Opinion | Easing the Inpatient-to-Outpatient Transition: There’s Got to Be a Better Way!

Leaving the hospital, returning to the real world, continues to be a challenging and confusing time for patients, full of opportunities for improving and continuing their care.

Instead, what we in the medical community mostly seem to see are miscommunications and medical missteps, which, despite everybody’s best efforts, leaves us with outcomes nobody wanted.

Last week, while I was supervising internal medicine residents in their morning outpatient clinic sessions, we were looking over the schedule when one of the interns said, “Oh, I know that patient!” However, that particular patient was not on her schedule, but was instead on the schedule of another resident in practice that morning. And, while reviewing the patient’s chart, we were able to look back and see literally dozens of admissions to the hospital over the past few years, interspersed with multiple broken appointments in several outpatient primary care and subspecialty practices within our institution.

The patient had been scheduled for a new patient appointment that morning with one of our senior residents, who had not participated in her care during this most recent hospital admission — nor any of those prior. And yet, buried several dozen pages into the discharge summary, after reams and reams of cut-and-pasted data, lengthy medical histories, and lab and imaging reports, were a number of things that were now apparently being “assigned” to the patient’s new primary care physician. When I asked the resident who was scheduled to see this patient if he had heard about these tasks that were now his, he told me he’d never taken care of the patient, nor had anyone reached out to him about this stuff that he was supposed to be handling.

In this particular section of the discharge summary, there also were tasks that were scheduled to be followed up on by several specialists, including a cardiologist, a gastroenterologist, and a hematologist, as well as their new primary care provider. But when I compared the names of the doctors who were involved in the hospital care with those who were scheduled to see the patient in the outpatient world, none of the names lined up. And when I pointed out to the resident what the chart said he was responsible for, he was aghast at the long list of things that someone said he was definitely going to be following up on, including multiple labs that were pending at discharge as well as ensuring that the patient made all of their follow-up appointments.

The intern who had recognized the patient’s name on the morning schedule told me that she had done a few days of coverage of this patient, when they had briefly been on her service, but she had neither admitted the patient nor discharged them. In addition, there were clearly numerous complicating social factors going on, as evidenced by the fact that the patient never seemed to come to any of the follow-up appointments which had been scheduled for them. The chart was full of comments about undiagnosed mental health disorders, as well as the patient being chronically undomiciled and having low health literacy.

So, did we think that this time things were going to go better? In this case, when that patient didn’t show up for their appointment with the resident that day, we tried to reach them, sending a message through the portal as well as calling the multiple phone numbers listed for them, all to no avail. Now what? Likely nothing to do but wait for another admission.

There have clearly been enormous benefits with sharing the electronic medical record between the inpatient and the outpatient worlds, and there are potentially tremendous strategies that we can continue to find and build upon. Quick and easy communication is just one of these, and many of us outpatient providers love to hear from the doctors who are taking care of our patients when they are admitted. But this random assignment — this idea that somehow by putting it down in a discharge summary it’s going to be so — seems like we’re not really doing the best we can to make sure patients get the care they need.

Instead of insisting that a discharge summary be a long and contorted document that no one’s ever going to actually read, it would probably be better if we turned the time of discharge into an active conversation, a time and place to engage and discuss and take on roles and responsibilities. “Here’s what we found in the hospital, here’s what we did, and here’s what we think should happen/needs to happen next. Do you agree?” Once everybody is on the same page, and they know what they’re taking on, we’re more likely to fight and ensure that these things happen.

I think we need to do a better job of building these things in advance, instead of trying to pick up the broken pieces after they’ve all fallen apart. We should take the hint when this patient keeps using the emergency department and admission to the hospital as the way to get their healthcare — maybe they are actually crying out for outstanding coordinated outpatient care across the spectrum of specialties and primary care. Clearly some intervention by social workers, community healthcare workers, and care managers could help this patient bridge the gap from the inpatient world to the care of those who are felt best suited to pick up the mantle of their care moving forward.

So let’s build a better system, fix the broken parts that are not doing their job, and recognize that just writing down that somebody’s going to do something isn’t the same as getting all the interested parties, including the patients themselves and the outpatient doctors, on board with the plan.

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