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Doctors & Hospitals
by Carolyn Clancy, M.D., AHRQ, AARP Bulletin, - December 17, 2008
If you have been a patient in the hospital, you may think that most of your medical needs have been taken care of by the time you’re ready to leave. You may also assume that everyone on your medical team—your doctors, nurses, and therapists—is on the same page about your future care needs.
I wish this were the case. In reality, studies show that one in four patients who are discharged from the hospital had an unexpected medical problem after they left the hospital. In some cases, the problems are serious, and the patient ends up back in the hospital.
Why does this happen?
One factor is the time lag between when you are released and when your primary care doctor gets the report (called a discharge summary) from the hospital.
This delay means your doctor isn’t immediately aware of which tests and procedures you had during your hospital stay or if you have other conditions that still need attention. Another problem can occur if test results aren’t complete by the time you leave the hospital. This means the test results won’t be included in the report your doctor gets.
Patients themselves often don’t realize they need to make appointments for tests or procedures after leaving the hospital. Research sponsored by my agency, the Agency for Healthcare Research and Quality, has found that more than one-third of the patients who left the hospital in need of more care, like lab tests or a referral to a specialist, failed to get that care.
Confusion about which drugs to take can also lead to experiencing a medical problem after you leave the hospital. Before a hospital stay, many patients stop taking their regular drugs and start taking new ones while they’re in the hospital. Once they leave the hospital, they may resume taking their regular drugs along with their new ones.
But new drugs may cause side effects if they’re taken with other medications, even vitamins. Patients who suffer heart failure, for example, need to take several types of powerful drugs that may cause harm if they are taken with certain drugs.
The good news is hospitals are working to improve the discharge process. Boston Medical Center in Massachusetts is a leader in this area. Family doctor Brian Jack, M.D., and his colleagues have transformed the way patients are discharged from the hospital and seen for follow-up care at nearby community health centers. The study, called Project RED (short for Re-Engineered Discharge), is funded by AHRQ.
Simple principles are at the heart of Project RED:
• Well-defined roles and responsibilities for everyone on the health care team.
• Patient education throughout the hospital stay.
• Easy flow of information from the patient’s doctor to the hospital team and back to the doctor.
• A written discharge plan.
Dr. Jack’s team uses 11 steps to put these principles into action. They include:
• Educating the patient about his or her diagnosis throughout the hospital stay.
• Making appointments for follow-up and testing.
• Discussing any tests or studies that have been completed in the hospital and deciding who is responsible for follow-up.
• Confirming the medication plan and making sure the patient understands changes in the routine and side effects to watch for.
• Reviewing steps to take if a problem arises.
• Asking the patient to explain in his or her own words the details of the discharge plan.
• Phoning the patient two to three days after discharge to identify and resolve any problems.
Patients who took part in the Project RED study said they felt better prepared to leave the hospital than those who did not participate. For example, 87 percent of those in the study said they knew which appointments they still needed to make, compared with 79 percent who did not participate. Two-thirds of the study group said they understood the main reason why they were in the hospital, compared with 57 percent of nonparticipants.
And a larger percentage of patients (89 percent) who took part in Project RED said they understood their medications after leaving the hospital, compared to those who did not participate in the study (83 percent).
Making sure that patients understand how and when to take their drugs is also a 2008 national patient safety goal of the Joint Commission, a group that reviews hospital care.
I believe that patients should ask their health care team questions—lots of them. But I also understand that a hospital stay can be a confusing and stressful time, which may prevent them from asking the questions they normally would.
That’s why I’m pleased that health professionals realize we need to do a better job of preparing patients for leaving the hospital. Working together, we can improve the chances that all patients will get on the road to better health.
I’m Dr. Carolyn Clancy, and that’s my opinion on how to navigate the health care system.
Carolyn Clancy, a general internist and researcher, is an expert in engaging consumers in their health care. She is the director of the U.S. Agency for Healthcare Research and Quality.
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