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A carefully crafted hospital discharge plan, shared with outpatient doctors, is essential to help your patients finish their recovery after they leave. Hopefully, it will prevent them from coming back to the hospital anytime soon as well. 

“I tell my patients all the time — it was very nice to meet you, it was great to take care of you, but I really hope I don’t see you again soon,” said Sharon Ostfeld-Johns, MD, an internal medicine and pediatric hospitalist at Yale New Haven Health in New Haven, Connecticut. 

Just because your patient is well enough to leave does not mean the workup is over, said Ruby Sahoo, DO, hospital medicine performance director at TeamHealth in Austin, Texas, and secretary of the board of directors of the Society of Hospital Medicine, Philadelphia. There’s often a significant amount of follow-up required to make sure the patient’s admitting diagnosis is properly managed after you pass the baton to the outpatient team, she said.

Therefore, the care plan devised by you, your case manager, nurses, and (most importantly) the patient needs to be properly communicated to primary care and other doctors outside the hospital.

If there is a breakdown in communication, the patient workup abruptly ends when it shouldn’t have, said Sahoo.

“In today’s modern-day healthcare system, good communication is the Achilles heel of hospital medicine,” said Brad Rosen, MD, vice president of Capacity Management at Cedars-Sinai Medical Center in Los Angeles. “Hospitalist medicine has a lot of hand-offs, and with every hand-off, there is the risk of ‘voltage drop’ of critical information — just like the kids’ game of telephone.”

There are several ways hospitalists and outside doctors communicate and coordinate care.

Electronic Medical (or Health) Records

Today, “everything is in the electronic medical record (EMR) — lab results, clinician notes, physician orders, care plans, medication lists, devices, referrals, discharge summaries — which is considered the ‘source of truth,’” said Rosen. 

“However, each patient’s chart is so bloated with so many results by every provider from multiple disciplines documenting their patient encounters and care plans in the EMR,” Rosen said.

As a result, it’s not always a reliable or efficient vehicle for effective communication between providers.

“EMRs have improved the way patient information is shared, but they’re not perfect,” said Eunice Ninet, registered nurse and manager of the Inpatient Specialty Program at Cedars-Sinai, Santa Monica, California. “Providers often have to search for the most up-to-date details, and not all patient encounters from other hospitals are always available. When used effectively, though, EMRs can be a valuable tool for real-time coordination.”

Discharge Summary. The record of your patient’s hospital stay is where you document their diagnosis, testing, treatments, medications, and your recommendations for follow-up. Electronic systems then fax a copy to the outpatient doctor.

Sounds seamless, but challenges remain. Doctors need to be enrolled in the system, hospitals need the correct fax number, and the discharge summary needs to get into the hands of the right provider before the follow-up appointment, said Ostfeld-Johns. 

To clearly communicate your patient’s condition and further needs, consider what details to include in the discharge summary:

• Be thorough. Anyone from a trainee to an attending doctor could be filling out the discharge summary, according to Ostfeld-Johns. Also, residency programs don’t always go into extensive training about high-quality summaries. For instance, in congestive heart failure, it’s important to include weight at discharge and dry weight, or weight without extra fluid buildup. That’s potentially life-saving information that could be left out of the summary, she said.
• Consider your audience. When an outpatient doctor does not have access to the same electronic health records system, the discharge summary might be the only patient documentation they get. “That really changes what you include — and how much you include — about lab values, vital signs, weight trends, etc.,” said Ostfeld-Johns.
• Keep it tight. “Sometimes discharge summaries have so much information, it becomes too much to navigate,” Sahoo said. “We need the right information, but it has to be presented in a way that’s easy to digest. We have to make sure the most important details don’t get lost in the other words. Adding more words doesn’t necessarily add more value.”

More Ways to Communicate With Outpatient Teams 

Email: This is an effective but relatively slow way for doctors to communicate, said Rosen. It can take from hours to days to get a response.

Secure messaging: This is a faster way to communicate and typically takes minutes to hours to get a response. “Group chats on a secure platform tend to be the most effective mechanism for coordinating simultaneously across multiple providers and ensuring all members of a patient’s care team are up to speed,” Rosen said.

Phone calls: Dialing an outpatient doctor can get an immediate response in a perfect world, but you could also end up playing phone tag. Hospitalists are typically busy in the mornings, doctors’ offices are closed for lunch, and primary care providers are seeing patients in the afternoons, said Ostfeld-Johns.

Think Outside the Chart 

Just as communication between hospitalists and outpatient doctors is crucial for a smooth transition of care, clear lines need to be set up within the hospital care team to make it happen.

Communication between a hospitalist and case manager is essential to ensure consistent messaging to the patient and their family regarding details and timing of the care transition outside the hospital, Rosen said.

It’s important that all necessary services — such as home health, medical equipment, and home infusions — are lined up for when the patient is stable enough for discharge, Rosen noted. 

Ostfeld-Johns agreed. “You could put together the ‘best’ medical plan you can think of, but you could be doing the ‘least’ good for the patient if there’s no way for you to put that plan in place,” she said. Imagine how your patient will make their way home from the hospital, get their next dose of medicine, or fill up a possibly empty fridge. This is “the real medicine” of a hospitalist, she added.

Communicate with patients, their families, your case managers, and social workers to find out what is doable vs impractical.

For some examples, consider the following questions:

• Are there transportation needs that will hinder your patient’s ability to get to follow-up medical appointments after they are released?
• How much support can their family provide? Can you assist with family and medical leave paperwork so they can take time off from work to help?
• Can a visiting nurse service come in? If so, how frequently, and what will they do when they get there?

There is no billing code for communication, collaboration, and creativity. But “this is what really makes a difference in people’s lives,” Ostfeld-Johns said.