In Dr. Suneel Dhand’s article, “We can do a better job with hospital discharge paperwork,” he advocates for physicians to do a better job at creating discharge instructions that are more appealing and easier for patients to understand. After all, coherent patient instructions are a crucial part in ensuring that patients are able to adhere to our recommendations, including taking appropriate medications, following up on subspecialty referrals and attending follow-up visits. This is an important step in decreasing preventable revisits and readmissions for chronic conditions. But writing “beautiful, colorful and easy-to-read” instructions are not enough. In order to make meaningful advances in decreasing unnecessary repeat visits and admissions, we need to build coordinated, multidisciplinary systems to support patients both while they are inside our facilities and when they go home.
As a general pediatrician, this concept is most salient in my care of children with asthma, the most common chronic disease of childhood, affecting 1 in 12 (or 6 million) children in the United States. When their condition is well-controlled, children with asthma can lead thriving, healthy lives. When their disease is not controlled, these children miss school due to countless urgent care visits and hospitalizations, participate in less physical activity, and cause their parents to miss work. Among children with asthma, 1 in 6 visits the emergency department and 1 in 20 are hospitalized for this condition every year. Those who are admitted to the hospital tend to be African-American and publicly insured. Preventing these visits and admissions can relieve a significant burden on our health care system and improve the lives of millions of children. It can also help alleviate the disproportionate burden of morbidity on children from African-American and low-socioeconomic backgrounds.
With the shift in health care delivery systems towards coordination and collaboration and the growing emphasis on payment models that emphasize quality, value and shared savings, pediatricians and pediatric care facilities have an opportunity to change the way we discharge patients. One way to do this is to join the wave of change in adult health care and support the development of pediatric accountable care organization (ACO) models. The ACO concept is made for pediatrics in many ways given its emphasis on patient-centered care, care coordination, primary care, quality measurement focused on improved outcomes, and population management. ACOs have tremendous potential to improve pediatric health outcomes and decrease preventable costs in caring for this vulnerable population.
How would ACOs decrease preventable asthma revisits and readmissions? By providing coordinated, multidisciplinary, wraparound support, especially during times of transition, like discharge from the hospital. Many children with asthma, especially those who require hospitalization, are referred to pulmonology and/or allergy subspecialists, who are important members of their health care team. By promoting collaboration between primary and subspecialty care, ACOs can improve subspecialty access for patients with asthma.
Children with asthma, especially those who have difficulty accessing care or have complex health conditions, can also benefit from patient navigators and care coordinators. ACOs encourage the incorporation of measures that improve the quality of care and result in cost savings for participating providers and health care facilities. Aside from patient navigators and care coordinators, these measures can include providing medications in hand at discharge, developing individualized asthma action plans, and improving patient/family education on asthma. Some ACOs are also extending their scope to address social determinants of health, a concept that is readily applicable to asthma. Pediatric ACOs can collaborate with legal organizations to form medical-legal partnerships, which can address housing-related issues, like mold and pests, that can exacerbate asthma.
Ultimately, pediatric ACOs provide numerous opportunities to improve asthma care and prevent unnecessary revisits and readmissions, including increased primary and subspecialty care coordination, quality improvement measures and novel partnerships to address social determinants of health.
In his article, Dr. Dhand acknowledges that there are many factors in the discharge process that need to be addressed aside from discharge paperwork. He is absolutely correct. However, I do not agree that “whatever patients do with [the paperwork] afterward — read it, put it on their fridge, or even throw it away — is up to them.” We cannot wash our hands of our patients once they leave our clinic or hospital. In order to meaningfully and sustainably improve health, we need to care about what patients do with our discharge instructions and whether we have the support systems in place for patients to be able to follow through on our recommendations. ACOs can be those support systems. At the end of the day, if a patient ends up back in the clinic or hospital because they were unable to fill their prescription, never got a call from the pulmonology clinic scheduler or live in a mold-infested housing complex, our health care system has failed them. We need to do better than writing good discharge instructions. We need to be more accountable for the health of our patients.
Bianca Argueza is a pediatrician.
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