Lost in translation: five parachutes for the "jumping into the void" at hospital discharge

Marco Inzitari

As in Sofia Coppola's melancholic and visual film of 15 years ago, the disorientation that is experienced during a phase of transition, which in the movie was a life transition whereas in our case a transition between care levels, could be converted into an opportunity to rethink the present and face the future with a renewed perspective. Especially if we are lucky enough to partner with good travel companions with whom we can share the same concerns.

At the 2018 International Conference on Integrated Care (# ICIC18, Utrecht, The Netherlands, May 23-25), Dr. Eric Coleman, a world leader in care transitions at hospital discharge, said: "We look too closely at when we will discharge or when we will see the patient once at home, and scarcely at what we will do with him or her ". According to Dr. Coleman, the clinical management pre and post-discharge should be improved, together with achieving these quantitative indicators.

"Have we transmitted pre-discharge information?", "For how many patients/year?", "Has the patient been visited before 48 hours after discharge?", "Have we shared information though the electronic medical records?” are all very useful binary questions (all of them linked, for example, to the Pre-Alt program, widely implemented in Catalonia), but don’t exhaust the problem of quality or the added value we provide. We must take care of the training and pro-activity of the professionals behind the "machines" or who are implementing the trajectories and, above all, work with patients and caregivers and make them an active part in the transitions.

The multiple needs of people in situations of clinical, functional and social complexity, and with frailty, mean that, even if we had the best integrated health and social care system possible, which still does not exist, the intervention of different resources, care levels or specialists would be inevitable. So these people will be exposed anyway to some healthcare transition. The transitions subsequent to a hospitalization are the most critical because often, upon discharge, the clinical or functional status of the person has changed, as well as the treatment, and the social and physical environment also requires adaptation to the new needs. The heterogeneity of patients and caregivers in terms of health literacy or economic resources can add complexity. Health care transitions, due to the multiplicity of factors and actors that intervene in them, and for the variability of situations and possible responses, can be classified as a complex problem. The period following a discharge from the hospital clearly exposes to risks that, symbolically, can culminate in a potential readmission in the first seven to thirty days post-discharge. In highly complex patients there is little evidence that these readmissions can be reduced. And, at the moment, no gold standard risk stratification and predictive tools for readmissions have been identified. On the other hand, re-admissions in the 30-days post-discharge are economically penalized in many Western countries, including the United States, on the basis of the Readmissions Reduction Program Hospital (HRRP), driven by the Affordable Care Act or Obamacare.

Apart from encouraging or penalizing re-admissions, what are the possible actions that we could we undertake, in a framework of cooperation between professionals, institutions that provide services, administration and, also, patients and caregivers? Here I list five tips from my personal library on "transitions care" and "complex interventions."

1. Complex problems, complex interventions. A reference systematic review on care transitions suggests that, when dealing with complex situations, complex interventions are more effective. Among the key of success, from the reviewed study, they include:

• To integrate a minimum of five activities such as discharge preparation, case management, telephone or face-to-face monitoring, remote monitoring, education and promotion of self-care, effective communication with primary care, rehabilitation interventions, and telephone hotlines to answer patient questions;
• To involve a minimum of two different professional figures in the intervention (multidisciplinarity);
• To direct part of the intervention to empower the person for self-care.

The actions affect both the hospital (pre-discharge) and the home or community setting (post-discharge). For the latter, in Catalonia we have the advantage of a more consolidated primary care, globally sensitized and more proactive than the US, although with a fairly heterogeneous response level. And also there is a very well implemented transitions management program (Pre-Alt), although with an heterogeneous "qualitative" content and a little evaluated impact.

Based on the principles of this review, in Parc Sanitari Pere Virgili we have structured the TransitionA program to manage complex transitions, led by nursing, which has been presented in a communication in # ICIC18. The program incorporates some of the aspects mentioned by Coleman in the same conference, as shared goal-setting with the patients facing the transition and specific techniques of reinforcement of adherence to medication and to recover the active life at home, plus a complement of direct contact with primary care pre-discharge.

2. Support to the transition. There is evidence that, in people with high complexity, a pre- and post-discharge intervention by the same team of professionals could improve the results: the range of possibilities is very extensive, as Jordi Varela commented in a "historical" post, and it’s not necessarily a matter of creating "complexity" management teams that care for patients both during admission and at home (of which there are also valid impact experiences for highly complex patients), but, at least, models with “supported discharge could be experimented. In this case, some primary care professional could move to the hospital before discharge to physically meet the patient, caregivers and hospital equipment, or occasionally these meetings between the same three actors could be organized at home, just after discharge, to reinforce the sense of coordination for the patient. In northern Barcelona we carried out, some years ago, some timid promising experience (specific cases in which primary care had moved to the hospital for a pre-discharge meeting). Clearly, the time and pressure of everyday care delivering represent limits, but possibly not the only obstacles. In my opinion, there is an inertia generated by a certain resistance to change the way of working and to understand that there are things of added value for which we must pass the barrier of our institutions and let others "entering our house".

3. Integrated and intense work at home. As a third factor, which is closely related to the previous one, an adequate intensity of care both pre and post discharge should be available depending on the complexity and needs of the person. In an earlier post we commented on this aspect.

4. Integration of social services. The integration of social services, with a direct and proactive activation of resources and an integrated assessment of continuity, is another key point. In Barcelona, ​​we are anxiously awaiting the evaluation of the Return Plan, piloted in 100 stroke patients between 2015 and 2016, thanks to the mutual trust between the City Council and the Department of Health, which allowed the direct activation of the Home Care Service (SAD), meals on wheels and tele-monitoring before the patient's returned home. Subsequently, the social services of the City Council, which financed these resources, were in charge of confirming the need and the service. These elements are core in successful integrated care programs such as PACE.

5. Innovative solutions, as a complement. Always at the # ICIC18 conference, we met other interesting innovative programs, such as Canada's Acute Care for Elders (ACE) Strategy, from Mount Sinai Hospital in Toronto, within which, as a component of the program, volunteers support the person during the first days after home discharge.

Clearly, the payment or reimbursement systems have to facilitate all this. In the USA, the objectives of the Readmissions Reduction Program Hospital (HRRP) seem to work and neither seem incompatible with the efficiency of the system and with the promotion of patient rotation. Until good adjusted per capita payment systems are implemented, introducing transversal territorial objectives (the achievement of which leads to a reward for all the providers), which is already happening in Catalonia, seems a good idea. But we must think about incentivizing, and not only in penalizing, and above all without thinking that powerful ICT solution and performance indicators will solve all the system problems. The stewardship of the Administration goes much further than this.