Annals for Hospitalists Inpatient Notes - Getting Past the “Black Box”—Opportunities for Hospitalists to Improve Postacute Care Transitions
Authors: Christine D. Jones, Robert E. Burke
Journal: Annals of Internal Medicine (2018)

Web Exclusives15 May 2018Annals for Hospitalists Inpatient Notes - Getting Past the “Black Box”—Opportunities for Hospitalists to Improve Postacute Care TransitionsChristine D. Jones, MD, MS and Robert E. Burke, MD, MSChristine D. Jones, MD, MSUniversity of Colorado School of Medicine, Colorado (C.D.J.)Search for more papers by this author and Robert E. Burke, MD, MSUniversity of Colorado School of Medicine, Denver, Colorado, and Department of Veterans Affairs Medical Center, Aurora, Colorado (R.E.B.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M18-0940 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail For many hospitalists, the care provided after hospital discharge in skilled-nursing facilities (SNFs) and home health care (HHC)—collectively termed postacute care (PAC)—represents a “black box.” Hospitalists often lack clarity about available resources, processes of care, and outcomes for patients discharged to PAC. This is important because approximately one third of adult inpatients are referred to PAC after hospital discharge, and this proportion is increasing as the population ages. Further, patients transitioning from the hospital to PAC have higher readmission rates than patients discharged home, and evidence suggests that suboptimal care transitions play a significant role in these cases (1–3). In ...References1. Burke RE, Lawrence E, Ladebue A, Ayele R, Lippmann B, Cumbler E, et al. How hospital clinicians select patients for skilled nursing facilities. J Am Geriatr Soc. 2017;65:2466-72. [PMID: 28682456] doi:10.1111/jgs.14954 CrossrefMedlineGoogle Scholar2. Jones CD, Jones J, Richard A, Bowles K, Lahoff D, Boxer RS, et al. “Connecting the dots”: a qualitative study of home health nurse perspectives on coordinating care for recently discharged patients. J Gen Intern Med. 2017;32:1114-21. [PMID: 28707258] doi:10.1007/s11606-017-4104-0 CrossrefMedlineGoogle Scholar3. Jones CD, Cumbler E, Honigman B, Burke RE, Boxer RS, Levy C, et al. Hospital to post-acute care facility transfers: identifying targets for information exchange quality improvement. J Am Med Dir Assoc. 2017;18:70-3. [PMID: 27815110] doi:10.1016/j.jamda.2016.09.009 CrossrefMedlineGoogle Scholar4. Moore AB, Krupp JE, Dufour AB, Sircar M, Travison TG, Abrams A, et al. Improving transitions to postacute care for elderly patients using a novel video-conferencing program: ECHO-care transitions. Am J Med. 2017;130:1199-204. [PMID: 28551043] doi:10.1016/j.amjmed.2017.04.041 CrossrefMedlineGoogle Scholar5. Vasilevskis EE, Ouslander JG, Mixon AS, Bell SP, Jacobsen JM, Saraf AA, et al. Potentially avoidable readmissions of patients discharged to post-acute care: perspectives of hospital and skilled nursing facility staff. J Am Geriatr Soc. 2017;65:269-76. [PMID: 27981557] doi:10.1111/jgs.14557 CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAffiliations: University of Colorado School of Medicine, Colorado (C.D.J.)University of Colorado School of Medicine, Denver, Colorado, and Department of Veterans Affairs Medical Center, Aurora, Colorado (R.E.B.)Disclaimer: The content of this article is solely the responsibility of the authors and does not necessarily represent the views of the Agency for Healthcare Research and Quality or the Department of Veterans Affairs.Grant Support: Dr. Jones is supported by grant K08HS024569 from the Agency for Healthcare Research and Quality. Dr. Burke is supported by a Veterans Affairs Health Services Research and Development Career Development Award.Disclosures: Dr. Jones reports a grant from AHRQ during the conduct of the study and a grant from Ohio Council for Home Care & Hospice outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-0940.Requests for Single Reprints: Christine D. Jones, MD, MS, Division of Hospital Medicine, Department of Medicine, University of Colorado School of Medicine, 12401 East 17th Avenue, Aurora, CO 80045; e-mail, christine.[email protected]edu. Previousarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAnnals for Hospitalists - 15 May 2018 David H. Wesorick and Vineet Chopra Metrics 15 May 2018Volume 168, Issue 10Page: HO2-HO3KeywordsDisclosureHealth careHealth care qualityHealth services researchHospital medicineHospitalistsInpatientsMotivationPatientsResearch quality assessment ePublished: 15 May 2018 Issue Published: 15 May 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...