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Transitions of Care and Neurohospitalists

Care transitions have become an increasing focus in the realm of hospital medicine, and appropriately so. The Centers for Medicare and Medicaid Services (CMS) has made this a priority, largely focusing on readmissions. By introducing a financial penalty, hospital administrators have needed to view this as more than just a patient safety and quality initiative. 1Beyond readmissions, many if not most hospitals have focused on throughput as well. Throughput refers to the efficiency with which a patient moves through the hospital system – transitioning from the Emergency Department to inpatient status and on through discharge.

High-performing neurohospitalist programs will be integrally involved in the management of care transitions given their applicability to their population of patients in general, but to stroke patients in particular. The timeliness of these transitions is of significant import for patients being treated with thrombolytics or with endovascular intervention. The quality of these transitions is of paramount importance for patients with cryptogenic stroke.

Given the complexity of cryptogenic stroke, the Neurohospitalist needs to create a system of care for these patients. There are a number of ways to develop a system of care. Cryptogenic stroke needs to be identified as a diagnosis in order for the system to be established and recognized by other providers and by Internal Medicine Hospitalists and Cardiologists in particular. Once the diagnosis is made, a clear algorithmic approach is needed. Each hospital or hospital system may have a different methodology, but order sets, pathways and protocols are typically facilitated in an electronic health record (EHR).

Management of cryptogenic stroke is complex and spans both the inpatient and outpatient world. Tests may take time to process and only become available after discharge, and others may need to be done on an outpatient basis. Frequently, the inpatient providers do not have outpatient practices, and there may be limited access to neurologists or other providers in the outpatient realm or patients may not followup consistently. Consideration should be given, in those cases in particular, to performing studies that can be done appropriately during an inpatient stay, or during the transition from inpatient to outpatient. The latter may include performing a test or applying/implanting cardiac monitoring after discharge, but before a patient has left the hospital campus – such as being discharged and going directly to a cardiology clinic.

No matter the process, a clear plan needs to be established at the time of discharge. A physician contact is necessary who will be the primary point person for assuring that results are reviewed and subsequent evaluations/testing performed as needed. Involving patients and their families is ideal so that they are clear on the diagnosis and tests that are planned or pending. Written materials may be helpful in this regard. High performing neurohospitalists will make direct communication by phone with the provider who will be seeing the patient after discharge to assure there is no “voltage drop” in information after discharge from the hospital.

Take home points

Proposed metrics for care transitions