medical error in medication continuity, diagnostic workup, or test follow‐up.7 It has been reported that 19%23% of patients suffer an adverse event, most frequently an adverse drug event (ADE).911 Half of ADEs are considered preventable or ameliorable (ie, their severity or duration could have been decreased). Most errors and adverse events in this setting result from a breakdown in communication between the hospital team and the patient or primary care physician.10

To promote more effective care transitions, The Joint Commission now requires accredited facilities to accurately and completely reconcile medications across the continuum of care.12 The Society of Hospital Medicine recently published recommendations for the discharge of elderly patients.13 The joint Society of Hospital MedicineSociety of General Internal Medicine Continuity of Care Task Force also recently published a systematic review with recommendations for improving the handoff of patient information at discharge.14 Apart from these reports, however, it is uncommon to find evidence‐based recommendations for hospital discharge applicable to a broad range of patients.15 This review highlights several important challenges for physicians who seek to provide high‐quality care during hospital discharge and the subsequent period of transition. Based on the best available evidence, recommendations are also provided for how to improve communication and facilitate the care transition for adult inpatients returning home.

INPATIENTOUTPATIENT PHYSICIAN DISCONTINUITY

Traditionally, primary care physicians have admitted their own patients, provided hospital care (in addition to seeing outpatients during the day), and followed patients after discharge. Under this model, continuity of care has been preserved; however, this method of care has faltered under the weight of inpatients and outpatients with more severe illnesses, rapid technological advancements, managed care pressuring outpatient physicians to see more patients, and a thrust toward reduced hospital costs and length of stay.16 Increases in the efficiency and quality of hospital care have accompanied a new reliance on the field of hospital medicine, while allowing PCPs to focus on outpatient care.1719 With more than 14,000 hospitalists currently practicing in the United States and 25,000 anticipated to be practicing by 2010, transfer of care from hospital‐based providers to PCPs has become increasingly common at discharge.20

Patient discharge summaries are the most common means of communication between inpatient and outpatient providers. However, numerous studies have shown that discharge summaries often fail to provide important administrative and medical information, such as the primary diagnosis, results of abnormal diagnostics, details about the hospital course, follow‐up plans, whether laboratory test results are pending, and patient or family counseling.14 Summaries also may not arrive in a timely manner and sometimes may not reach the PCP at all.2123

At the time patients first follow up with their PCPs after hospitalization, discharge summaries have not yet arrived about 75% of the time,22, 24, 25 restricting the PCPs' ability to provide adequate follow‐up care in 24% of hospital follow‐up visits, according to one study.26 In another investigation, PCPs reported being unaware of 62% of the pending test results that returned after discharge, of which 37% were considered actionable.27

CHANGES AND DISCREPANCIES IN THE MEDICATION REGIMEN

Medication errors make up a large portion of the adverse events patients may experience in the period following hospital discharge.7 In fact, errors during the ordering of admission or discharge medications make up almost half of all hospital medication errors.4043 At transition points such as admission and discharge, errors are often associated with changes in the medication regimen, including discrepancies between the new set of medication orders and what the patient was taking previously. In 2 recent studies, 54% of patients experienced at least 1 unintended medication discrepancy on admission to the hospital, and 39%‐45% of these discrepancies were considered a potential threat to the patient.44, 45

At discharge, differences between the prescribed medication regimen and the prehospital regimen may exist for several reasons. First, physicians may not obtain a comprehensive and accurate medication history at the time of admission.46 The medication history elicited from the patient at hospital admission is often affected by health literacy, language barriers, current health status, medication‐history interviewing skills, and time constraints.47 Physicians may not consult other important sources of medication information, including family members, prescription lists or bottles, and community pharmacy records. The most common error in the admission medication history is omitting a medication taken at home.46 Additionally, several providers, including a physician, a nurse, and an inpatient pharmacist, may independently take medication histories for the same patient. These multiple accounts lead to discrepancies that are rarely recognized or corrected.

Second, a patient's medication regimen can be significantly altered several times during a hospitalization. Acute illness may cause physicians to hold certain medications, discontinue others, or change prescribed doses during hospitalization.48 In addition, at most hospitals closed drug formularies necessitate automatic substitution of 1 medication for another drug in the same class during the patient's hospital stay.49 Changes from long‐acting to short‐acting medications are also routinely made in the name of tighter control (eg, of blood pressure). One study of hospitalized elders found that 40% of all admission medications had been discontinued by discharge and that 45% of all discharge medications were newly started during the hospitalization.3

Finally, at discharge, the current medication regimen needs to be reconciled with the preadmission medication regimen in a thoughtful manner.2 This includes resuming medications held or modified at admission for clinical reasons, resuming medications that were substituted in the hospital for formulary or pharmacokinetic reasons, and stopping newly started medications that were only required during the hospitalization (eg, for prevention of venous thromboembolism or stress ulcers).50 It is difficult, even in hospitals with advanced electronic health information systems, to prompt physicians to make these necessary changes. In a recent study, unexplained discrepancies between the preadmission medication list and discharge medication orders were noted in 49% of hospital discharges.51 Errors in discharge medication reconciliation may subsequently increase the risk of postdischarge ADEs.51

SELF‐CARE RESPONSIBILITIES AND SOCIAL SUPPORT

Compounding the difficulties at discharge are the economic pressures on our health care system, causing patients to be released from the hospital quicker and sicker than ever before.68 The scope of care provided to patients also undergoes a major shift at discharge. Multidisciplinary providers no longer continually review the health status and needs of patients; instead, patients must follow up with their outpatient physician over a period of days to weeks. In the interim, the patients themselves are responsible for administering new medications, participating in physical therapy, and tracking their own symptoms to see if they are worsening. For many patients, sufficient social and family support is not available to help perform these activities effectively. Unfortunately, hospital personnel often inaccurately assess patients' functional status and overestimate patients' knowledge of required self‐care activities.69

INEFFECTIVE PHYSICIANPATIENT COMMUNICATION

Physicianpatient communication is fundamental to the practice of medicine and is crucially important at discharge. However, several studies have demonstrated a disconnect between physician information giving and patient understanding.76, 9690 When providing instructions, physicians commonly use medical jargon and attempt to cover a wealth of information in a limited amount of time.69, 87 They also tend to rely on verbal instructions and fail to provide supplementary audiovisual materials (eg, educational handouts or videos) that could aid patient comprehension. Physicians may not point out important self‐care tasks that patients should carry out at home. The entire interaction may be rushed or seem rushed. Moreover, when physicians solicit questions from patients, they may only allow for yes/no responses by using statements like Any questions? or Do you have any questions? that make it easy for patients to simply respond, No. The encounter usually comes to an end without true confirmation of a patient's level of understanding or assessment of a patient's ability to perform the self‐care activities and medication management required on returning home.81

Adding to the challenges of effective physicianpatient communication is the large number of adult Americans (more than 90 million) who have limited functional literacy skills.91, 92 Such patients typically have difficulty reading and understanding medical instructions, medication labels, and appointment slips.9396 Not surprisingly, patients with limited literacy skills know less about their chronic illnesses and how to manage their diseases.97 Having low literacy is also linked to increased use of emergency department services, a higher risk of hospitalization, and higher health care costs.9799 Patients with limited English proficiency have similar or even greater challenges and also have longer stays in the hospital.100

CONCLUSIONS

The transition from hospital to home is a vulnerable period of discontinuity and potential adverse events. Hospitalists and other inpatient providers should not view discharge as an end to their obligation to patients but rather should attempt to promote a safe and efficient transition of care. Hospitalists can play an important role in bridging the gap between inpatient and outpatient care through appropriate discharge planning and effective communication with patients, their family members, and outpatient physicians.

As the counterpart to hospital admission, hospital discharge is a necessary process experienced by each living patient. For all patients except those being transferred to a continuing care facility, discharge is a period of transition from hospital to home that involves a transfer in responsibility from the inpatient provider or hospitalist to the patient and primary care physician (PCP).1 Prescription medications are commonly altered at this transition point, with patients asked to discontinue some medications, switch to a new dosage schedule of others, or begin new treatments.2, 3 Self‐care responsibilities also increase in number and importance, presenting new challenges for patients and their families as they return home.4 Under these circumstances, ineffective planning and coordination of care can undermine patient satisfaction, facilitate adverse events, and contribute to more frequent hospital readmissions.58

Following hospital discharge nearly half (49%) of hospitalized patients experience at least 1 medical error in medication continuity, diagnostic workup, or test follow‐up.7 It has been reported that 19%23% of patients suffer an adverse event, most frequently an adverse drug event (ADE).911 Half of ADEs are considered preventable or ameliorable (ie, their severity or duration could have been decreased). Most errors and adverse events in this setting result from a breakdown in communication between the hospital team and the patient or primary care physician.10

To promote more effective care transitions, The Joint Commission now requires accredited facilities to accurately and completely reconcile medications across the continuum of care.12 The Society of Hospital Medicine recently published recommendations for the discharge of elderly patients.13 The joint Society of Hospital MedicineSociety of General Internal Medicine Continuity of Care Task Force also recently published a systematic review with recommendations for improving the handoff of patient information at discharge.14 Apart from these reports, however, it is uncommon to find evidence‐based recommendations for hospital discharge applicable to a broad range of patients.15 This review highlights several important challenges for physicians who seek to provide high‐quality care during hospital discharge and the subsequent period of transition. Based on the best available evidence, recommendations are also provided for how to improve communication and facilitate the care transition for adult inpatients returning home.

INPATIENTOUTPATIENT PHYSICIAN DISCONTINUITY

Traditionally, primary care physicians have admitted their own patients, provided hospital care (in addition to seeing outpatients during the day), and followed patients after discharge. Under this model, continuity of care has been preserved; however, this method of care has faltered under the weight of inpatients and outpatients with more severe illnesses, rapid technological advancements, managed care pressuring outpatient physicians to see more patients, and a thrust toward reduced hospital costs and length of stay.16 Increases in the efficiency and quality of hospital care have accompanied a new reliance on the field of hospital medicine, while allowing PCPs to focus on outpatient care.1719 With more than 14,000 hospitalists currently practicing in the United States and 25,000 anticipated to be practicing by 2010, transfer of care from hospital‐based providers to PCPs has become increasingly common at discharge.20

Patient discharge summaries are the most common means of communication between inpatient and outpatient providers. However, numerous studies have shown that discharge summaries often fail to provide important administrative and medical information, such as the primary diagnosis, results of abnormal diagnostics, details about the hospital course, follow‐up plans, whether laboratory test results are pending, and patient or family counseling.14 Summaries also may not arrive in a timely manner and sometimes may not reach the PCP at all.2123

At the time patients first follow up with their PCPs after hospitalization, discharge summaries have not yet arrived about 75% of the time,22, 24, 25 restricting the PCPs' ability to provide adequate follow‐up care in 24% of hospital follow‐up visits, according to one study.26 In another investigation, PCPs reported being unaware of 62% of the pending test results that returned after discharge, of which 37% were considered actionable.27

CHANGES AND DISCREPANCIES IN THE MEDICATION REGIMEN

Medication errors make up a large portion of the adverse events patients may experience in the period following hospital discharge.7 In fact, errors during the ordering of admission or discharge medications make up almost half of all hospital medication errors.4043 At transition points such as admission and discharge, errors are often associated with changes in the medication regimen, including discrepancies between the new set of medication orders and what the patient was taking previously. In 2 recent studies, 54% of patients experienced at least 1 unintended medication discrepancy on admission to the hospital, and 39%‐45% of these discrepancies were considered a potential threat to the patient.44, 45

At discharge, differences between the prescribed medication regimen and the prehospital regimen may exist for several reasons. First, physicians may not obtain a comprehensive and accurate medication history at the time of admission.46 The medication history elicited from the patient at hospital admission is often affected by health literacy, language barriers, current health status, medication‐history interviewing skills, and time constraints.47 Physicians may not consult other important sources of medication information, including family members, prescription lists or bottles, and community pharmacy records. The most common error in the admission medication history is omitting a medication taken at home.46 Additionally, several providers, including a physician, a nurse, and an inpatient pharmacist, may independently take medication histories for the same patient. These multiple accounts lead to discrepancies that are rarely recognized or corrected.

Second, a patient's medication regimen can be significantly altered several times during a hospitalization. Acute illness may cause physicians to hold certain medications, discontinue others, or change prescribed doses during hospitalization.48 In addition, at most hospitals closed drug formularies necessitate automatic substitution of 1 medication for another drug in the same class during the patient's hospital stay.49 Changes from long‐acting to short‐acting medications are also routinely made in the name of tighter control (eg, of blood pressure). One study of hospitalized elders found that 40% of all admission medications had been discontinued by discharge and that 45% of all discharge medications were newly started during the hospitalization.3

Finally, at discharge, the current medication regimen needs to be reconciled with the preadmission medication regimen in a thoughtful manner.2 This includes resuming medications held or modified at admission for clinical reasons, resuming medications that were substituted in the hospital for formulary or pharmacokinetic reasons, and stopping newly started medications that were only required during the hospitalization (eg, for prevention of venous thromboembolism or stress ulcers).50 It is difficult, even in hospitals with advanced electronic health information systems, to prompt physicians to make these necessary changes. In a recent study, unexplained discrepancies between the preadmission medication list and discharge medication orders were noted in 49% of hospital discharges.51 Errors in discharge medication reconciliation may subsequently increase the risk of postdischarge ADEs.51

SELF‐CARE RESPONSIBILITIES AND SOCIAL SUPPORT

Compounding the difficulties at discharge are the economic pressures on our health care system, causing patients to be released from the hospital quicker and sicker than ever before.68 The scope of care provided to patients also undergoes a major shift at discharge. Multidisciplinary providers no longer continually review the health status and needs of patients; instead, patients must follow up with their outpatient physician over a period of days to weeks. In the interim, the patients themselves are responsible for administering new medications, participating in physical therapy, and tracking their own symptoms to see if they are worsening. For many patients, sufficient social and family support is not available to help perform these activities effectively. Unfortunately, hospital personnel often inaccurately assess patients' functional status and overestimate patients' knowledge of required self‐care activities.69

INEFFECTIVE PHYSICIANPATIENT COMMUNICATION

Physicianpatient communication is fundamental to the practice of medicine and is crucially important at discharge. However, several studies have demonstrated a disconnect between physician information giving and patient understanding.76, 9690 When providing instructions, physicians commonly use medical jargon and attempt to cover a wealth of information in a limited amount of time.69, 87 They also tend to rely on verbal instructions and fail to provide supplementary audiovisual materials (eg, educational handouts or videos) that could aid patient comprehension. Physicians may not point out important self‐care tasks that patients should carry out at home. The entire interaction may be rushed or seem rushed. Moreover, when physicians solicit questions from patients, they may only allow for yes/no responses by using statements like Any questions? or Do you have any questions? that make it easy for patients to simply respond, No. The encounter usually comes to an end without true confirmation of a patient's level of understanding or assessment of a patient's ability to perform the self‐care activities and medication management required on returning home.81

Adding to the challenges of effective physicianpatient communication is the large number of adult Americans (more than 90 million) who have limited functional literacy skills.91, 92 Such patients typically have difficulty reading and understanding medical instructions, medication labels, and appointment slips.9396 Not surprisingly, patients with limited literacy skills know less about their chronic illnesses and how to manage their diseases.97 Having low literacy is also linked to increased use of emergency department services, a higher risk of hospitalization, and higher health care costs.9799 Patients with limited English proficiency have similar or even greater challenges and also have longer stays in the hospital.100

CONCLUSIONS

The transition from hospital to home is a vulnerable period of discontinuity and potential adverse events. Hospitalists and other inpatient providers should not view discharge as an end to their obligation to patients but rather should attempt to promote a safe and efficient transition of care. Hospitalists can play an important role in bridging the gap between inpatient and outpatient care through appropriate discharge planning and effective communication with patients, their family members, and outpatient physicians.

As a hospital practitioner, you have undoubtedly experienced the frustration of witnessing how easily the excellent care you provide can unravel as the patient goes out the door. Patients are admitted acutely ill, and largely attributed to your clinical acumen, they are discharged tuned up and stable to return home. Days later, however, you may learn that your best‐laid discharge plans were not properly executed, and the patient returned with yet another exacerbation. Clearly this scenario represents a major setback for the patient and family caregivers. Possibly dismissed as another episode of patient noncompliance, such readmissions are now being recognized as system failures and reflect a discharge process that has been described as random events connected to highly variable actions with only a remote possibility of meeting implied expectations (Roger Resar, MD, Senior Fellow, Institute for Healthcare Improvement).

Once an area that received relatively little attention, transitions out of the hospital has been identified as a priority area in need of action by a confluence of recent research and national activities. Recognizing the expanding evidence for lapses in quality and safety, many esteemed organizations, including the Joint Commission, the Centers for Medicare and Medicaid Services and their accompanying Quality Improvement Organizations, the Institute for Healthcare Improvement, the Institute of Medicine, National Quality Forum, the Medicare Payment Advisory Committee, the American Board of Internal Medicine Foundation, the National Transitions of Care Coalition, the American College of Physicians, the Society for General Medicine, and the Society for Hospital Medicine, are currently focusing their efforts on how to optimize transitions. All have articulated the need for further clinical investigation that can offer greater insight into the nature of the problems that arise during this vulnerable period and what the potential solutions are.

In this edition of the Journal of Hospital Medicine, 3 teams of investigators have responded to this need, making timely, important, and unique contributions to advance the field.13 Specifically, each of these articles further raises awareness that a patient's transition out of the hospital often unfolds quickly in a fast‐paced, chaotic manner, placing many competing demands on clinicians, patients, and family caregivers. Not surprisingly, such competing demands can contribute to deficits in quality and safety. The authors of these studies all directly identify the central role of communication among clinicians as well as between patients and clinicians in ensuring successful handoffs, further affirming the Joint Commission's finding that inadequate communication is the leading cause of sentinel events.4 In this respect, communication is more than simply the transfer of information; rather, it involves the need to ensure comprehension and provide an opportunity to have a 2‐way dialogue. Importantly, these articles share a common approach in fostering our understanding of the perspective of patients and family caregivers with a particular focus on disadvantaged populations.

Kripalani and colleagues conducted a comprehensive review of the state of the science for those key hospital discharge issues that pertain to hospitalists. They identified a number of challenges including communication between hospital‐ and ambulatory‐based clinicians, medication reconciliation, timely hospital follow‐up, and engaging patients in self‐care. For each of these priority areas, the authors provide pragmatic recommendations for improving care that could be implemented within the current state of practice, either individually or as a bundle of interventions.

Recognizing that patients are often the only common thread across different sites of care, Strunin and colleagues demonstrate the value of including the voice of the patient in helping clinicians to understand the challenges and larger context in which they attempt to follow through with discharge instructions. Strunin et al. found that among a range of factors that contribute to adherence problems, many were nonmedical. Fortunately, a number of these are modifiable and point to the need to both prioritize recommendations to patients and to simplify them whenever possible. The authors' findings resonate with a growing literature that examines the hospital discharge process from the patient's perspective.510

Flacker and colleagues surveyed older patients to gain greater insights into their information needs at discharge. From a process standpoint, they demonstrated that a posthospital survey was feasible and acceptable to older patients. In and of itself, this finding has important implications in the context of national efforts aimed at implementing performance measurement and accompanying public reporting. It also may reflect patients' eagerness to be contacted after discharge; hospitalization is a major event in patients' lives, and attentive follow‐up is appreciated. The authors found that more than half of patients did not recall being asked about how they would care for themselves on returning home from the hospital. Although there may be a variety of explanations for this finding, it nevertheless points to an immediate area for intervention.

Collectively, these 3 articles set the stage for a proposed clinical investigation agenda aimed at optimizing transitions out of the hospital (see Table 1).

These 5 recommendations have the potential to ensure that the gains patients make in our hospitals are maintained long after discharge.

• 1

  Greater Recognition for the Integral Role of Family Caregivers. The patient and family caregivers should be integrated into health care professionals' efforts to improve care coordination across settings. Family caregivers have been silent partners in health care delivery, functioning as de facto care coordinators. During care handoffs, family caregivers make important contributions to ensuring quality, safety, and adherence to patient preferences; their role needs to be formally recognized and supported. An important initial step would be standardizing the approach to defining the types and intensity of the roles family caregivers play to facilitate improved communication. One proposed working definition is the FACED classification developed by one of the authors (E.C.). Modeled after the TNM system used in cancer, each letter of FACED refers to a different contribution made by a family caregiver: F = Financial; A = Advocacy; C = Care coordination; E = Emotional support; and D = Direct care provision. A simple numeric rating system could be developed whereby 0 = does not contribute in this area and 3 = makes significant contribution to this area. Such a straightforward approach would readily inform all members of the health care team about the caregivers' roles and capabilities and how they can optimally collaborate in the care plan.

• 2

  Empirically Define Appropriate Follow‐Up Interval. At present, patients are given rather arbitrary and generic instructions for when to obtain follow‐up with their outpatient primary care physician or specialist. Surgical patients are often instructed to follow up with their surgeon, and yet most of the readmissions of these patients are attributable to medical conditions (personal communication, Steven Jencks, MD, Centers for Medicare and Medicaid Services). Furthermore, a significant number of discharged medical and surgical patients are readmitted to the hospital within 30 days without any outpatient contact with a health professional. One may envision an evidence‐based tiered approach whereby patients are assigned a hospital readmission risk score at the time of discharge that then determines the timing of their follow‐up appointment. Using this framework, the highest‐risk patients may be encouraged to receive follow‐up within 2472 hours, whereas lower‐risk patients may be able to wait 1421 days. Of course, there will need to be sufficient access to outpatient physicians, who will need to be available, to ensure the success of this strategy.

• 3

  Define Physician Accountability for Patients Referred to Home Health on Hospital Discharge. Communication problems between the hospital and the home health care agency are a source of aggravation for both parties, not to mention patients. Typically, a hospitalist provides the initial order for services and then expects subsequent home care coordination to be managed by an outpatient physician. Unfortunately, in some cases the patient may not have an outpatient physician or the patient's primary physician may be unaware of the recent hospitalization and thus unwilling to assume management of an unfamiliar care plan. As a result, home care nurses often cannot identify a physician to respond to their questions or concerns. At the center of this problem lies a lack of understanding of where the responsibility of the ordering hospitalist ends and the outpatient physician assuming care begins. Recognizing the profound costs of failed home health care leading to hospital readmission, the nation's Quality Improvement Organizations launched a national campaign in 2006 to address this problem. Hospitalists should engage in this effort and not punt the entire responsibility to home health agenciesimagine if hospitals and hospitalists were financially penalized if a patient was readmitted.

• 4

  Delineate the Role of the Hospitalist in the Advanced Medical Home. Modeled after a concept with origins in pediatrics, the American College of Physicians and American Academy of Family Physicians are promoting the advanced medical home as a new care model that aims to provide comprehensive ambulatory care with an explicit focus on care coordination.11 The Centers for Medicare and Medicaid Services is planning to initiate a demonstration of this approach. What has not been adequately underscored is how the advanced medical home will communicate essential clinical information with the hospitalist and what, if any, will be the role of the hospitalist in relation to a patient's medical home? Ideally, the medical home approach will alleviate many of the current access problems that impede timely follow‐up.

• 5

  Develop Ability to Examine Episodes of Care. Patients with complex conditions often require care from different practitioners in multiple settings. From the vantage point of health care professionals, these may appear to occur as merely a string of individual interactions, including hospital admissions and discharges. However from the patient's perspective, the experience is more appropriately characterized as a journey across an aggregated episode of care. The National Quality Forum is currently exploring how to measure quality of care delivered across such an episode of care. Additionally, the Centers for Medicare and Medicaid Services is developing a new assessment tool that will transcend acute and postacute care settings, the Continuity Assessment Record and Evaluation (CARE). This tool will potentially enhance our ability to measure care across a predefined episode. Measurement can further pave the way for payment reform designed to align incentives toward higher‐quality care transitions. Currently, professional fees for coronary artery bypass grafting surgery are bundled across an episode, including hospital and posthospital care settings. Extending this approach to a wider array of conditions and services could encourage new perspectives on the timing of discharge and the use of posthospital care venues. For example, under bundled payment, incentives might support a plan to keep a patient in the hospital an extra 1 or 2 days in order to obviate a transfer to a skilled nursing facility and the concomitant risks of transfer‐related problems. Further, bundled payment may allow for the provision of additional services not currently covered, including transportation, as identified by Strunin and colleagues.3

Hospitalists are well positioned to offer leadership in these high‐leverage areas and thereby make a unique contribution to the quality and safety of care transitions. By so doing, they are poised to reaffirm their professionalism,12 ensuring that the excellent care that they provide in the hospital is sustained well into the future.

As a hospital practitioner, you have undoubtedly experienced the frustration of witnessing how easily the excellent care you provide can unravel as the patient goes out the door. Patients are admitted acutely ill, and largely attributed to your clinical acumen, they are discharged tuned up and stable to return home. Days later, however, you may learn that your best‐laid discharge plans were not properly executed, and the patient returned with yet another exacerbation. Clearly this scenario represents a major setback for the patient and family caregivers. Possibly dismissed as another episode of patient noncompliance, such readmissions are now being recognized as system failures and reflect a discharge process that has been described as random events connected to highly variable actions with only a remote possibility of meeting implied expectations (Roger Resar, MD, Senior Fellow, Institute for Healthcare Improvement).

Once an area that received relatively little attention, transitions out of the hospital has been identified as a priority area in need of action by a confluence of recent research and national activities. Recognizing the expanding evidence for lapses in quality and safety, many esteemed organizations, including the Joint Commission, the Centers for Medicare and Medicaid Services and their accompanying Quality Improvement Organizations, the Institute for Healthcare Improvement, the Institute of Medicine, National Quality Forum, the Medicare Payment Advisory Committee, the American Board of Internal Medicine Foundation, the National Transitions of Care Coalition, the American College of Physicians, the Society for General Medicine, and the Society for Hospital Medicine, are currently focusing their efforts on how to optimize transitions. All have articulated the need for further clinical investigation that can offer greater insight into the nature of the problems that arise during this vulnerable period and what the potential solutions are.

In this edition of the Journal of Hospital Medicine, 3 teams of investigators have responded to this need, making timely, important, and unique contributions to advance the field.13 Specifically, each of these articles further raises awareness that a patient's transition out of the hospital often unfolds quickly in a fast‐paced, chaotic manner, placing many competing demands on clinicians, patients, and family caregivers. Not surprisingly, such competing demands can contribute to deficits in quality and safety. The authors of these studies all directly identify the central role of communication among clinicians as well as between patients and clinicians in ensuring successful handoffs, further affirming the Joint Commission's finding that inadequate communication is the leading cause of sentinel events.4 In this respect, communication is more than simply the transfer of information; rather, it involves the need to ensure comprehension and provide an opportunity to have a 2‐way dialogue. Importantly, these articles share a common approach in fostering our understanding of the perspective of patients and family caregivers with a particular focus on disadvantaged populations.

Kripalani and colleagues conducted a comprehensive review of the state of the science for those key hospital discharge issues that pertain to hospitalists. They identified a number of challenges including communication between hospital‐ and ambulatory‐based clinicians, medication reconciliation, timely hospital follow‐up, and engaging patients in self‐care. For each of these priority areas, the authors provide pragmatic recommendations for improving care that could be implemented within the current state of practice, either individually or as a bundle of interventions.

Recognizing that patients are often the only common thread across different sites of care, Strunin and colleagues demonstrate the value of including the voice of the patient in helping clinicians to understand the challenges and larger context in which they attempt to follow through with discharge instructions. Strunin et al. found that among a range of factors that contribute to adherence problems, many were nonmedical. Fortunately, a number of these are modifiable and point to the need to both prioritize recommendations to patients and to simplify them whenever possible. The authors' findings resonate with a growing literature that examines the hospital discharge process from the patient's perspective.510

Flacker and colleagues surveyed older patients to gain greater insights into their information needs at discharge. From a process standpoint, they demonstrated that a posthospital survey was feasible and acceptable to older patients. In and of itself, this finding has important implications in the context of national efforts aimed at implementing performance measurement and accompanying public reporting. It also may reflect patients' eagerness to be contacted after discharge; hospitalization is a major event in patients' lives, and attentive follow‐up is appreciated. The authors found that more than half of patients did not recall being asked about how they would care for themselves on returning home from the hospital. Although there may be a variety of explanations for this finding, it nevertheless points to an immediate area for intervention.

Collectively, these 3 articles set the stage for a proposed clinical investigation agenda aimed at optimizing transitions out of the hospital (see Table 1).

These 5 recommendations have the potential to ensure that the gains patients make in our hospitals are maintained long after discharge.

• 1

  Greater Recognition for the Integral Role of Family Caregivers. The patient and family caregivers should be integrated into health care professionals' efforts to improve care coordination across settings. Family caregivers have been silent partners in health care delivery, functioning as de facto care coordinators. During care handoffs, family caregivers make important contributions to ensuring quality, safety, and adherence to patient preferences; their role needs to be formally recognized and supported. An important initial step would be standardizing the approach to defining the types and intensity of the roles family caregivers play to facilitate improved communication. One proposed working definition is the FACED classification developed by one of the authors (E.C.). Modeled after the TNM system used in cancer, each letter of FACED refers to a different contribution made by a family caregiver: F = Financial; A = Advocacy; C = Care coordination; E = Emotional support; and D = Direct care provision. A simple numeric rating system could be developed whereby 0 = does not contribute in this area and 3 = makes significant contribution to this area. Such a straightforward approach would readily inform all members of the health care team about the caregivers' roles and capabilities and how they can optimally collaborate in the care plan.

• 2

  Empirically Define Appropriate Follow‐Up Interval. At present, patients are given rather arbitrary and generic instructions for when to obtain follow‐up with their outpatient primary care physician or specialist. Surgical patients are often instructed to follow up with their surgeon, and yet most of the readmissions of these patients are attributable to medical conditions (personal communication, Steven Jencks, MD, Centers for Medicare and Medicaid Services). Furthermore, a significant number of discharged medical and surgical patients are readmitted to the hospital within 30 days without any outpatient contact with a health professional. One may envision an evidence‐based tiered approach whereby patients are assigned a hospital readmission risk score at the time of discharge that then determines the timing of their follow‐up appointment. Using this framework, the highest‐risk patients may be encouraged to receive follow‐up within 2472 hours, whereas lower‐risk patients may be able to wait 1421 days. Of course, there will need to be sufficient access to outpatient physicians, who will need to be available, to ensure the success of this strategy.

• 3

  Define Physician Accountability for Patients Referred to Home Health on Hospital Discharge. Communication problems between the hospital and the home health care agency are a source of aggravation for both parties, not to mention patients. Typically, a hospitalist provides the initial order for services and then expects subsequent home care coordination to be managed by an outpatient physician. Unfortunately, in some cases the patient may not have an outpatient physician or the patient's primary physician may be unaware of the recent hospitalization and thus unwilling to assume management of an unfamiliar care plan. As a result, home care nurses often cannot identify a physician to respond to their questions or concerns. At the center of this problem lies a lack of understanding of where the responsibility of the ordering hospitalist ends and the outpatient physician assuming care begins. Recognizing the profound costs of failed home health care leading to hospital readmission, the nation's Quality Improvement Organizations launched a national campaign in 2006 to address this problem. Hospitalists should engage in this effort and not punt the entire responsibility to home health agenciesimagine if hospitals and hospitalists were financially penalized if a patient was readmitted.

• 4

  Delineate the Role of the Hospitalist in the Advanced Medical Home. Modeled after a concept with origins in pediatrics, the American College of Physicians and American Academy of Family Physicians are promoting the advanced medical home as a new care model that aims to provide comprehensive ambulatory care with an explicit focus on care coordination.11 The Centers for Medicare and Medicaid Services is planning to initiate a demonstration of this approach. What has not been adequately underscored is how the advanced medical home will communicate essential clinical information with the hospitalist and what, if any, will be the role of the hospitalist in relation to a patient's medical home? Ideally, the medical home approach will alleviate many of the current access problems that impede timely follow‐up.

• 5

  Develop Ability to Examine Episodes of Care. Patients with complex conditions often require care from different practitioners in multiple settings. From the vantage point of health care professionals, these may appear to occur as merely a string of individual interactions, including hospital admissions and discharges. However from the patient's perspective, the experience is more appropriately characterized as a journey across an aggregated episode of care. The National Quality Forum is currently exploring how to measure quality of care delivered across such an episode of care. Additionally, the Centers for Medicare and Medicaid Services is developing a new assessment tool that will transcend acute and postacute care settings, the Continuity Assessment Record and Evaluation (CARE). This tool will potentially enhance our ability to measure care across a predefined episode. Measurement can further pave the way for payment reform designed to align incentives toward higher‐quality care transitions. Currently, professional fees for coronary artery bypass grafting surgery are bundled across an episode, including hospital and posthospital care settings. Extending this approach to a wider array of conditions and services could encourage new perspectives on the timing of discharge and the use of posthospital care venues. For example, under bundled payment, incentives might support a plan to keep a patient in the hospital an extra 1 or 2 days in order to obviate a transfer to a skilled nursing facility and the concomitant risks of transfer‐related problems. Further, bundled payment may allow for the provision of additional services not currently covered, including transportation, as identified by Strunin and colleagues.3

Hospitalists are well positioned to offer leadership in these high‐leverage areas and thereby make a unique contribution to the quality and safety of care transitions. By so doing, they are poised to reaffirm their professionalism,12 ensuring that the excellent care that they provide in the hospital is sustained well into the future.

As a hospital practitioner, you have undoubtedly experienced the frustration of witnessing how easily the excellent care you provide can unravel as the patient goes out the door. Patients are admitted acutely ill, and largely attributed to your clinical acumen, they are discharged tuned up and stable to return home. Days later, however, you may learn that your best‐laid discharge plans were not properly executed, and the patient returned with yet another exacerbation. Clearly this scenario represents a major setback for the patient and family caregivers. Possibly dismissed as another episode of patient noncompliance, such readmissions are now being recognized as system failures and reflect a discharge process that has been described as random events connected to highly variable actions with only a remote possibility of meeting implied expectations (Roger Resar, MD, Senior Fellow, Institute for Healthcare Improvement).

Once an area that received relatively little attention, transitions out of the hospital has been identified as a priority area in need of action by a confluence of recent research and national activities. Recognizing the expanding evidence for lapses in quality and safety, many esteemed organizations, including the Joint Commission, the Centers for Medicare and Medicaid Services and their accompanying Quality Improvement Organizations, the Institute for Healthcare Improvement, the Institute of Medicine, National Quality Forum, the Medicare Payment Advisory Committee, the American Board of Internal Medicine Foundation, the National Transitions of Care Coalition, the American College of Physicians, the Society for General Medicine, and the Society for Hospital Medicine, are currently focusing their efforts on how to optimize transitions. All have articulated the need for further clinical investigation that can offer greater insight into the nature of the problems that arise during this vulnerable period and what the potential solutions are.

In this edition of the Journal of Hospital Medicine, 3 teams of investigators have responded to this need, making timely, important, and unique contributions to advance the field.13 Specifically, each of these articles further raises awareness that a patient's transition out of the hospital often unfolds quickly in a fast‐paced, chaotic manner, placing many competing demands on clinicians, patients, and family caregivers. Not surprisingly, such competing demands can contribute to deficits in quality and safety. The authors of these studies all directly identify the central role of communication among clinicians as well as between patients and clinicians in ensuring successful handoffs, further affirming the Joint Commission's finding that inadequate communication is the leading cause of sentinel events.4 In this respect, communication is more than simply the transfer of information; rather, it involves the need to ensure comprehension and provide an opportunity to have a 2‐way dialogue. Importantly, these articles share a common approach in fostering our understanding of the perspective of patients and family caregivers with a particular focus on disadvantaged populations.

Kripalani and colleagues conducted a comprehensive review of the state of the science for those key hospital discharge issues that pertain to hospitalists. They identified a number of challenges including communication between hospital‐ and ambulatory‐based clinicians, medication reconciliation, timely hospital follow‐up, and engaging patients in self‐care. For each of these priority areas, the authors provide pragmatic recommendations for improving care that could be implemented within the current state of practice, either individually or as a bundle of interventions.

Recognizing that patients are often the only common thread across different sites of care, Strunin and colleagues demonstrate the value of including the voice of the patient in helping clinicians to understand the challenges and larger context in which they attempt to follow through with discharge instructions. Strunin et al. found that among a range of factors that contribute to adherence problems, many were nonmedical. Fortunately, a number of these are modifiable and point to the need to both prioritize recommendations to patients and to simplify them whenever possible. The authors' findings resonate with a growing literature that examines the hospital discharge process from the patient's perspective.510

Flacker and colleagues surveyed older patients to gain greater insights into their information needs at discharge. From a process standpoint, they demonstrated that a posthospital survey was feasible and acceptable to older patients. In and of itself, this finding has important implications in the context of national efforts aimed at implementing performance measurement and accompanying public reporting. It also may reflect patients' eagerness to be contacted after discharge; hospitalization is a major event in patients' lives, and attentive follow‐up is appreciated. The authors found that more than half of patients did not recall being asked about how they would care for themselves on returning home from the hospital. Although there may be a variety of explanations for this finding, it nevertheless points to an immediate area for intervention.

Collectively, these 3 articles set the stage for a proposed clinical investigation agenda aimed at optimizing transitions out of the hospital (see Table 1).

These 5 recommendations have the potential to ensure that the gains patients make in our hospitals are maintained long after discharge.

• 1

  Greater Recognition for the Integral Role of Family Caregivers. The patient and family caregivers should be integrated into health care professionals' efforts to improve care coordination across settings. Family caregivers have been silent partners in health care delivery, functioning as de facto care coordinators. During care handoffs, family caregivers make important contributions to ensuring quality, safety, and adherence to patient preferences; their role needs to be formally recognized and supported. An important initial step would be standardizing the approach to defining the types and intensity of the roles family caregivers play to facilitate improved communication. One proposed working definition is the FACED classification developed by one of the authors (E.C.). Modeled after the TNM system used in cancer, each letter of FACED refers to a different contribution made by a family caregiver: F = Financial; A = Advocacy; C = Care coordination; E = Emotional support; and D = Direct care provision. A simple numeric rating system could be developed whereby 0 = does not contribute in this area and 3 = makes significant contribution to this area. Such a straightforward approach would readily inform all members of the health care team about the caregivers' roles and capabilities and how they can optimally collaborate in the care plan.

• 2

  Empirically Define Appropriate Follow‐Up Interval. At present, patients are given rather arbitrary and generic instructions for when to obtain follow‐up with their outpatient primary care physician or specialist. Surgical patients are often instructed to follow up with their surgeon, and yet most of the readmissions of these patients are attributable to medical conditions (personal communication, Steven Jencks, MD, Centers for Medicare and Medicaid Services). Furthermore, a significant number of discharged medical and surgical patients are readmitted to the hospital within 30 days without any outpatient contact with a health professional. One may envision an evidence‐based tiered approach whereby patients are assigned a hospital readmission risk score at the time of discharge that then determines the timing of their follow‐up appointment. Using this framework, the highest‐risk patients may be encouraged to receive follow‐up within 2472 hours, whereas lower‐risk patients may be able to wait 1421 days. Of course, there will need to be sufficient access to outpatient physicians, who will need to be available, to ensure the success of this strategy.

• 3

  Define Physician Accountability for Patients Referred to Home Health on Hospital Discharge. Communication problems between the hospital and the home health care agency are a source of aggravation for both parties, not to mention patients. Typically, a hospitalist provides the initial order for services and then expects subsequent home care coordination to be managed by an outpatient physician. Unfortunately, in some cases the patient may not have an outpatient physician or the patient's primary physician may be unaware of the recent hospitalization and thus unwilling to assume management of an unfamiliar care plan. As a result, home care nurses often cannot identify a physician to respond to their questions or concerns. At the center of this problem lies a lack of understanding of where the responsibility of the ordering hospitalist ends and the outpatient physician assuming care begins. Recognizing the profound costs of failed home health care leading to hospital readmission, the nation's Quality Improvement Organizations launched a national campaign in 2006 to address this problem. Hospitalists should engage in this effort and not punt the entire responsibility to home health agenciesimagine if hospitals and hospitalists were financially penalized if a patient was readmitted.

• 4

  Delineate the Role of the Hospitalist in the Advanced Medical Home. Modeled after a concept with origins in pediatrics, the American College of Physicians and American Academy of Family Physicians are promoting the advanced medical home as a new care model that aims to provide comprehensive ambulatory care with an explicit focus on care coordination.11 The Centers for Medicare and Medicaid Services is planning to initiate a demonstration of this approach. What has not been adequately underscored is how the advanced medical home will communicate essential clinical information with the hospitalist and what, if any, will be the role of the hospitalist in relation to a patient's medical home? Ideally, the medical home approach will alleviate many of the current access problems that impede timely follow‐up.

• 5

  Develop Ability to Examine Episodes of Care. Patients with complex conditions often require care from different practitioners in multiple settings. From the vantage point of health care professionals, these may appear to occur as merely a string of individual interactions, including hospital admissions and discharges. However from the patient's perspective, the experience is more appropriately characterized as a journey across an aggregated episode of care. The National Quality Forum is currently exploring how to measure quality of care delivered across such an episode of care. Additionally, the Centers for Medicare and Medicaid Services is developing a new assessment tool that will transcend acute and postacute care settings, the Continuity Assessment Record and Evaluation (CARE). This tool will potentially enhance our ability to measure care across a predefined episode. Measurement can further pave the way for payment reform designed to align incentives toward higher‐quality care transitions. Currently, professional fees for coronary artery bypass grafting surgery are bundled across an episode, including hospital and posthospital care settings. Extending this approach to a wider array of conditions and services could encourage new perspectives on the timing of discharge and the use of posthospital care venues. For example, under bundled payment, incentives might support a plan to keep a patient in the hospital an extra 1 or 2 days in order to obviate a transfer to a skilled nursing facility and the concomitant risks of transfer‐related problems. Further, bundled payment may allow for the provision of additional services not currently covered, including transportation, as identified by Strunin and colleagues.3

Hospitalists are well positioned to offer leadership in these high‐leverage areas and thereby make a unique contribution to the quality and safety of care transitions. By so doing, they are poised to reaffirm their professionalism,12 ensuring that the excellent care that they provide in the hospital is sustained well into the future.