July 1 marked the debut of several features in this year’s healthcare reform legislation, including the acceptance of uninsured applicants to high-risk insurance pools. For many hospitalists and other doctors, however, the new arrivals only heightened their disappointment over the legislation’s lost opportunity: a permanent fix to the flawed sustainable growth rate, or SGR, that dictates Medicare reimbursements.

“It should have been taken care of in that bill,” says Ron Greeno, MD, SFHM, a member of SHM’s Public Policy Committee and CMO of Brentwood, Tenn.-based Cogent Healthcare. “Obviously, there’s a lot of frustration around the issue, especially on the membership side.”

June provided a stark reminder of the potential for catastrophe should the annual rate cuts to Medicare reimbursements to physicians—21.3% to date—ever go into effect. Congress eventually pushed through yet another temporary fix, delaying any cut from June 1 until Dec. 1 (after the midterm elections, of course) and even tacking on a 2.2% increase. But the House didn’t pass the extension until June 24, nearly a week after the Centers for Medicare & Medicaid Services (CMS) began processing June claims at the lower rate.

By that point, some doctors had begun refusing to see Medicare patients. Both doctors and hospitals have since had to resubmit some June claims to gain the full value, creating new headaches and expenses over the additional paperwork. “It’s wreaking havoc on the provider community,” Dr. Greeno says. “The uncertainty that has been created around these short-term fixes is very disquieting.”

Doctors and hospitals have had to resubmit some June claims to gain the full value, creating expenses over the additional paperwork. And then, of course, there’s the new Nov. 30 deadline facing a lame-duck Congress. As politicians continue dithering over a permanent fix and an accompanying price tag of $250 billion or more over a decade, CMS has announced next year’s rate cut. With a 6.1% decrease slated to take effect on Jan. 1, 2011, the combined SGR-mandated drop would reach nearly 30%. Ouch.

Find out the latest information on SGR reform and contact your legislators in support of permanent repeal through SHM's Legislative Action Center.

July 1 marked the debut of several features in this year’s healthcare reform legislation, including the acceptance of uninsured applicants to high-risk insurance pools. For many hospitalists and other doctors, however, the new arrivals only heightened their disappointment over the legislation’s lost opportunity: a permanent fix to the flawed sustainable growth rate, or SGR, that dictates Medicare reimbursements.

“It should have been taken care of in that bill,” says Ron Greeno, MD, SFHM, a member of SHM’s Public Policy Committee and CMO of Brentwood, Tenn.-based Cogent Healthcare. “Obviously, there’s a lot of frustration around the issue, especially on the membership side.”

June provided a stark reminder of the potential for catastrophe should the annual rate cuts to Medicare reimbursements to physicians—21.3% to date—ever go into effect. Congress eventually pushed through yet another temporary fix, delaying any cut from June 1 until Dec. 1 (after the midterm elections, of course) and even tacking on a 2.2% increase. But the House didn’t pass the extension until June 24, nearly a week after the Centers for Medicare & Medicaid Services (CMS) began processing June claims at the lower rate.

By that point, some doctors had begun refusing to see Medicare patients. Both doctors and hospitals have since had to resubmit some June claims to gain the full value, creating new headaches and expenses over the additional paperwork. “It’s wreaking havoc on the provider community,” Dr. Greeno says. “The uncertainty that has been created around these short-term fixes is very disquieting.”

Doctors and hospitals have had to resubmit some June claims to gain the full value, creating expenses over the additional paperwork. And then, of course, there’s the new Nov. 30 deadline facing a lame-duck Congress. As politicians continue dithering over a permanent fix and an accompanying price tag of $250 billion or more over a decade, CMS has announced next year’s rate cut. With a 6.1% decrease slated to take effect on Jan. 1, 2011, the combined SGR-mandated drop would reach nearly 30%. Ouch.

Find out the latest information on SGR reform and contact your legislators in support of permanent repeal through SHM's Legislative Action Center.

July 1 marked the debut of several features in this year’s healthcare reform legislation, including the acceptance of uninsured applicants to high-risk insurance pools. For many hospitalists and other doctors, however, the new arrivals only heightened their disappointment over the legislation’s lost opportunity: a permanent fix to the flawed sustainable growth rate, or SGR, that dictates Medicare reimbursements.

“It should have been taken care of in that bill,” says Ron Greeno, MD, SFHM, a member of SHM’s Public Policy Committee and CMO of Brentwood, Tenn.-based Cogent Healthcare. “Obviously, there’s a lot of frustration around the issue, especially on the membership side.”

June provided a stark reminder of the potential for catastrophe should the annual rate cuts to Medicare reimbursements to physicians—21.3% to date—ever go into effect. Congress eventually pushed through yet another temporary fix, delaying any cut from June 1 until Dec. 1 (after the midterm elections, of course) and even tacking on a 2.2% increase. But the House didn’t pass the extension until June 24, nearly a week after the Centers for Medicare & Medicaid Services (CMS) began processing June claims at the lower rate.

By that point, some doctors had begun refusing to see Medicare patients. Both doctors and hospitals have since had to resubmit some June claims to gain the full value, creating new headaches and expenses over the additional paperwork. “It’s wreaking havoc on the provider community,” Dr. Greeno says. “The uncertainty that has been created around these short-term fixes is very disquieting.”

Doctors and hospitals have had to resubmit some June claims to gain the full value, creating expenses over the additional paperwork. And then, of course, there’s the new Nov. 30 deadline facing a lame-duck Congress. As politicians continue dithering over a permanent fix and an accompanying price tag of $250 billion or more over a decade, CMS has announced next year’s rate cut. With a 6.1% decrease slated to take effect on Jan. 1, 2011, the combined SGR-mandated drop would reach nearly 30%. Ouch.

Find out the latest information on SGR reform and contact your legislators in support of permanent repeal through SHM's Legislative Action Center.

Before Matthew Schreiber, MD, became chief medical officer of Piedmont Hospital in Atlanta, he was director of hospitalist services for the four-hospital Piedmont health system, and before that, a hospitalist for the system’s smallest hospital, 35-bed Piedmont Mountainside in Jasper, Ga., population 2,000, so he knows just how different transitions of care are between hospitals large and small.

In many rural communities, the hospitalist concept has only recently been introduced, and patients are accustomed to PCPs being responsible for all of their medical care. But it can be easier to achieve high-quality handoffs in rural areas because the number of physicians involved is much smaller, Dr. Schreiber says.

“At Piedmont Mountainside, only eight physicians made most of our referrals. It was possible to memorize their office numbers and their call-coverage arrangements,” he explains. Some doctors are accessible 24 hours, seven days a week, while others take their patients’ charts home overnight in case they get called. This encourages an individualized approach to communicating with them. “It makes the care feel more personal, with a different level of accountability,” Dr. Schreiber says. “You feel a connection to the patient and the doctor—and that your job isn’t done when the patient goes home.”

Rural hospitals and doctors also tend to have closer relationships with community services like home health agencies. “We can give the medication list to the home health nurse and say, ‘This is what we think the patient is taking. We want you to go in and find out what they’re actually taking and reconcile the two,’ ” Dr. Schreiber says.

However, small and rural hospitals—particularly stand-alone and critical access facilities—are less likely to have computerized tools for automating and facilitating care transitions, Dr. Schreiber says. In some cases, the rural hospitalist carries a pager and takes calls 24/7.

Dr. Schreiber says it’s important to hand patients a piece of paper that summarizes their condition, key events in the hospitalization, and new medications, all in patient-friendly language, to take home and post on the refrigerator. “In our experience, patients hold onto this document and bring it to the doctor’s office or even to the emergency room,” he says, adding that if the formal discharge summary doesn’t reach the PCP in time, this summary could be a godsend.

Visit our website for more information about local and national efforts to improve care transitions.

Check out the SHM website for information on Project BOOST (Better Outcomes for Older Adults through Safer Transitions), a national QI initiative to improve handoffs and transitions.

Before Matthew Schreiber, MD, became chief medical officer of Piedmont Hospital in Atlanta, he was director of hospitalist services for the four-hospital Piedmont health system, and before that, a hospitalist for the system’s smallest hospital, 35-bed Piedmont Mountainside in Jasper, Ga., population 2,000, so he knows just how different transitions of care are between hospitals large and small.

In many rural communities, the hospitalist concept has only recently been introduced, and patients are accustomed to PCPs being responsible for all of their medical care. But it can be easier to achieve high-quality handoffs in rural areas because the number of physicians involved is much smaller, Dr. Schreiber says.

“At Piedmont Mountainside, only eight physicians made most of our referrals. It was possible to memorize their office numbers and their call-coverage arrangements,” he explains. Some doctors are accessible 24 hours, seven days a week, while others take their patients’ charts home overnight in case they get called. This encourages an individualized approach to communicating with them. “It makes the care feel more personal, with a different level of accountability,” Dr. Schreiber says. “You feel a connection to the patient and the doctor—and that your job isn’t done when the patient goes home.”

Rural hospitals and doctors also tend to have closer relationships with community services like home health agencies. “We can give the medication list to the home health nurse and say, ‘This is what we think the patient is taking. We want you to go in and find out what they’re actually taking and reconcile the two,’ ” Dr. Schreiber says.

However, small and rural hospitals—particularly stand-alone and critical access facilities—are less likely to have computerized tools for automating and facilitating care transitions, Dr. Schreiber says. In some cases, the rural hospitalist carries a pager and takes calls 24/7.

Dr. Schreiber says it’s important to hand patients a piece of paper that summarizes their condition, key events in the hospitalization, and new medications, all in patient-friendly language, to take home and post on the refrigerator. “In our experience, patients hold onto this document and bring it to the doctor’s office or even to the emergency room,” he says, adding that if the formal discharge summary doesn’t reach the PCP in time, this summary could be a godsend.

Visit our website for more information about local and national efforts to improve care transitions.

Check out the SHM website for information on Project BOOST (Better Outcomes for Older Adults through Safer Transitions), a national QI initiative to improve handoffs and transitions.

Before Matthew Schreiber, MD, became chief medical officer of Piedmont Hospital in Atlanta, he was director of hospitalist services for the four-hospital Piedmont health system, and before that, a hospitalist for the system’s smallest hospital, 35-bed Piedmont Mountainside in Jasper, Ga., population 2,000, so he knows just how different transitions of care are between hospitals large and small.

In many rural communities, the hospitalist concept has only recently been introduced, and patients are accustomed to PCPs being responsible for all of their medical care. But it can be easier to achieve high-quality handoffs in rural areas because the number of physicians involved is much smaller, Dr. Schreiber says.

“At Piedmont Mountainside, only eight physicians made most of our referrals. It was possible to memorize their office numbers and their call-coverage arrangements,” he explains. Some doctors are accessible 24 hours, seven days a week, while others take their patients’ charts home overnight in case they get called. This encourages an individualized approach to communicating with them. “It makes the care feel more personal, with a different level of accountability,” Dr. Schreiber says. “You feel a connection to the patient and the doctor—and that your job isn’t done when the patient goes home.”

Rural hospitals and doctors also tend to have closer relationships with community services like home health agencies. “We can give the medication list to the home health nurse and say, ‘This is what we think the patient is taking. We want you to go in and find out what they’re actually taking and reconcile the two,’ ” Dr. Schreiber says.

However, small and rural hospitals—particularly stand-alone and critical access facilities—are less likely to have computerized tools for automating and facilitating care transitions, Dr. Schreiber says. In some cases, the rural hospitalist carries a pager and takes calls 24/7.

Dr. Schreiber says it’s important to hand patients a piece of paper that summarizes their condition, key events in the hospitalization, and new medications, all in patient-friendly language, to take home and post on the refrigerator. “In our experience, patients hold onto this document and bring it to the doctor’s office or even to the emergency room,” he says, adding that if the formal discharge summary doesn’t reach the PCP in time, this summary could be a godsend.

Visit our website for more information about local and national efforts to improve care transitions.

Check out the SHM website for information on Project BOOST (Better Outcomes for Older Adults through Safer Transitions), a national QI initiative to improve handoffs and transitions.

Brad Schmidt, MD, can remember recruiting hospitalists to the HM program at Dean Clinic at St. Mary’s Hospital in Madison, Wis., seven years ago. He was a young doctor, just a couple of years removed from residency.

Back then, having Dr. Schmidt recruit hospitalists was a matter of necessity. He was the only hospitalist practicing at St. Mary’s. Today, hospitalists continue to be in charge of recruiting at Dean’s 18-physician HM department, but now it’s by design.

“It’s critical for hospitalists to get involved, because doctors being recruited want to be part of a team. They want to know how they would be contributing,” says Dr. Schmidt, who is the medical director of eight departments, including the HM department. “I also think it’s important for people to know who they are going to be working with.”

For hospitalists looking to advance their careers, being recruited by a group that heavily involves its own hospitalists in the process can provide an opportunity to get an in-depth look at the prospective job and community, observes Kenneth G. Simone, DO, FHM, founder and president of Hospitalist and Practice Solutions, a practice-management consultancy based in Veazie, Maine. At the same time, hospitalists who are active in recruitment efforts are helping their own pursuits, says Dr. Simone, a member of Team Hospitalist and author of several HM-centered books, including “Hospitalist Recruit-ment and Retention.”

It gives new meaning to the saying recruiting is a two-way street. In this case, it’s a two-way street to success if hospitalists at both ends of the recruitment process use the situation to their advantage.

Candidate Advantage

If given the chance to interact with hospitalists at a potential job, a candidate should really pay attention to what the workday is like, Dr. Simone says. How is the workload? What kind of specialist support are the hospitalists getting? Are primary-care physicians (PCPs) referring patients to the group? Is there a good rapport with nursing staff?

“As a candidate, I should be asking why they are looking for a provider,” Dr. Simone says. “Is it growth? Is it turnover due to burnout?”

Having hospitalists engaged in the recruitment effort gives a candidate a great opportunity to ask questions he or she might not be comfortable asking of a director or hospital human resources personnel, Dr. Simone says. A candidate also gets a chance to observe the level of collegiality among prospective coworkers and gauge if the hospitalists are happy in the workplace and with the community.

Hospitalists who are good at recruiting show that they are a leader, a good communicator, and a positive person. They can put this on a resume and give examples of what they did to help bring a quality provider to the team.

—Kenneth G. Simone, DO, FHM, president, Hospitalist and Practice Solutions, Veazie, Maine, Team Hospitalist member

“They want to know that they are not just a cog in the wheel, not just a person filling a shift,” Dr. Schmidt explains. “By and large, they want to be part of a team.”

According to Drs. Simone and Schmidt, hospitalist job candidates should make an effort to:

• Ask potential colleagues to show them the local neighborhoods, services, and cultural and entertainment amenities;
• Get the e-mail addresses and phone numbers of the hospitalists to contact them with any follow-up questions after the interview and site visit; and
• Meet the group’s newest hospitalists, as they are the people who are in the best position to talk about the job transition.

A candidate’s goal is to gather enough information to determine if the job opportunity is the best fit for them and their family, Dr. Schmidt says. But candidates must remember that the time they spend and the conversations they share with the group’s hospitalists are still part of the interview process, Dr. Simone emphasizes. “If the person interviewing for a job has a lot of questions about vacation time and workload, that could send a signal that he or she doesn’t have a good work ethic,” he says.

Conversely, candidates should be wary of any program that doesn’t in some degree include their hospitalists in the recruitment process. It could mean that the group is trying to hide something, or that morale is so low that the hospitalists don’t want to promote the program. “I personally would be very uncomfortable not knowing who my partners would be,” Dr. Schmidt says.

Other red flags to look out for are constant references to the job’s competitive salary, which could indicate problems in other areas that the hospitalist practice is trying to mask, and no references to challenging issues the group is facing. If the group appears too good to be true, it probably is, Dr. Simone says.

Recruitment = Leadership

Hospitalists who get involved in their group’s recruitment efforts show their employer and supervisor that they are team players and care about the group and its future. It shows they are willing to help the program beyond providing patient care, and it demonstrates to both current and future employers that they have valuable professional characteristics and skills.

“Hospitalists who are good at recruiting show that they are a leader, a good communicator, and a positive person,” Dr. Simone says. “They can put this on a resume and give examples of what they did to help bring a quality provider to the team.”

When recruiting, be honest about the program’s strengths and weaknesses. “You want to avoid telling a candidate something a program is not,” Dr. Schmidt says. “You should be open about the program’s goals, workload, and expectations.”

Hospitalists who help in recruiting can frame the challenges a program is facing in a positive light. If an HM program is having trouble with, for example, a pulmonology group that is understaffed, the hospitalist recruiting candidates could explain the program is temporarily cross-covering patients at night until a new specialist can be found, Dr. Simone explains. He also notes it’s always best to place negatives into a context that shows the hospitalist group is working on a solution.

Getting engaged in recruiting also helps a hospitalist improve their current job by strengthening their team with good doctors who care about doing quality work, Drs. Schmidt and Simone say.

And that is more important than building a resume. TH

Lisa Ryan is a freelance writer based in New Jersey.

Brad Schmidt, MD, can remember recruiting hospitalists to the HM program at Dean Clinic at St. Mary’s Hospital in Madison, Wis., seven years ago. He was a young doctor, just a couple of years removed from residency.

Back then, having Dr. Schmidt recruit hospitalists was a matter of necessity. He was the only hospitalist practicing at St. Mary’s. Today, hospitalists continue to be in charge of recruiting at Dean’s 18-physician HM department, but now it’s by design.

“It’s critical for hospitalists to get involved, because doctors being recruited want to be part of a team. They want to know how they would be contributing,” says Dr. Schmidt, who is the medical director of eight departments, including the HM department. “I also think it’s important for people to know who they are going to be working with.”

For hospitalists looking to advance their careers, being recruited by a group that heavily involves its own hospitalists in the process can provide an opportunity to get an in-depth look at the prospective job and community, observes Kenneth G. Simone, DO, FHM, founder and president of Hospitalist and Practice Solutions, a practice-management consultancy based in Veazie, Maine. At the same time, hospitalists who are active in recruitment efforts are helping their own pursuits, says Dr. Simone, a member of Team Hospitalist and author of several HM-centered books, including “Hospitalist Recruit-ment and Retention.”

It gives new meaning to the saying recruiting is a two-way street. In this case, it’s a two-way street to success if hospitalists at both ends of the recruitment process use the situation to their advantage.

Candidate Advantage

If given the chance to interact with hospitalists at a potential job, a candidate should really pay attention to what the workday is like, Dr. Simone says. How is the workload? What kind of specialist support are the hospitalists getting? Are primary-care physicians (PCPs) referring patients to the group? Is there a good rapport with nursing staff?

“As a candidate, I should be asking why they are looking for a provider,” Dr. Simone says. “Is it growth? Is it turnover due to burnout?”

Having hospitalists engaged in the recruitment effort gives a candidate a great opportunity to ask questions he or she might not be comfortable asking of a director or hospital human resources personnel, Dr. Simone says. A candidate also gets a chance to observe the level of collegiality among prospective coworkers and gauge if the hospitalists are happy in the workplace and with the community.

Hospitalists who are good at recruiting show that they are a leader, a good communicator, and a positive person. They can put this on a resume and give examples of what they did to help bring a quality provider to the team.

—Kenneth G. Simone, DO, FHM, president, Hospitalist and Practice Solutions, Veazie, Maine, Team Hospitalist member

“They want to know that they are not just a cog in the wheel, not just a person filling a shift,” Dr. Schmidt explains. “By and large, they want to be part of a team.”

According to Drs. Simone and Schmidt, hospitalist job candidates should make an effort to:

• Ask potential colleagues to show them the local neighborhoods, services, and cultural and entertainment amenities;
• Get the e-mail addresses and phone numbers of the hospitalists to contact them with any follow-up questions after the interview and site visit; and
• Meet the group’s newest hospitalists, as they are the people who are in the best position to talk about the job transition.

A candidate’s goal is to gather enough information to determine if the job opportunity is the best fit for them and their family, Dr. Schmidt says. But candidates must remember that the time they spend and the conversations they share with the group’s hospitalists are still part of the interview process, Dr. Simone emphasizes. “If the person interviewing for a job has a lot of questions about vacation time and workload, that could send a signal that he or she doesn’t have a good work ethic,” he says.

Conversely, candidates should be wary of any program that doesn’t in some degree include their hospitalists in the recruitment process. It could mean that the group is trying to hide something, or that morale is so low that the hospitalists don’t want to promote the program. “I personally would be very uncomfortable not knowing who my partners would be,” Dr. Schmidt says.

Other red flags to look out for are constant references to the job’s competitive salary, which could indicate problems in other areas that the hospitalist practice is trying to mask, and no references to challenging issues the group is facing. If the group appears too good to be true, it probably is, Dr. Simone says.

Recruitment = Leadership

Hospitalists who get involved in their group’s recruitment efforts show their employer and supervisor that they are team players and care about the group and its future. It shows they are willing to help the program beyond providing patient care, and it demonstrates to both current and future employers that they have valuable professional characteristics and skills.

“Hospitalists who are good at recruiting show that they are a leader, a good communicator, and a positive person,” Dr. Simone says. “They can put this on a resume and give examples of what they did to help bring a quality provider to the team.”

When recruiting, be honest about the program’s strengths and weaknesses. “You want to avoid telling a candidate something a program is not,” Dr. Schmidt says. “You should be open about the program’s goals, workload, and expectations.”

Hospitalists who help in recruiting can frame the challenges a program is facing in a positive light. If an HM program is having trouble with, for example, a pulmonology group that is understaffed, the hospitalist recruiting candidates could explain the program is temporarily cross-covering patients at night until a new specialist can be found, Dr. Simone explains. He also notes it’s always best to place negatives into a context that shows the hospitalist group is working on a solution.

Getting engaged in recruiting also helps a hospitalist improve their current job by strengthening their team with good doctors who care about doing quality work, Drs. Schmidt and Simone say.

And that is more important than building a resume. TH

Lisa Ryan is a freelance writer based in New Jersey.

Brad Schmidt, MD, can remember recruiting hospitalists to the HM program at Dean Clinic at St. Mary’s Hospital in Madison, Wis., seven years ago. He was a young doctor, just a couple of years removed from residency.

Back then, having Dr. Schmidt recruit hospitalists was a matter of necessity. He was the only hospitalist practicing at St. Mary’s. Today, hospitalists continue to be in charge of recruiting at Dean’s 18-physician HM department, but now it’s by design.

“It’s critical for hospitalists to get involved, because doctors being recruited want to be part of a team. They want to know how they would be contributing,” says Dr. Schmidt, who is the medical director of eight departments, including the HM department. “I also think it’s important for people to know who they are going to be working with.”

For hospitalists looking to advance their careers, being recruited by a group that heavily involves its own hospitalists in the process can provide an opportunity to get an in-depth look at the prospective job and community, observes Kenneth G. Simone, DO, FHM, founder and president of Hospitalist and Practice Solutions, a practice-management consultancy based in Veazie, Maine. At the same time, hospitalists who are active in recruitment efforts are helping their own pursuits, says Dr. Simone, a member of Team Hospitalist and author of several HM-centered books, including “Hospitalist Recruit-ment and Retention.”

It gives new meaning to the saying recruiting is a two-way street. In this case, it’s a two-way street to success if hospitalists at both ends of the recruitment process use the situation to their advantage.

Candidate Advantage

If given the chance to interact with hospitalists at a potential job, a candidate should really pay attention to what the workday is like, Dr. Simone says. How is the workload? What kind of specialist support are the hospitalists getting? Are primary-care physicians (PCPs) referring patients to the group? Is there a good rapport with nursing staff?

“As a candidate, I should be asking why they are looking for a provider,” Dr. Simone says. “Is it growth? Is it turnover due to burnout?”

Having hospitalists engaged in the recruitment effort gives a candidate a great opportunity to ask questions he or she might not be comfortable asking of a director or hospital human resources personnel, Dr. Simone says. A candidate also gets a chance to observe the level of collegiality among prospective coworkers and gauge if the hospitalists are happy in the workplace and with the community.

Hospitalists who are good at recruiting show that they are a leader, a good communicator, and a positive person. They can put this on a resume and give examples of what they did to help bring a quality provider to the team.

—Kenneth G. Simone, DO, FHM, president, Hospitalist and Practice Solutions, Veazie, Maine, Team Hospitalist member

“They want to know that they are not just a cog in the wheel, not just a person filling a shift,” Dr. Schmidt explains. “By and large, they want to be part of a team.”

According to Drs. Simone and Schmidt, hospitalist job candidates should make an effort to:

• Ask potential colleagues to show them the local neighborhoods, services, and cultural and entertainment amenities;
• Get the e-mail addresses and phone numbers of the hospitalists to contact them with any follow-up questions after the interview and site visit; and
• Meet the group’s newest hospitalists, as they are the people who are in the best position to talk about the job transition.

A candidate’s goal is to gather enough information to determine if the job opportunity is the best fit for them and their family, Dr. Schmidt says. But candidates must remember that the time they spend and the conversations they share with the group’s hospitalists are still part of the interview process, Dr. Simone emphasizes. “If the person interviewing for a job has a lot of questions about vacation time and workload, that could send a signal that he or she doesn’t have a good work ethic,” he says.

Conversely, candidates should be wary of any program that doesn’t in some degree include their hospitalists in the recruitment process. It could mean that the group is trying to hide something, or that morale is so low that the hospitalists don’t want to promote the program. “I personally would be very uncomfortable not knowing who my partners would be,” Dr. Schmidt says.

Other red flags to look out for are constant references to the job’s competitive salary, which could indicate problems in other areas that the hospitalist practice is trying to mask, and no references to challenging issues the group is facing. If the group appears too good to be true, it probably is, Dr. Simone says.

Recruitment = Leadership

Hospitalists who get involved in their group’s recruitment efforts show their employer and supervisor that they are team players and care about the group and its future. It shows they are willing to help the program beyond providing patient care, and it demonstrates to both current and future employers that they have valuable professional characteristics and skills.

“Hospitalists who are good at recruiting show that they are a leader, a good communicator, and a positive person,” Dr. Simone says. “They can put this on a resume and give examples of what they did to help bring a quality provider to the team.”

When recruiting, be honest about the program’s strengths and weaknesses. “You want to avoid telling a candidate something a program is not,” Dr. Schmidt says. “You should be open about the program’s goals, workload, and expectations.”

Hospitalists who help in recruiting can frame the challenges a program is facing in a positive light. If an HM program is having trouble with, for example, a pulmonology group that is understaffed, the hospitalist recruiting candidates could explain the program is temporarily cross-covering patients at night until a new specialist can be found, Dr. Simone explains. He also notes it’s always best to place negatives into a context that shows the hospitalist group is working on a solution.

Getting engaged in recruiting also helps a hospitalist improve their current job by strengthening their team with good doctors who care about doing quality work, Drs. Schmidt and Simone say.

And that is more important than building a resume. TH

Lisa Ryan is a freelance writer based in New Jersey.

Christina Payne, MD, is a third-year resident at Emory University Hospital in Atlanta who will begin her first hospitalist job, with Emory in September. In spite of her dearth of practical experience, she already has experience researching one of the most vexing problems confronting HM: how to improve transitions of care.

Dr. Payne has been studying the benefits of a structured electronic tool that generates a standardized sign-out list of a hospital team’s full census at the time of shift change, compared with the usual, highly variable sign-out practices of medical residents. At a poster presentation at Internal Medicine 2010 in April in Toronto, Dr. Payne and colleagues reported that residents using the tool were twice as confident at performing handoffs, had lower rates of perceived near-miss events, and were happier.¹

“Hospitalists everywhere are starting to realize the importance of trying to reduce opportunities for human error that occur during care transitions,” Dr. Payne says. “The biggest thing I learned from this research is the importance of standardizing the handoff process [with information communicated consistently].

“It is essential to keep communication lines open,” Dr. Payne adds. “No tool can replace the importance of communication between doctors and the need to sit down and talk. The ideal signout happens in a quiet room where the two of you can talk about active patients and achieve rapport. But, realistically, how often does that happen?”

Standardization is one of a handful of strategies hospitalists, researchers, and policymakers are using to tackle transitions—both in-hospital handoffs and post-discharge transitions—with outpatient care. Some hospitalists are using practice simulations and training strategies; others have implemented medication reconciliation checks at every discharge, checklists and other communication strategies, team-based quality-improvement (QI) initiatives, and new technologies to enhance and streamline communication. Some interventions follow the patient from the hospital to the community physician with a phone call, follow-up clinic, or other contact; others aim to empower the patient to be a better self-advocate. But for hospitalists, the challenge is to communicate the right amount of transfer information to the right receiver at the right time.

No matter the technique, the goal is the same: Improve the handoff and discharge process in a way that promotes efficiency and patient safety. And hospitalists are at the forefront of the changing landscape of care transitions.

Under the Microscope

Care transitions of all kinds are under the magnifying glass of national healthcare reform, with growing recognition of the need to make care safer and reduce the preventable, costly hospital readmissions caused by incomplete handoffs. Care transitions for hospitalists include internal handoffs, both at daily shift changes and at service changes when an outgoing provider is leaving after a period of consecutive daily shifts. These typically involve a sign-out process and face-to-face encounter, with some kind of written backup. One teaching institution reported that such handoffs take place 4,000 times per day in the hospital, or 1.6 million times per year.²

This is a complex problem and it needs a multifaceted solution. But this lies squarely within the hospitalist arena. We’re part of everything that happens in the hospital.

—Arpana Vidyarthi, MD, University of California at San Francisco

Geographical transitions can be from one floor or department to another, or out the hospital door to another facility or home. Transitions typically involve a discharge process and a written discharge summary. Care transitions also include hospital admissions, which put the hospitalist in the role of handoff receiver rather than initiator, plus a variety of other transitions involving nurses, physician extenders, and other practitioners.

Each transition is a major decision point in the course of a patient’s hospitalization; each transition also presents a time of heightened vulnerability (e.g., potential communication breakdowns, medication errors, patient anxiety or confusion, etc.). In fact, according to a Transitions of Care Consensus Policy Statement published in 2009 by SHM and five other medical societies, handoffs are ubiquitous in HM, with significant patient safety and quality deficiencies in handoffs existing in the current system.³

Poor communication at the time of handoff has been implicated in near-misses and adverse events in a variety of healthcare contexts, including 70% of hospital sentinel events studied by The Joint Commission, which named standardized handoffs (with an opportunity for interactive communication) as a National Patient Safety Goal in 2006.⁴ The federal government is studying care transitions, supporting demonstration projects for Medicare enrollees, and including readmission rates in national hospital report card data.

Dr. Arora

“Transitions of care and handoffs are a huge focus right now because of the increased fragmentation of care in the United States. Hospitalists are in charge of a greater percentage of hospitalized patients, which means more coordination of care is needed,” says Vineet Arora, MD, MA, FHM, assistant professor of medicine and associate director of the internal-medicine residency at the University of Chicago, and chair of the SHM task force on handoffs.

Inadequate communication and poor care transitions can undermine hospitalists’ best care-planning efforts, erode patients’ and families’ confidence and satisfaction with hospital care, and leave primary-care physicians (PCPs) feeling unsatisfied with the relationship. As many as 1 in 5 Medicare beneficiary hospitalizations result in a readmission within 30 days, and while not all of these are preventable, far too many are.⁵ Another prospective cohort study found that 1 in 5 patients discharged from the hospital to the home experienced an adverse event within three weeks of discharge.⁶ Complex comorbidities, advanced age, unknown PCP, and limited healthcare literacy present hospitalists with extremely difficult transitions.

Patient safety and cost control are the linchpins to national efforts to improve transitions of care. Dr. Arora recently coauthored an original research paper, which will be published in the Journal of Hospital Medicine in September, showing older hospitalized patients are twice as likely to report problems after discharge if their PCPs were not aware they were hospitalized.

“With escalating healthcare costs, people are looking at ways to save money and reduce redundant care,” Dr. Arora explains, pointing out, as an example, repeated tests resulting from inadequate communication between healthcare providers.

The System Must Change

“All of the effort we put into saving someone’s life—the years of experience, training, medical school, and residency—all of it comes to bear on that hospitalized patient. And it can all be unraveled at the time of discharge if it’s not handled properly,” says Arpana Vidyarthi, MD, a hospitalist and director of quality at the University of California at San Francisco.

Dr. Vidyarthi views in-hospital and discharge transitions as integrally related. “The analysis is similar, even if different techniques may be needed,” she says, adding that, fundamentally, it involves having a system that allows people—or forces them—to do the “right thing.”

That’s why achieving effective care transitions will require more than just a standardized tool or process, Dr. Vidyarthi says. “This is about understanding the ways people communicate and finding ways to train them to communicate better,” she says. “The problem we have is not a lack of information, but how to communicate what, to whom, and when.”

What’s really needed, Dr. Vidyarthi says, is a hospital’s commitment to more effective transitions and its hospitalists’ leadership in driving a comprehensive, multidisciplinary, team- and evidence-based QI process. The new process should be a QI-based solution to a hospital’s care-transitions issues. “Before you can standardize your process, you need to understand it,” she says. “This is a complex problem, and it needs a multifaceted solution. But this lies squarely within the hospitalist arena. We’re part of everything that happens in the hospital.

We created an intervention that automatically triggers an e-mail with the finalized test results to the responsible providers. The intervention creates a loop of communication between the inpatient attending and the PCP. What we hope to show in our research over the next year or two is whether the intervention actually increases awareness of test results by providers.

—Anuj Dalal, MD, Brigham and Women’s Hospital, Boston

Hospital administrators are looking to HM to solve transition and readmission problems now, says Tina Budnitz, MPH, BOOST Project Director (Better Outcomes for Older Adults through Safe Transitions). She expects the scrutiny from the C-suite, legislators, and watchdog groups to increase as the spotlight continues to shine on the healthcare system.

“Any hospitalist can act as a leader in their institution,” Budnitz says. “Be a change agent, pull a group together, and start asking questions: Do we have safe care-transitions practices and processes in place? Just by asking the right question, you can be a catalyst for the system.”

Budnitz also emphasizes the importance of teamwork in the hospital setting. “How can I help my teammates? What am I communicating to the nurses on rounds?” she says. “Can you initiate dialogue with your outpatient medical groups: ‘These faxes we’re sending you—is that information getting to you in ways and times that are helpful? And, by the way, when your patient is admitted, this information would really help me.’ ”

Dr. Arora

Innovative Strategies

One of the most important initiatives responding to concerns about care transitions is Project BOOST (www.hos pitalmedicine.org/BOOST), a comprehensive toolkit for improving a hospital’s transitions of care. The project aims to build a national consensus for best practices in transitions; collaborate with representatives from the Agency for Healthcare Research and Quality (AHRQ), the Centers for Medicare and Medicaid Services (CMS), and the Joint Commission; and develop a national resource library, Budnitz says.

“Project BOOST not only puts forth best practices for admitting patients, planning for discharge, and then doing the discharge, it also helps show facilities how to change their systems, with resources and tools for analyzing and re-engineering the system,” she says. “Sites get one-to-one assistance from a mentor.”

Six hospitals signed on to the pilot program in 2008; 24 more joined last year. In January, SHM announced a collaborative with the University of Michigan and Blue Cross Blue Shield of Michigan for 15 Michigan hospitals to receive training and mentorship starting in May. And last month, SHM and the California HealthCare Foundation announced a Project BOOST initiative for 20 of the health system’s hospitals (see “California Dreamin’”, p. 6). Other free resources offered on the BOOST Web portal include clinical, data collection, and project management tools. SHM also has a DVD that explains how to use the “teachback” method to improve communication with patients.

Jennifer Myers, MD, FHM, assistant professor of clinical medicine and patient-safety officer at the Hospital of the University of Pennsylvania in Philadelphia, is a Project BOOST participant who spearheaded a process change to improve the quality of her facility’s discharge summary, along with accompanying resident education.⁷ The discharge summary recently was integrated with the hospital’s electronic health record (EHR) system.

“We’ve gone from dictating the discharge summary to an electronic version completed by the hospitalist, with prompts for key components of the summary, which allows us to create summaries more efficiently—ideally on the day of discharge, but usually within 48 hours,” Dr. Myers says. “We previously researched whether teaching made a difference in the quality of discharges; we found that it did. So we look forward to standardizing our teaching approach around this important topic for all residents.”

Another care-transitions innovation receiving a lot of attention from the government and the private sector is Project RED (Re-Engineered Discharge), led by Brian Jack, MD, vice chair of the department of family medicine at Boston Medical Center. The Project RED research group develops and tests strategies to improve the hospital discharge process to promote patient safety and reduce rehospitalization rates.

“We used re-engineering tools borrowed from other fields, brought together experts from all over the hospital, divided up the whole discharge process, and identified key principles,” Dr. Jack explains. The resulting discharge strategy is reflected in an 11-item checklist of discrete, mutually reinforcing components, which have been shown to reduce rehospitalization rates by 32% while raising patient satisfaction.⁸ It includes comprehensive discharge and after-hospital plans, a nurse discharge advocate, and a medication reconciliation phone call to the patient. A virtual “patient advocate,” a computerized avatar named Louise, is now being tested. If successful, it will allow patients to interact with a touch-screen teacher of the after-care plan who has time to work at the patient’s pace.

Technology and Transitions

Dr. Chopra

Informatics can be a key player in facilitating care transitions, says Anuj Dalal, MD, a hospitalist and instructor in medicine at Brigham and Women’s Hospital in Boston. He is using one of his hospital’s technological strengths—a well-established, firewall-protected e-mail system—to help improve the discharge process.

“We decided to try to improve awareness of test results pending at the time of discharge,” Dr. Dalal explains. “We created an intervention that automatically triggers an e-mail with the finalized test results to the responsible providers. The intervention creates a loop of communication between the inpatient attending and the PCP. What we hope to show in our research over the next year or two is whether the intervention actually increases awareness of test results by providers.”

One thing to remember is that “all kinds of things can go wrong with care transitions,” no matter the size of the institution, the experience of the staff, or technological limitations, says Vineet Chopra, MD, FACP, a hospitalist at the University of Michigan Health System in Ann Arbor. “The problems of transitions vary from place to place, day to day, time of day, shift changes; and let’s not forget physician extenders and the other members of the healthcare team,” he says. “The more complicated the team, the more complicated the information needing to be handed off becomes.”

Who Else Is Looking at Transitions of Care?

Dr. Zadzam

SHM convened the Handoffs Task Force in 2006. The team systematically reviewed the literature and published recommendations in the September 2009 Journal of Hospital Medicine.⁹ The recommendations are aimed at both community and academic hospitals, as well as hospitalists and other healthcare providers. A new collaborative designed to supplement Project BOOST for hospitalist group handoffs and help put the guidelines into practice is in the works, says Dr. Arora, the task force’s chair.

SHM and five medical groups, including the American College of Physicians, issued a Transitions of Care Consensus Statement, published in the July 2009 issue of the Journal of Hospital Medicine.⁵ Guiding principles relate to education, measurement, accountability, timely interchange of information, inclusion of patient and family, respect for the medical home, and the need for national standards.

The Joint Commission’s Center for Transforming Health Care, established in 2009 to solve healthcare’s most critical safety and quality problems, has made handoff communications its second major target, and is now working with 10 healthcare systems. Standardized handoff processes and communications were the subject of the Joint Commission’s 2006 National Patient Safety Goal, while the Comprehensive Accreditation Manual for Hospitals also specifies that before a hospital discharges or transfers a patient, it should inform and educate the patient about his or her follow-up care and services.

“We now have a safety goal under review dealing with medication reconciliation, and there are relevant standards related to culturally sensitive communication and low-literacy-level communication,” says Deborah Zadzam, PhD, RN, FAAN, director of international quality and performance measures for Joint Commission Resources. “The essential message the Joint Commission has for hospitalists is to communicate clearly, effectively and thoroughly; don’t assume you are understood or that you understand.”—LB

Before he joined the group at the university, Dr. Chopra worked at a community hospital, St. Joseph’s Mercy Hospital in Hot Springs, Ark. “It’s hard to come up with a one-size-fits-all solution when there are so many variables,” he says. At the community hospital, “we mandated that the hospitalist call the PCP at the time of discharge. At the academic medical center, we share an EHR with the PCPs and can reach them electronically. We are required to have the discharge summary in the computer before the patient leaves the hospital, and we mandate that hospitalists are reachable by e-mail or phone when they are off.

“I’m not a believer in throwing more technology at problems and just adding more layers of information tools,” Dr. Chopra adds. “Hospitalists who used to carry stethoscopes now also have a clipboard, phone, pager, PDA, and nine different signouts in their pockets. What we want to do is make their life easier. Here, we are looking at technology as a means to do that.”

Dr. Chopra and hospitalist colleague Prasanth Gosineni, MD, have been working with an Ann Arbor tech company called Synaptin to develop a lightweight, mobile client application designed to work on smartphones. Still in pilot testing, it would allow for task-oriented and priority-based messaging in real time and the systematic transfer of important information for the next hospitalist shift.

“You need to be able to share information in a systematic way, but that’s only half of the answer. The other half is the ability to ask specific questions,” Dr. Chopra says. “Technology doesn’t take away from the face-to-face encounter that needs to happen. Nothing will replace face time, but part of the solution is to provide data efficiently and in a way that is easily accessible.”

Dr. Chopra admits that EHR presents both positives and negatives to improved transitions and patient care, “depending on how well it works and what smart features it offers,” he says, “but also recognizing that EHR and other technologies have also taken us farther away from face-to-face exchanges. Some would say that’s part of the problem.”

Handoffs, discharges, and other transitions are ubiquitous in HM—and fraught with the potential for costly and harmful errors. The ideal of an interactive, face-to-face handoff simply is not available for many care transitions. However, hospitalists are challenged to find solutions that will work in their hospitals, with their teams, and their types of patients. Patients and policymakers expect nothing less. TH

Larry Beresford is a freelance writer based in Oakland, Calif.

References

1. Payne C, Stein J, Dressler D. Implementation of a structured electronic tool to improve patient handoffs and resident satisfaction. Poster abstract: Internal Medicine 2010, April 21-24, 2010, Toronto.
2. Vidyarthi AR. Triple Handoff. AHRQ WebM&M website. Available at: webmm.ahrq.gov/case.aspx? caseID=134. Published May 2006. Accessed May 29, 2010.
3. Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus Policy Statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine. J Hosp Med. 2009;4(6):364-370.
4. 2006 National Patient Safety Goals. The Joint Commission website. Available at: www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/06_npsgs.htm. Accessed June 8, 2010.
5. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009; 2:360:1418-1428.
6. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161-167.
7. Myers JS, Jaipaul CK, Kogan JR, Krekun S, Bellini LM, Shea JA. Are discharge summaries teachable? The effects of a discharge summary curriculum on the quality of discharge summaries in an internal medicine residency program. Acad Med. 2006; 81(10):S5-S8.
8. Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178-187.
9. Arora VM, Manjarrez E, Dressler DD, Basaviah P, Halasyamani L, Kripalani S. Hospitalist handoffs: a systematic review and task force recommendations. J Hosp Med. 2009;4(7): 433-440.
10. Halasyamani L, Kripalani S, Coleman E, et al. Transition of care for hospitalized elderly patients—development of a discharge checklist for hospitalists. J Hosp Med. 2006;1(6):354-360.
11. Schnipper JL, Kirwin JL, Cotugno MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Int Med. 2006;166(5):565-571.
12. Dudas V, Bookwalter T, Kerr KM, Pantilat SZ. The impact of follow-up telephone calls to patients after hospitalization. Am J Med. 2001;111(9B): 26S-30S.

Care Transition Tips for Hospitalists and Groups

Dr. Arora

One recognized key to effective internal handoffs is the face-to-face verbal update, with opportunities to ask questions, priority given to sicker patients, and a written backup filling in the blanks with information that might become important as the patient’s condition changes. But if that is not practical for your HM group, what tools and processes will come closest to the ideal?

A key to effective discharge from the hospital is connection with the PCP, although face-to-face encounters with PCPs are highly unlikely. Hospitalists say there are levels of connection with PCPs, from the urgent (“I need to talk to someone right now”) to the routine (“It’s OK if they get this information tomorrow”). Many often wonder if there should be two levels of discharge communication with PCPs: an immediate message relaying crucial information and a formal discharge summary coming later.

For HM groups, the following is a list of suggestions from transitions-of-care researchers:

• Keep accurate and up-to-date contact information, including preferred communication medium, on referring physicians; survey them on their satisfaction with the discharge communications they receive from hospitalists.
• Partner with hospital administrators and with patient-safety and quality officers to address handoff issues.
• Partner with IT staff to help bridge the divide between clinicians and information technology.
• Track such outcomes as rehospitalization rates.
• Offer formal training on handoffs, discharges, and effective communication to physicians and other providers.
• Standardize the signout process, with computerized tools when appropriate, and create automated systems for following up on tests and lab results that come back after discharge.
• Structure shifts and their overlaps to help facilitate signouts.
• Consider implementing a discharge checklist.¹⁰
• Develop a strategy for medication reconciliation, with someone assigned to the process, be that a hospitalist, pharmacist or nurse.¹¹
• Advocate for a post-discharge call-back policy by assigned staff at defined intervals, either for every patient discharged or for those targeted as higher-risk.¹²
• Consider creating a post-discharge clinic and/or a phone number that discharged patients can call to clarify post-discharge questions and concerns.

For individual hospitalists:

Contribute to The Hospitalist

Have a story idea or a clinical question you’d like answered? We’d like to hear about it. Send your questions and story ideas to Editor Jason Carris, [email protected], or to Physician Editor Jeff Glasheen, MD, SFHM, [email protected].

• Understand the transition process, where it fails, and why.
• Be open to changing the way you do things. Be accountable for transitions, and a role model for others.
• Focus on the present—today’s baseline, current to-do items, and what to expect next in the patient’s care.
• Track patients and their future discharge needs from the day of admission. What’s the likely date for going home? What does the patient need to learn in the meantime? Help nurses focus on achieving those needs and, if possible, schedule the initial outpatient clinic appointment before the patient leaves the hospital.
• Take time to talk your patients, listen to their concerns and confirm their understanding of what lies ahead.

For hospitalists on the receiving end of transition messages:

• Actively listen—stay focused, limit interruptions, take notes.
• Ask questions to ensure your understanding and read back what you understand to be the communication.
• Have a system for keeping track of to-do items requiring follow-up.—LB

Christina Payne, MD, is a third-year resident at Emory University Hospital in Atlanta who will begin her first hospitalist job, with Emory in September. In spite of her dearth of practical experience, she already has experience researching one of the most vexing problems confronting HM: how to improve transitions of care.

Dr. Payne has been studying the benefits of a structured electronic tool that generates a standardized sign-out list of a hospital team’s full census at the time of shift change, compared with the usual, highly variable sign-out practices of medical residents. At a poster presentation at Internal Medicine 2010 in April in Toronto, Dr. Payne and colleagues reported that residents using the tool were twice as confident at performing handoffs, had lower rates of perceived near-miss events, and were happier.¹

“Hospitalists everywhere are starting to realize the importance of trying to reduce opportunities for human error that occur during care transitions,” Dr. Payne says. “The biggest thing I learned from this research is the importance of standardizing the handoff process [with information communicated consistently].

“It is essential to keep communication lines open,” Dr. Payne adds. “No tool can replace the importance of communication between doctors and the need to sit down and talk. The ideal signout happens in a quiet room where the two of you can talk about active patients and achieve rapport. But, realistically, how often does that happen?”

Standardization is one of a handful of strategies hospitalists, researchers, and policymakers are using to tackle transitions—both in-hospital handoffs and post-discharge transitions—with outpatient care. Some hospitalists are using practice simulations and training strategies; others have implemented medication reconciliation checks at every discharge, checklists and other communication strategies, team-based quality-improvement (QI) initiatives, and new technologies to enhance and streamline communication. Some interventions follow the patient from the hospital to the community physician with a phone call, follow-up clinic, or other contact; others aim to empower the patient to be a better self-advocate. But for hospitalists, the challenge is to communicate the right amount of transfer information to the right receiver at the right time.

No matter the technique, the goal is the same: Improve the handoff and discharge process in a way that promotes efficiency and patient safety. And hospitalists are at the forefront of the changing landscape of care transitions.

Under the Microscope

Care transitions of all kinds are under the magnifying glass of national healthcare reform, with growing recognition of the need to make care safer and reduce the preventable, costly hospital readmissions caused by incomplete handoffs. Care transitions for hospitalists include internal handoffs, both at daily shift changes and at service changes when an outgoing provider is leaving after a period of consecutive daily shifts. These typically involve a sign-out process and face-to-face encounter, with some kind of written backup. One teaching institution reported that such handoffs take place 4,000 times per day in the hospital, or 1.6 million times per year.²

This is a complex problem and it needs a multifaceted solution. But this lies squarely within the hospitalist arena. We’re part of everything that happens in the hospital.

—Arpana Vidyarthi, MD, University of California at San Francisco

Geographical transitions can be from one floor or department to another, or out the hospital door to another facility or home. Transitions typically involve a discharge process and a written discharge summary. Care transitions also include hospital admissions, which put the hospitalist in the role of handoff receiver rather than initiator, plus a variety of other transitions involving nurses, physician extenders, and other practitioners.

Each transition is a major decision point in the course of a patient’s hospitalization; each transition also presents a time of heightened vulnerability (e.g., potential communication breakdowns, medication errors, patient anxiety or confusion, etc.). In fact, according to a Transitions of Care Consensus Policy Statement published in 2009 by SHM and five other medical societies, handoffs are ubiquitous in HM, with significant patient safety and quality deficiencies in handoffs existing in the current system.³

Poor communication at the time of handoff has been implicated in near-misses and adverse events in a variety of healthcare contexts, including 70% of hospital sentinel events studied by The Joint Commission, which named standardized handoffs (with an opportunity for interactive communication) as a National Patient Safety Goal in 2006.⁴ The federal government is studying care transitions, supporting demonstration projects for Medicare enrollees, and including readmission rates in national hospital report card data.

Dr. Arora

“Transitions of care and handoffs are a huge focus right now because of the increased fragmentation of care in the United States. Hospitalists are in charge of a greater percentage of hospitalized patients, which means more coordination of care is needed,” says Vineet Arora, MD, MA, FHM, assistant professor of medicine and associate director of the internal-medicine residency at the University of Chicago, and chair of the SHM task force on handoffs.

Inadequate communication and poor care transitions can undermine hospitalists’ best care-planning efforts, erode patients’ and families’ confidence and satisfaction with hospital care, and leave primary-care physicians (PCPs) feeling unsatisfied with the relationship. As many as 1 in 5 Medicare beneficiary hospitalizations result in a readmission within 30 days, and while not all of these are preventable, far too many are.⁵ Another prospective cohort study found that 1 in 5 patients discharged from the hospital to the home experienced an adverse event within three weeks of discharge.⁶ Complex comorbidities, advanced age, unknown PCP, and limited healthcare literacy present hospitalists with extremely difficult transitions.

Patient safety and cost control are the linchpins to national efforts to improve transitions of care. Dr. Arora recently coauthored an original research paper, which will be published in the Journal of Hospital Medicine in September, showing older hospitalized patients are twice as likely to report problems after discharge if their PCPs were not aware they were hospitalized.

“With escalating healthcare costs, people are looking at ways to save money and reduce redundant care,” Dr. Arora explains, pointing out, as an example, repeated tests resulting from inadequate communication between healthcare providers.

The System Must Change

“All of the effort we put into saving someone’s life—the years of experience, training, medical school, and residency—all of it comes to bear on that hospitalized patient. And it can all be unraveled at the time of discharge if it’s not handled properly,” says Arpana Vidyarthi, MD, a hospitalist and director of quality at the University of California at San Francisco.

Dr. Vidyarthi views in-hospital and discharge transitions as integrally related. “The analysis is similar, even if different techniques may be needed,” she says, adding that, fundamentally, it involves having a system that allows people—or forces them—to do the “right thing.”

That’s why achieving effective care transitions will require more than just a standardized tool or process, Dr. Vidyarthi says. “This is about understanding the ways people communicate and finding ways to train them to communicate better,” she says. “The problem we have is not a lack of information, but how to communicate what, to whom, and when.”

What’s really needed, Dr. Vidyarthi says, is a hospital’s commitment to more effective transitions and its hospitalists’ leadership in driving a comprehensive, multidisciplinary, team- and evidence-based QI process. The new process should be a QI-based solution to a hospital’s care-transitions issues. “Before you can standardize your process, you need to understand it,” she says. “This is a complex problem, and it needs a multifaceted solution. But this lies squarely within the hospitalist arena. We’re part of everything that happens in the hospital.

We created an intervention that automatically triggers an e-mail with the finalized test results to the responsible providers. The intervention creates a loop of communication between the inpatient attending and the PCP. What we hope to show in our research over the next year or two is whether the intervention actually increases awareness of test results by providers.

—Anuj Dalal, MD, Brigham and Women’s Hospital, Boston

Hospital administrators are looking to HM to solve transition and readmission problems now, says Tina Budnitz, MPH, BOOST Project Director (Better Outcomes for Older Adults through Safe Transitions). She expects the scrutiny from the C-suite, legislators, and watchdog groups to increase as the spotlight continues to shine on the healthcare system.

“Any hospitalist can act as a leader in their institution,” Budnitz says. “Be a change agent, pull a group together, and start asking questions: Do we have safe care-transitions practices and processes in place? Just by asking the right question, you can be a catalyst for the system.”

Budnitz also emphasizes the importance of teamwork in the hospital setting. “How can I help my teammates? What am I communicating to the nurses on rounds?” she says. “Can you initiate dialogue with your outpatient medical groups: ‘These faxes we’re sending you—is that information getting to you in ways and times that are helpful? And, by the way, when your patient is admitted, this information would really help me.’ ”

Dr. Arora

Innovative Strategies

One of the most important initiatives responding to concerns about care transitions is Project BOOST (www.hos pitalmedicine.org/BOOST), a comprehensive toolkit for improving a hospital’s transitions of care. The project aims to build a national consensus for best practices in transitions; collaborate with representatives from the Agency for Healthcare Research and Quality (AHRQ), the Centers for Medicare and Medicaid Services (CMS), and the Joint Commission; and develop a national resource library, Budnitz says.

“Project BOOST not only puts forth best practices for admitting patients, planning for discharge, and then doing the discharge, it also helps show facilities how to change their systems, with resources and tools for analyzing and re-engineering the system,” she says. “Sites get one-to-one assistance from a mentor.”

Six hospitals signed on to the pilot program in 2008; 24 more joined last year. In January, SHM announced a collaborative with the University of Michigan and Blue Cross Blue Shield of Michigan for 15 Michigan hospitals to receive training and mentorship starting in May. And last month, SHM and the California HealthCare Foundation announced a Project BOOST initiative for 20 of the health system’s hospitals (see “California Dreamin’”, p. 6). Other free resources offered on the BOOST Web portal include clinical, data collection, and project management tools. SHM also has a DVD that explains how to use the “teachback” method to improve communication with patients.

Jennifer Myers, MD, FHM, assistant professor of clinical medicine and patient-safety officer at the Hospital of the University of Pennsylvania in Philadelphia, is a Project BOOST participant who spearheaded a process change to improve the quality of her facility’s discharge summary, along with accompanying resident education.⁷ The discharge summary recently was integrated with the hospital’s electronic health record (EHR) system.

“We’ve gone from dictating the discharge summary to an electronic version completed by the hospitalist, with prompts for key components of the summary, which allows us to create summaries more efficiently—ideally on the day of discharge, but usually within 48 hours,” Dr. Myers says. “We previously researched whether teaching made a difference in the quality of discharges; we found that it did. So we look forward to standardizing our teaching approach around this important topic for all residents.”

Another care-transitions innovation receiving a lot of attention from the government and the private sector is Project RED (Re-Engineered Discharge), led by Brian Jack, MD, vice chair of the department of family medicine at Boston Medical Center. The Project RED research group develops and tests strategies to improve the hospital discharge process to promote patient safety and reduce rehospitalization rates.

“We used re-engineering tools borrowed from other fields, brought together experts from all over the hospital, divided up the whole discharge process, and identified key principles,” Dr. Jack explains. The resulting discharge strategy is reflected in an 11-item checklist of discrete, mutually reinforcing components, which have been shown to reduce rehospitalization rates by 32% while raising patient satisfaction.⁸ It includes comprehensive discharge and after-hospital plans, a nurse discharge advocate, and a medication reconciliation phone call to the patient. A virtual “patient advocate,” a computerized avatar named Louise, is now being tested. If successful, it will allow patients to interact with a touch-screen teacher of the after-care plan who has time to work at the patient’s pace.

Technology and Transitions

Dr. Chopra

Informatics can be a key player in facilitating care transitions, says Anuj Dalal, MD, a hospitalist and instructor in medicine at Brigham and Women’s Hospital in Boston. He is using one of his hospital’s technological strengths—a well-established, firewall-protected e-mail system—to help improve the discharge process.

“We decided to try to improve awareness of test results pending at the time of discharge,” Dr. Dalal explains. “We created an intervention that automatically triggers an e-mail with the finalized test results to the responsible providers. The intervention creates a loop of communication between the inpatient attending and the PCP. What we hope to show in our research over the next year or two is whether the intervention actually increases awareness of test results by providers.”

One thing to remember is that “all kinds of things can go wrong with care transitions,” no matter the size of the institution, the experience of the staff, or technological limitations, says Vineet Chopra, MD, FACP, a hospitalist at the University of Michigan Health System in Ann Arbor. “The problems of transitions vary from place to place, day to day, time of day, shift changes; and let’s not forget physician extenders and the other members of the healthcare team,” he says. “The more complicated the team, the more complicated the information needing to be handed off becomes.”

Who Else Is Looking at Transitions of Care?

Dr. Zadzam

SHM convened the Handoffs Task Force in 2006. The team systematically reviewed the literature and published recommendations in the September 2009 Journal of Hospital Medicine.⁹ The recommendations are aimed at both community and academic hospitals, as well as hospitalists and other healthcare providers. A new collaborative designed to supplement Project BOOST for hospitalist group handoffs and help put the guidelines into practice is in the works, says Dr. Arora, the task force’s chair.

SHM and five medical groups, including the American College of Physicians, issued a Transitions of Care Consensus Statement, published in the July 2009 issue of the Journal of Hospital Medicine.⁵ Guiding principles relate to education, measurement, accountability, timely interchange of information, inclusion of patient and family, respect for the medical home, and the need for national standards.

The Joint Commission’s Center for Transforming Health Care, established in 2009 to solve healthcare’s most critical safety and quality problems, has made handoff communications its second major target, and is now working with 10 healthcare systems. Standardized handoff processes and communications were the subject of the Joint Commission’s 2006 National Patient Safety Goal, while the Comprehensive Accreditation Manual for Hospitals also specifies that before a hospital discharges or transfers a patient, it should inform and educate the patient about his or her follow-up care and services.

“We now have a safety goal under review dealing with medication reconciliation, and there are relevant standards related to culturally sensitive communication and low-literacy-level communication,” says Deborah Zadzam, PhD, RN, FAAN, director of international quality and performance measures for Joint Commission Resources. “The essential message the Joint Commission has for hospitalists is to communicate clearly, effectively and thoroughly; don’t assume you are understood or that you understand.”—LB

Before he joined the group at the university, Dr. Chopra worked at a community hospital, St. Joseph’s Mercy Hospital in Hot Springs, Ark. “It’s hard to come up with a one-size-fits-all solution when there are so many variables,” he says. At the community hospital, “we mandated that the hospitalist call the PCP at the time of discharge. At the academic medical center, we share an EHR with the PCPs and can reach them electronically. We are required to have the discharge summary in the computer before the patient leaves the hospital, and we mandate that hospitalists are reachable by e-mail or phone when they are off.

“I’m not a believer in throwing more technology at problems and just adding more layers of information tools,” Dr. Chopra adds. “Hospitalists who used to carry stethoscopes now also have a clipboard, phone, pager, PDA, and nine different signouts in their pockets. What we want to do is make their life easier. Here, we are looking at technology as a means to do that.”

Dr. Chopra and hospitalist colleague Prasanth Gosineni, MD, have been working with an Ann Arbor tech company called Synaptin to develop a lightweight, mobile client application designed to work on smartphones. Still in pilot testing, it would allow for task-oriented and priority-based messaging in real time and the systematic transfer of important information for the next hospitalist shift.

“You need to be able to share information in a systematic way, but that’s only half of the answer. The other half is the ability to ask specific questions,” Dr. Chopra says. “Technology doesn’t take away from the face-to-face encounter that needs to happen. Nothing will replace face time, but part of the solution is to provide data efficiently and in a way that is easily accessible.”

Dr. Chopra admits that EHR presents both positives and negatives to improved transitions and patient care, “depending on how well it works and what smart features it offers,” he says, “but also recognizing that EHR and other technologies have also taken us farther away from face-to-face exchanges. Some would say that’s part of the problem.”

Handoffs, discharges, and other transitions are ubiquitous in HM—and fraught with the potential for costly and harmful errors. The ideal of an interactive, face-to-face handoff simply is not available for many care transitions. However, hospitalists are challenged to find solutions that will work in their hospitals, with their teams, and their types of patients. Patients and policymakers expect nothing less. TH

Larry Beresford is a freelance writer based in Oakland, Calif.

References

1. Payne C, Stein J, Dressler D. Implementation of a structured electronic tool to improve patient handoffs and resident satisfaction. Poster abstract: Internal Medicine 2010, April 21-24, 2010, Toronto.
2. Vidyarthi AR. Triple Handoff. AHRQ WebM&M website. Available at: webmm.ahrq.gov/case.aspx? caseID=134. Published May 2006. Accessed May 29, 2010.
3. Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus Policy Statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine. J Hosp Med. 2009;4(6):364-370.
4. 2006 National Patient Safety Goals. The Joint Commission website. Available at: www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/06_npsgs.htm. Accessed June 8, 2010.
5. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009; 2:360:1418-1428.
6. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161-167.
7. Myers JS, Jaipaul CK, Kogan JR, Krekun S, Bellini LM, Shea JA. Are discharge summaries teachable? The effects of a discharge summary curriculum on the quality of discharge summaries in an internal medicine residency program. Acad Med. 2006; 81(10):S5-S8.
8. Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178-187.
9. Arora VM, Manjarrez E, Dressler DD, Basaviah P, Halasyamani L, Kripalani S. Hospitalist handoffs: a systematic review and task force recommendations. J Hosp Med. 2009;4(7): 433-440.
10. Halasyamani L, Kripalani S, Coleman E, et al. Transition of care for hospitalized elderly patients—development of a discharge checklist for hospitalists. J Hosp Med. 2006;1(6):354-360.
11. Schnipper JL, Kirwin JL, Cotugno MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Int Med. 2006;166(5):565-571.
12. Dudas V, Bookwalter T, Kerr KM, Pantilat SZ. The impact of follow-up telephone calls to patients after hospitalization. Am J Med. 2001;111(9B): 26S-30S.

Care Transition Tips for Hospitalists and Groups

Dr. Arora

One recognized key to effective internal handoffs is the face-to-face verbal update, with opportunities to ask questions, priority given to sicker patients, and a written backup filling in the blanks with information that might become important as the patient’s condition changes. But if that is not practical for your HM group, what tools and processes will come closest to the ideal?

A key to effective discharge from the hospital is connection with the PCP, although face-to-face encounters with PCPs are highly unlikely. Hospitalists say there are levels of connection with PCPs, from the urgent (“I need to talk to someone right now”) to the routine (“It’s OK if they get this information tomorrow”). Many often wonder if there should be two levels of discharge communication with PCPs: an immediate message relaying crucial information and a formal discharge summary coming later.

For HM groups, the following is a list of suggestions from transitions-of-care researchers:

• Keep accurate and up-to-date contact information, including preferred communication medium, on referring physicians; survey them on their satisfaction with the discharge communications they receive from hospitalists.
• Partner with hospital administrators and with patient-safety and quality officers to address handoff issues.
• Partner with IT staff to help bridge the divide between clinicians and information technology.
• Track such outcomes as rehospitalization rates.
• Offer formal training on handoffs, discharges, and effective communication to physicians and other providers.
• Standardize the signout process, with computerized tools when appropriate, and create automated systems for following up on tests and lab results that come back after discharge.
• Structure shifts and their overlaps to help facilitate signouts.
• Consider implementing a discharge checklist.¹⁰
• Develop a strategy for medication reconciliation, with someone assigned to the process, be that a hospitalist, pharmacist or nurse.¹¹
• Advocate for a post-discharge call-back policy by assigned staff at defined intervals, either for every patient discharged or for those targeted as higher-risk.¹²
• Consider creating a post-discharge clinic and/or a phone number that discharged patients can call to clarify post-discharge questions and concerns.

For individual hospitalists:

Contribute to The Hospitalist

Have a story idea or a clinical question you’d like answered? We’d like to hear about it. Send your questions and story ideas to Editor Jason Carris, [email protected], or to Physician Editor Jeff Glasheen, MD, SFHM, [email protected].

• Understand the transition process, where it fails, and why.
• Be open to changing the way you do things. Be accountable for transitions, and a role model for others.
• Focus on the present—today’s baseline, current to-do items, and what to expect next in the patient’s care.
• Track patients and their future discharge needs from the day of admission. What’s the likely date for going home? What does the patient need to learn in the meantime? Help nurses focus on achieving those needs and, if possible, schedule the initial outpatient clinic appointment before the patient leaves the hospital.
• Take time to talk your patients, listen to their concerns and confirm their understanding of what lies ahead.

For hospitalists on the receiving end of transition messages:

• Actively listen—stay focused, limit interruptions, take notes.
• Ask questions to ensure your understanding and read back what you understand to be the communication.
• Have a system for keeping track of to-do items requiring follow-up.—LB

Christina Payne, MD, is a third-year resident at Emory University Hospital in Atlanta who will begin her first hospitalist job, with Emory in September. In spite of her dearth of practical experience, she already has experience researching one of the most vexing problems confronting HM: how to improve transitions of care.

Dr. Payne has been studying the benefits of a structured electronic tool that generates a standardized sign-out list of a hospital team’s full census at the time of shift change, compared with the usual, highly variable sign-out practices of medical residents. At a poster presentation at Internal Medicine 2010 in April in Toronto, Dr. Payne and colleagues reported that residents using the tool were twice as confident at performing handoffs, had lower rates of perceived near-miss events, and were happier.¹

“Hospitalists everywhere are starting to realize the importance of trying to reduce opportunities for human error that occur during care transitions,” Dr. Payne says. “The biggest thing I learned from this research is the importance of standardizing the handoff process [with information communicated consistently].

“It is essential to keep communication lines open,” Dr. Payne adds. “No tool can replace the importance of communication between doctors and the need to sit down and talk. The ideal signout happens in a quiet room where the two of you can talk about active patients and achieve rapport. But, realistically, how often does that happen?”

Standardization is one of a handful of strategies hospitalists, researchers, and policymakers are using to tackle transitions—both in-hospital handoffs and post-discharge transitions—with outpatient care. Some hospitalists are using practice simulations and training strategies; others have implemented medication reconciliation checks at every discharge, checklists and other communication strategies, team-based quality-improvement (QI) initiatives, and new technologies to enhance and streamline communication. Some interventions follow the patient from the hospital to the community physician with a phone call, follow-up clinic, or other contact; others aim to empower the patient to be a better self-advocate. But for hospitalists, the challenge is to communicate the right amount of transfer information to the right receiver at the right time.

No matter the technique, the goal is the same: Improve the handoff and discharge process in a way that promotes efficiency and patient safety. And hospitalists are at the forefront of the changing landscape of care transitions.

Under the Microscope

Care transitions of all kinds are under the magnifying glass of national healthcare reform, with growing recognition of the need to make care safer and reduce the preventable, costly hospital readmissions caused by incomplete handoffs. Care transitions for hospitalists include internal handoffs, both at daily shift changes and at service changes when an outgoing provider is leaving after a period of consecutive daily shifts. These typically involve a sign-out process and face-to-face encounter, with some kind of written backup. One teaching institution reported that such handoffs take place 4,000 times per day in the hospital, or 1.6 million times per year.²

This is a complex problem and it needs a multifaceted solution. But this lies squarely within the hospitalist arena. We’re part of everything that happens in the hospital.

—Arpana Vidyarthi, MD, University of California at San Francisco

Geographical transitions can be from one floor or department to another, or out the hospital door to another facility or home. Transitions typically involve a discharge process and a written discharge summary. Care transitions also include hospital admissions, which put the hospitalist in the role of handoff receiver rather than initiator, plus a variety of other transitions involving nurses, physician extenders, and other practitioners.

Each transition is a major decision point in the course of a patient’s hospitalization; each transition also presents a time of heightened vulnerability (e.g., potential communication breakdowns, medication errors, patient anxiety or confusion, etc.). In fact, according to a Transitions of Care Consensus Policy Statement published in 2009 by SHM and five other medical societies, handoffs are ubiquitous in HM, with significant patient safety and quality deficiencies in handoffs existing in the current system.³

Poor communication at the time of handoff has been implicated in near-misses and adverse events in a variety of healthcare contexts, including 70% of hospital sentinel events studied by The Joint Commission, which named standardized handoffs (with an opportunity for interactive communication) as a National Patient Safety Goal in 2006.⁴ The federal government is studying care transitions, supporting demonstration projects for Medicare enrollees, and including readmission rates in national hospital report card data.

Dr. Arora

“Transitions of care and handoffs are a huge focus right now because of the increased fragmentation of care in the United States. Hospitalists are in charge of a greater percentage of hospitalized patients, which means more coordination of care is needed,” says Vineet Arora, MD, MA, FHM, assistant professor of medicine and associate director of the internal-medicine residency at the University of Chicago, and chair of the SHM task force on handoffs.

Inadequate communication and poor care transitions can undermine hospitalists’ best care-planning efforts, erode patients’ and families’ confidence and satisfaction with hospital care, and leave primary-care physicians (PCPs) feeling unsatisfied with the relationship. As many as 1 in 5 Medicare beneficiary hospitalizations result in a readmission within 30 days, and while not all of these are preventable, far too many are.⁵ Another prospective cohort study found that 1 in 5 patients discharged from the hospital to the home experienced an adverse event within three weeks of discharge.⁶ Complex comorbidities, advanced age, unknown PCP, and limited healthcare literacy present hospitalists with extremely difficult transitions.

Patient safety and cost control are the linchpins to national efforts to improve transitions of care. Dr. Arora recently coauthored an original research paper, which will be published in the Journal of Hospital Medicine in September, showing older hospitalized patients are twice as likely to report problems after discharge if their PCPs were not aware they were hospitalized.

“With escalating healthcare costs, people are looking at ways to save money and reduce redundant care,” Dr. Arora explains, pointing out, as an example, repeated tests resulting from inadequate communication between healthcare providers.

The System Must Change

“All of the effort we put into saving someone’s life—the years of experience, training, medical school, and residency—all of it comes to bear on that hospitalized patient. And it can all be unraveled at the time of discharge if it’s not handled properly,” says Arpana Vidyarthi, MD, a hospitalist and director of quality at the University of California at San Francisco.

Dr. Vidyarthi views in-hospital and discharge transitions as integrally related. “The analysis is similar, even if different techniques may be needed,” she says, adding that, fundamentally, it involves having a system that allows people—or forces them—to do the “right thing.”

That’s why achieving effective care transitions will require more than just a standardized tool or process, Dr. Vidyarthi says. “This is about understanding the ways people communicate and finding ways to train them to communicate better,” she says. “The problem we have is not a lack of information, but how to communicate what, to whom, and when.”

What’s really needed, Dr. Vidyarthi says, is a hospital’s commitment to more effective transitions and its hospitalists’ leadership in driving a comprehensive, multidisciplinary, team- and evidence-based QI process. The new process should be a QI-based solution to a hospital’s care-transitions issues. “Before you can standardize your process, you need to understand it,” she says. “This is a complex problem, and it needs a multifaceted solution. But this lies squarely within the hospitalist arena. We’re part of everything that happens in the hospital.

We created an intervention that automatically triggers an e-mail with the finalized test results to the responsible providers. The intervention creates a loop of communication between the inpatient attending and the PCP. What we hope to show in our research over the next year or two is whether the intervention actually increases awareness of test results by providers.

—Anuj Dalal, MD, Brigham and Women’s Hospital, Boston

Hospital administrators are looking to HM to solve transition and readmission problems now, says Tina Budnitz, MPH, BOOST Project Director (Better Outcomes for Older Adults through Safe Transitions). She expects the scrutiny from the C-suite, legislators, and watchdog groups to increase as the spotlight continues to shine on the healthcare system.

“Any hospitalist can act as a leader in their institution,” Budnitz says. “Be a change agent, pull a group together, and start asking questions: Do we have safe care-transitions practices and processes in place? Just by asking the right question, you can be a catalyst for the system.”

Budnitz also emphasizes the importance of teamwork in the hospital setting. “How can I help my teammates? What am I communicating to the nurses on rounds?” she says. “Can you initiate dialogue with your outpatient medical groups: ‘These faxes we’re sending you—is that information getting to you in ways and times that are helpful? And, by the way, when your patient is admitted, this information would really help me.’ ”

Dr. Arora

Innovative Strategies

One of the most important initiatives responding to concerns about care transitions is Project BOOST (www.hos pitalmedicine.org/BOOST), a comprehensive toolkit for improving a hospital’s transitions of care. The project aims to build a national consensus for best practices in transitions; collaborate with representatives from the Agency for Healthcare Research and Quality (AHRQ), the Centers for Medicare and Medicaid Services (CMS), and the Joint Commission; and develop a national resource library, Budnitz says.

“Project BOOST not only puts forth best practices for admitting patients, planning for discharge, and then doing the discharge, it also helps show facilities how to change their systems, with resources and tools for analyzing and re-engineering the system,” she says. “Sites get one-to-one assistance from a mentor.”

Six hospitals signed on to the pilot program in 2008; 24 more joined last year. In January, SHM announced a collaborative with the University of Michigan and Blue Cross Blue Shield of Michigan for 15 Michigan hospitals to receive training and mentorship starting in May. And last month, SHM and the California HealthCare Foundation announced a Project BOOST initiative for 20 of the health system’s hospitals (see “California Dreamin’”, p. 6). Other free resources offered on the BOOST Web portal include clinical, data collection, and project management tools. SHM also has a DVD that explains how to use the “teachback” method to improve communication with patients.

Jennifer Myers, MD, FHM, assistant professor of clinical medicine and patient-safety officer at the Hospital of the University of Pennsylvania in Philadelphia, is a Project BOOST participant who spearheaded a process change to improve the quality of her facility’s discharge summary, along with accompanying resident education.⁷ The discharge summary recently was integrated with the hospital’s electronic health record (EHR) system.

“We’ve gone from dictating the discharge summary to an electronic version completed by the hospitalist, with prompts for key components of the summary, which allows us to create summaries more efficiently—ideally on the day of discharge, but usually within 48 hours,” Dr. Myers says. “We previously researched whether teaching made a difference in the quality of discharges; we found that it did. So we look forward to standardizing our teaching approach around this important topic for all residents.”

Another care-transitions innovation receiving a lot of attention from the government and the private sector is Project RED (Re-Engineered Discharge), led by Brian Jack, MD, vice chair of the department of family medicine at Boston Medical Center. The Project RED research group develops and tests strategies to improve the hospital discharge process to promote patient safety and reduce rehospitalization rates.

“We used re-engineering tools borrowed from other fields, brought together experts from all over the hospital, divided up the whole discharge process, and identified key principles,” Dr. Jack explains. The resulting discharge strategy is reflected in an 11-item checklist of discrete, mutually reinforcing components, which have been shown to reduce rehospitalization rates by 32% while raising patient satisfaction.⁸ It includes comprehensive discharge and after-hospital plans, a nurse discharge advocate, and a medication reconciliation phone call to the patient. A virtual “patient advocate,” a computerized avatar named Louise, is now being tested. If successful, it will allow patients to interact with a touch-screen teacher of the after-care plan who has time to work at the patient’s pace.

Technology and Transitions

Dr. Chopra

Informatics can be a key player in facilitating care transitions, says Anuj Dalal, MD, a hospitalist and instructor in medicine at Brigham and Women’s Hospital in Boston. He is using one of his hospital’s technological strengths—a well-established, firewall-protected e-mail system—to help improve the discharge process.

“We decided to try to improve awareness of test results pending at the time of discharge,” Dr. Dalal explains. “We created an intervention that automatically triggers an e-mail with the finalized test results to the responsible providers. The intervention creates a loop of communication between the inpatient attending and the PCP. What we hope to show in our research over the next year or two is whether the intervention actually increases awareness of test results by providers.”

One thing to remember is that “all kinds of things can go wrong with care transitions,” no matter the size of the institution, the experience of the staff, or technological limitations, says Vineet Chopra, MD, FACP, a hospitalist at the University of Michigan Health System in Ann Arbor. “The problems of transitions vary from place to place, day to day, time of day, shift changes; and let’s not forget physician extenders and the other members of the healthcare team,” he says. “The more complicated the team, the more complicated the information needing to be handed off becomes.”

Who Else Is Looking at Transitions of Care?

Dr. Zadzam

SHM convened the Handoffs Task Force in 2006. The team systematically reviewed the literature and published recommendations in the September 2009 Journal of Hospital Medicine.⁹ The recommendations are aimed at both community and academic hospitals, as well as hospitalists and other healthcare providers. A new collaborative designed to supplement Project BOOST for hospitalist group handoffs and help put the guidelines into practice is in the works, says Dr. Arora, the task force’s chair.

SHM and five medical groups, including the American College of Physicians, issued a Transitions of Care Consensus Statement, published in the July 2009 issue of the Journal of Hospital Medicine.⁵ Guiding principles relate to education, measurement, accountability, timely interchange of information, inclusion of patient and family, respect for the medical home, and the need for national standards.

The Joint Commission’s Center for Transforming Health Care, established in 2009 to solve healthcare’s most critical safety and quality problems, has made handoff communications its second major target, and is now working with 10 healthcare systems. Standardized handoff processes and communications were the subject of the Joint Commission’s 2006 National Patient Safety Goal, while the Comprehensive Accreditation Manual for Hospitals also specifies that before a hospital discharges or transfers a patient, it should inform and educate the patient about his or her follow-up care and services.

“We now have a safety goal under review dealing with medication reconciliation, and there are relevant standards related to culturally sensitive communication and low-literacy-level communication,” says Deborah Zadzam, PhD, RN, FAAN, director of international quality and performance measures for Joint Commission Resources. “The essential message the Joint Commission has for hospitalists is to communicate clearly, effectively and thoroughly; don’t assume you are understood or that you understand.”—LB

Before he joined the group at the university, Dr. Chopra worked at a community hospital, St. Joseph’s Mercy Hospital in Hot Springs, Ark. “It’s hard to come up with a one-size-fits-all solution when there are so many variables,” he says. At the community hospital, “we mandated that the hospitalist call the PCP at the time of discharge. At the academic medical center, we share an EHR with the PCPs and can reach them electronically. We are required to have the discharge summary in the computer before the patient leaves the hospital, and we mandate that hospitalists are reachable by e-mail or phone when they are off.

“I’m not a believer in throwing more technology at problems and just adding more layers of information tools,” Dr. Chopra adds. “Hospitalists who used to carry stethoscopes now also have a clipboard, phone, pager, PDA, and nine different signouts in their pockets. What we want to do is make their life easier. Here, we are looking at technology as a means to do that.”

Dr. Chopra and hospitalist colleague Prasanth Gosineni, MD, have been working with an Ann Arbor tech company called Synaptin to develop a lightweight, mobile client application designed to work on smartphones. Still in pilot testing, it would allow for task-oriented and priority-based messaging in real time and the systematic transfer of important information for the next hospitalist shift.

“You need to be able to share information in a systematic way, but that’s only half of the answer. The other half is the ability to ask specific questions,” Dr. Chopra says. “Technology doesn’t take away from the face-to-face encounter that needs to happen. Nothing will replace face time, but part of the solution is to provide data efficiently and in a way that is easily accessible.”

Dr. Chopra admits that EHR presents both positives and negatives to improved transitions and patient care, “depending on how well it works and what smart features it offers,” he says, “but also recognizing that EHR and other technologies have also taken us farther away from face-to-face exchanges. Some would say that’s part of the problem.”

Handoffs, discharges, and other transitions are ubiquitous in HM—and fraught with the potential for costly and harmful errors. The ideal of an interactive, face-to-face handoff simply is not available for many care transitions. However, hospitalists are challenged to find solutions that will work in their hospitals, with their teams, and their types of patients. Patients and policymakers expect nothing less. TH

Larry Beresford is a freelance writer based in Oakland, Calif.

References

1. Payne C, Stein J, Dressler D. Implementation of a structured electronic tool to improve patient handoffs and resident satisfaction. Poster abstract: Internal Medicine 2010, April 21-24, 2010, Toronto.
2. Vidyarthi AR. Triple Handoff. AHRQ WebM&M website. Available at: webmm.ahrq.gov/case.aspx? caseID=134. Published May 2006. Accessed May 29, 2010.
3. Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus Policy Statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine. J Hosp Med. 2009;4(6):364-370.
4. 2006 National Patient Safety Goals. The Joint Commission website. Available at: www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/06_npsgs.htm. Accessed June 8, 2010.
5. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009; 2:360:1418-1428.
6. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161-167.
7. Myers JS, Jaipaul CK, Kogan JR, Krekun S, Bellini LM, Shea JA. Are discharge summaries teachable? The effects of a discharge summary curriculum on the quality of discharge summaries in an internal medicine residency program. Acad Med. 2006; 81(10):S5-S8.
8. Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178-187.
9. Arora VM, Manjarrez E, Dressler DD, Basaviah P, Halasyamani L, Kripalani S. Hospitalist handoffs: a systematic review and task force recommendations. J Hosp Med. 2009;4(7): 433-440.
10. Halasyamani L, Kripalani S, Coleman E, et al. Transition of care for hospitalized elderly patients—development of a discharge checklist for hospitalists. J Hosp Med. 2006;1(6):354-360.
11. Schnipper JL, Kirwin JL, Cotugno MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Int Med. 2006;166(5):565-571.
12. Dudas V, Bookwalter T, Kerr KM, Pantilat SZ. The impact of follow-up telephone calls to patients after hospitalization. Am J Med. 2001;111(9B): 26S-30S.

Care Transition Tips for Hospitalists and Groups

Dr. Arora

One recognized key to effective internal handoffs is the face-to-face verbal update, with opportunities to ask questions, priority given to sicker patients, and a written backup filling in the blanks with information that might become important as the patient’s condition changes. But if that is not practical for your HM group, what tools and processes will come closest to the ideal?

A key to effective discharge from the hospital is connection with the PCP, although face-to-face encounters with PCPs are highly unlikely. Hospitalists say there are levels of connection with PCPs, from the urgent (“I need to talk to someone right now”) to the routine (“It’s OK if they get this information tomorrow”). Many often wonder if there should be two levels of discharge communication with PCPs: an immediate message relaying crucial information and a formal discharge summary coming later.

For HM groups, the following is a list of suggestions from transitions-of-care researchers:

• Keep accurate and up-to-date contact information, including preferred communication medium, on referring physicians; survey them on their satisfaction with the discharge communications they receive from hospitalists.
• Partner with hospital administrators and with patient-safety and quality officers to address handoff issues.
• Partner with IT staff to help bridge the divide between clinicians and information technology.
• Track such outcomes as rehospitalization rates.
• Offer formal training on handoffs, discharges, and effective communication to physicians and other providers.
• Standardize the signout process, with computerized tools when appropriate, and create automated systems for following up on tests and lab results that come back after discharge.
• Structure shifts and their overlaps to help facilitate signouts.
• Consider implementing a discharge checklist.¹⁰
• Develop a strategy for medication reconciliation, with someone assigned to the process, be that a hospitalist, pharmacist or nurse.¹¹
• Advocate for a post-discharge call-back policy by assigned staff at defined intervals, either for every patient discharged or for those targeted as higher-risk.¹²
• Consider creating a post-discharge clinic and/or a phone number that discharged patients can call to clarify post-discharge questions and concerns.

For individual hospitalists:

Contribute to The Hospitalist

Have a story idea or a clinical question you’d like answered? We’d like to hear about it. Send your questions and story ideas to Editor Jason Carris, [email protected], or to Physician Editor Jeff Glasheen, MD, SFHM, [email protected].

• Understand the transition process, where it fails, and why.
• Be open to changing the way you do things. Be accountable for transitions, and a role model for others.
• Focus on the present—today’s baseline, current to-do items, and what to expect next in the patient’s care.
• Track patients and their future discharge needs from the day of admission. What’s the likely date for going home? What does the patient need to learn in the meantime? Help nurses focus on achieving those needs and, if possible, schedule the initial outpatient clinic appointment before the patient leaves the hospital.
• Take time to talk your patients, listen to their concerns and confirm their understanding of what lies ahead.

For hospitalists on the receiving end of transition messages:

• Actively listen—stay focused, limit interruptions, take notes.
• Ask questions to ensure your understanding and read back what you understand to be the communication.
• Have a system for keeping track of to-do items requiring follow-up.—LB

Project BOOST, SHM’s popular mentorship program designed to help hospitals reduce readmissions, is headed to the most populous state in the country. In a joint venture with the California HealthCare Foundation, Project BOOST (Better Outcomes for Older Adults through Safe Transitions) will launch a groundbreaking, two-year program in 20 hospitals in the Golden State.

The California HealthCare Founda-tion will cover almost half of the $28,000 in tuition costs for each hospital accepted into the collaborative program. Individual sites will be responsible for the other $14,500.

click for large version

In year one, hospitals will begin improving their discharge procedures using Project BOOST’s toolkit and one-on-one mentorships with leaders in the field. The second year of the project will focus on training additional mentors in California. The foundation has committed not only to improving outcomes in the first 20 sites, but also building a sustainable infrastructure that will allow gains to quickly spread throughout the state.

Recruiting for the California sites has just begun. Potential applicants can visit www.hospitalmedicine.org/boost for more information.

“California is a microcosm for the challenges and opportunities for hospitalized care in our healthcare system,” says Janet Nagamine, RN, MD, SFHM, program leader for the California BOOST program and an SHM board member. “We are very excited to work with the California HealthCare Foundation, one of the state’s leaders in healthcare quality improvement. … Their support will help California’s hospitals and primary-care physicians [PCPs] safely transition patients from hospital to home during that vulnerable period.”

click for large version

Project BOOST’s Continued Expansion

The California program will be SHM’s largest state-specific program to date, representing the fourth wave of BOOST’s continued expansion. With the support of the John A. Hartford Foundation, the program began with six pilot sites throughout the country in 2008. In 2009, Hartford funded 24 additional sites.

In January, SHM, the University of Michigan, and Blue Cross Blue Shield of Michigan announced the first state-specific Project BOOST program. The three organizations announced Michigan’s 14 participating sites in May.

Two other hospital sites began implementing Project BOOST on a tuition-based model in May.

Readmission Challenge

Most hospitalists are intimately familiar with the challenges involved with transitions of care. Research in the April 2009 New England Journal of Medicine by Stephen F. Jencks, MD, MPH, Mark V. Williams, MD, FHM, and Eric A. Coleman, MD, MPH, indicates that 1 in 5 hospitalized patients is readmitted to the hospital within a month of their discharge.¹

Balancing the three-legged stool of communication between the hospitalist, PCP, and patient can be demanding. For the individual hospitalist or PCP, it requires intense attention to detail, strong communication skills, and patience. For hospitals, safe transitions require a systemic, team-based approach.

But the alternative—continued or increased readmissions after discharge—is even more taxing. The study found that unplanned readmissions cost Medicare $17.4 billion each year, making estimates of the total cost even higher.1

Looking beyond the costs directly associated with readmissions, the study’s authors see the issue as a potential vital sign that could assess overall healthcare quality. “Although the readmission rate is often presented as a measure of the performance of hospitals, it may also be a useful indicator of the performance of our healthcare system,” they write.

The Approach: Gain Traction, Results

Rather than forcing a one-size-fits-all process on every hospital site, Project BOOST provides individual hospitals with the capacity and experience necessary to implement processes that best fit their unique situation.

Project BOOST sites participate in a two-pronged program consisting of a yearlong, one-on-one mentorship with the leaders in the field. It begins with an intensive, two-day conference and the Project BOOST toolkit.

The toolkit includes printed materials and a new DVD for use by hospitalists and other care providers to facilitate communication with patients and caregivers during discharge.

New case studies published by SHM document some of the program’s earliest successes.

At Piedmont Hospital, a 481-bed acute-care hospital near Atlanta, the full implementation of Project BOOST in one hospital unit has improved many of its “vital signs” in comparison with units that have not implemented BOOST, including decreased length of stay and lower 30-day readmissions (see “Piedmont Hospital: Project BOOST unit vs. regular hospital units,” p. 6).

For St. Mary’s Medical Center, a 582-bed community teaching hospital in St. Louis, hospitalists implementing Project BOOST made a major difference in just three months:

Not only did the Project BOOST unit nearly halve 30-day readmissions (7% from 12%), but the program also increased patient satisfaction, to 68% from 52%.

BOOSTing into the Future

Project BOOST benefits haven’t been limited to program sites and their patients. New innovations from the mentored implementation program have led to resources that all hospitals can use.

SHM recently introduced a new DVD and curriculum package that teaches nurses and discharge planners to use the “teachback” method to communicate with patients during the discharge process. It helps ensure that patients fully understand their care plans and post-discharge instructions.

The teachback package is available at the SHM online store (www.hospitalmedicine.org); it is $85 for SHM members and $125 for nonmembers.

SHM has also launched a BOOST data center and a BOOST community site. The data center enables sites to enter, track, and benchmark key outcomes, which can then be evaluated against comparison units at their own hospitals, BOOST averages, and subsets of hospitals with similar characteristics. The BOOST community site facilitates the sharing of ideas and documents between BOOST hospitals.

New funding approaches will help Project BOOST to continue to reach more hospitals. Since its inception, third parties have provided financial resources for the program.

Now, SHM is offering a tuition-based model, open to hospitals nationwide, which is set to begin this fall.

SHM is accepting applications at www.hospitalmedicine.org/boost. TH

Brendon Shank is a freelance writer based in Philadelphia.

Reference

1. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Eng J Med. 2009:360:1418-1428.

Project BOOST, SHM’s popular mentorship program designed to help hospitals reduce readmissions, is headed to the most populous state in the country. In a joint venture with the California HealthCare Foundation, Project BOOST (Better Outcomes for Older Adults through Safe Transitions) will launch a groundbreaking, two-year program in 20 hospitals in the Golden State.

The California HealthCare Founda-tion will cover almost half of the $28,000 in tuition costs for each hospital accepted into the collaborative program. Individual sites will be responsible for the other $14,500.

click for large version

In year one, hospitals will begin improving their discharge procedures using Project BOOST’s toolkit and one-on-one mentorships with leaders in the field. The second year of the project will focus on training additional mentors in California. The foundation has committed not only to improving outcomes in the first 20 sites, but also building a sustainable infrastructure that will allow gains to quickly spread throughout the state.

Recruiting for the California sites has just begun. Potential applicants can visit www.hospitalmedicine.org/boost for more information.

“California is a microcosm for the challenges and opportunities for hospitalized care in our healthcare system,” says Janet Nagamine, RN, MD, SFHM, program leader for the California BOOST program and an SHM board member. “We are very excited to work with the California HealthCare Foundation, one of the state’s leaders in healthcare quality improvement. … Their support will help California’s hospitals and primary-care physicians [PCPs] safely transition patients from hospital to home during that vulnerable period.”

click for large version

Project BOOST’s Continued Expansion

The California program will be SHM’s largest state-specific program to date, representing the fourth wave of BOOST’s continued expansion. With the support of the John A. Hartford Foundation, the program began with six pilot sites throughout the country in 2008. In 2009, Hartford funded 24 additional sites.

In January, SHM, the University of Michigan, and Blue Cross Blue Shield of Michigan announced the first state-specific Project BOOST program. The three organizations announced Michigan’s 14 participating sites in May.

Two other hospital sites began implementing Project BOOST on a tuition-based model in May.

Readmission Challenge

Most hospitalists are intimately familiar with the challenges involved with transitions of care. Research in the April 2009 New England Journal of Medicine by Stephen F. Jencks, MD, MPH, Mark V. Williams, MD, FHM, and Eric A. Coleman, MD, MPH, indicates that 1 in 5 hospitalized patients is readmitted to the hospital within a month of their discharge.¹

Balancing the three-legged stool of communication between the hospitalist, PCP, and patient can be demanding. For the individual hospitalist or PCP, it requires intense attention to detail, strong communication skills, and patience. For hospitals, safe transitions require a systemic, team-based approach.

But the alternative—continued or increased readmissions after discharge—is even more taxing. The study found that unplanned readmissions cost Medicare $17.4 billion each year, making estimates of the total cost even higher.1

Looking beyond the costs directly associated with readmissions, the study’s authors see the issue as a potential vital sign that could assess overall healthcare quality. “Although the readmission rate is often presented as a measure of the performance of hospitals, it may also be a useful indicator of the performance of our healthcare system,” they write.

The Approach: Gain Traction, Results

Rather than forcing a one-size-fits-all process on every hospital site, Project BOOST provides individual hospitals with the capacity and experience necessary to implement processes that best fit their unique situation.

Project BOOST sites participate in a two-pronged program consisting of a yearlong, one-on-one mentorship with the leaders in the field. It begins with an intensive, two-day conference and the Project BOOST toolkit.

The toolkit includes printed materials and a new DVD for use by hospitalists and other care providers to facilitate communication with patients and caregivers during discharge.

New case studies published by SHM document some of the program’s earliest successes.

At Piedmont Hospital, a 481-bed acute-care hospital near Atlanta, the full implementation of Project BOOST in one hospital unit has improved many of its “vital signs” in comparison with units that have not implemented BOOST, including decreased length of stay and lower 30-day readmissions (see “Piedmont Hospital: Project BOOST unit vs. regular hospital units,” p. 6).

For St. Mary’s Medical Center, a 582-bed community teaching hospital in St. Louis, hospitalists implementing Project BOOST made a major difference in just three months:

Not only did the Project BOOST unit nearly halve 30-day readmissions (7% from 12%), but the program also increased patient satisfaction, to 68% from 52%.

BOOSTing into the Future

Project BOOST benefits haven’t been limited to program sites and their patients. New innovations from the mentored implementation program have led to resources that all hospitals can use.

SHM recently introduced a new DVD and curriculum package that teaches nurses and discharge planners to use the “teachback” method to communicate with patients during the discharge process. It helps ensure that patients fully understand their care plans and post-discharge instructions.

The teachback package is available at the SHM online store (www.hospitalmedicine.org); it is $85 for SHM members and $125 for nonmembers.

SHM has also launched a BOOST data center and a BOOST community site. The data center enables sites to enter, track, and benchmark key outcomes, which can then be evaluated against comparison units at their own hospitals, BOOST averages, and subsets of hospitals with similar characteristics. The BOOST community site facilitates the sharing of ideas and documents between BOOST hospitals.

New funding approaches will help Project BOOST to continue to reach more hospitals. Since its inception, third parties have provided financial resources for the program.

Now, SHM is offering a tuition-based model, open to hospitals nationwide, which is set to begin this fall.

SHM is accepting applications at www.hospitalmedicine.org/boost. TH

Brendon Shank is a freelance writer based in Philadelphia.

Reference

1. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Eng J Med. 2009:360:1418-1428.

Project BOOST, SHM’s popular mentorship program designed to help hospitals reduce readmissions, is headed to the most populous state in the country. In a joint venture with the California HealthCare Foundation, Project BOOST (Better Outcomes for Older Adults through Safe Transitions) will launch a groundbreaking, two-year program in 20 hospitals in the Golden State.

The California HealthCare Founda-tion will cover almost half of the $28,000 in tuition costs for each hospital accepted into the collaborative program. Individual sites will be responsible for the other $14,500.

click for large version

In year one, hospitals will begin improving their discharge procedures using Project BOOST’s toolkit and one-on-one mentorships with leaders in the field. The second year of the project will focus on training additional mentors in California. The foundation has committed not only to improving outcomes in the first 20 sites, but also building a sustainable infrastructure that will allow gains to quickly spread throughout the state.

Recruiting for the California sites has just begun. Potential applicants can visit www.hospitalmedicine.org/boost for more information.

“California is a microcosm for the challenges and opportunities for hospitalized care in our healthcare system,” says Janet Nagamine, RN, MD, SFHM, program leader for the California BOOST program and an SHM board member. “We are very excited to work with the California HealthCare Foundation, one of the state’s leaders in healthcare quality improvement. … Their support will help California’s hospitals and primary-care physicians [PCPs] safely transition patients from hospital to home during that vulnerable period.”

click for large version

Project BOOST’s Continued Expansion

The California program will be SHM’s largest state-specific program to date, representing the fourth wave of BOOST’s continued expansion. With the support of the John A. Hartford Foundation, the program began with six pilot sites throughout the country in 2008. In 2009, Hartford funded 24 additional sites.

In January, SHM, the University of Michigan, and Blue Cross Blue Shield of Michigan announced the first state-specific Project BOOST program. The three organizations announced Michigan’s 14 participating sites in May.

Two other hospital sites began implementing Project BOOST on a tuition-based model in May.

Readmission Challenge

Most hospitalists are intimately familiar with the challenges involved with transitions of care. Research in the April 2009 New England Journal of Medicine by Stephen F. Jencks, MD, MPH, Mark V. Williams, MD, FHM, and Eric A. Coleman, MD, MPH, indicates that 1 in 5 hospitalized patients is readmitted to the hospital within a month of their discharge.¹

Balancing the three-legged stool of communication between the hospitalist, PCP, and patient can be demanding. For the individual hospitalist or PCP, it requires intense attention to detail, strong communication skills, and patience. For hospitals, safe transitions require a systemic, team-based approach.

But the alternative—continued or increased readmissions after discharge—is even more taxing. The study found that unplanned readmissions cost Medicare $17.4 billion each year, making estimates of the total cost even higher.1

Looking beyond the costs directly associated with readmissions, the study’s authors see the issue as a potential vital sign that could assess overall healthcare quality. “Although the readmission rate is often presented as a measure of the performance of hospitals, it may also be a useful indicator of the performance of our healthcare system,” they write.

The Approach: Gain Traction, Results

Rather than forcing a one-size-fits-all process on every hospital site, Project BOOST provides individual hospitals with the capacity and experience necessary to implement processes that best fit their unique situation.

Project BOOST sites participate in a two-pronged program consisting of a yearlong, one-on-one mentorship with the leaders in the field. It begins with an intensive, two-day conference and the Project BOOST toolkit.

The toolkit includes printed materials and a new DVD for use by hospitalists and other care providers to facilitate communication with patients and caregivers during discharge.

New case studies published by SHM document some of the program’s earliest successes.

At Piedmont Hospital, a 481-bed acute-care hospital near Atlanta, the full implementation of Project BOOST in one hospital unit has improved many of its “vital signs” in comparison with units that have not implemented BOOST, including decreased length of stay and lower 30-day readmissions (see “Piedmont Hospital: Project BOOST unit vs. regular hospital units,” p. 6).

For St. Mary’s Medical Center, a 582-bed community teaching hospital in St. Louis, hospitalists implementing Project BOOST made a major difference in just three months:

Not only did the Project BOOST unit nearly halve 30-day readmissions (7% from 12%), but the program also increased patient satisfaction, to 68% from 52%.

BOOSTing into the Future

Project BOOST benefits haven’t been limited to program sites and their patients. New innovations from the mentored implementation program have led to resources that all hospitals can use.

SHM recently introduced a new DVD and curriculum package that teaches nurses and discharge planners to use the “teachback” method to communicate with patients during the discharge process. It helps ensure that patients fully understand their care plans and post-discharge instructions.

The teachback package is available at the SHM online store (www.hospitalmedicine.org); it is $85 for SHM members and $125 for nonmembers.

SHM has also launched a BOOST data center and a BOOST community site. The data center enables sites to enter, track, and benchmark key outcomes, which can then be evaluated against comparison units at their own hospitals, BOOST averages, and subsets of hospitals with similar characteristics. The BOOST community site facilitates the sharing of ideas and documents between BOOST hospitals.

New funding approaches will help Project BOOST to continue to reach more hospitals. Since its inception, third parties have provided financial resources for the program.

Now, SHM is offering a tuition-based model, open to hospitals nationwide, which is set to begin this fall.

SHM is accepting applications at www.hospitalmedicine.org/boost. TH

Brendon Shank is a freelance writer based in Philadelphia.

Reference

1. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Eng J Med. 2009:360:1418-1428.

New Drugs, Indications, Dosage Forms, and Approval Recommendations

• Acetaminophen intravenous (Ofirmev) received a complete response letter in February from the FDA related to facility manufacturing deficiencies. The FDA did not cite any safety or efficacy issues and is not requiring any additional studies to be done prior to approval.¹ The third-party manufacturer has submitted its response to the FDA and is ready to resubmit their new drug application (NDA) for this agent. It is being investigated to treat fever and pain in adults and children.²
• Ciprofloxacin dry powder inhaler (DPI) has received orphan drug status from the FDA for treating pulmonary infections in cystic fibrosis (CF) patients.^3,4 It is in clinical trials to determine if it can improve pulmonary function in CF patients with Pseudomonas aeruginosa infections.
• Carglumic acid (Carbaglu) has been approved by the FDA to treat the metabolic disorder N-acetylglutamate synthetase (NAGS) deficiency.⁵ NAGS deficiency is an extremely rare genetic disorder that presents shortly after birth. It results in hyperammonemia, and can be fatal if not rapidly detected and managed. Carglumic acid treats the hyperammonemia within three days, with a lowering of the ammonia level within 24 hours. In clinical trials, a small number of patients (n=23) received the drug from six months to 21 years; the majority of patients were able to maintain normal ammonia levels long-term with continued treatment. It is recommended that carglumic acid only be administered by physicians who have experience dealing with metabolic disorders. The starting dose is between 100 mg/kg/day and 250 mg/kg/day for treatment of acute hyperammonemia. Using other agents to lower the ammonia level during acute episodes is recommended. Dosing should be based on the ammonia level and the patient’s symptoms.
• CK-2017357 has received orphan drug status for treating amyotrophic lateral sclerosis (ALS), or Lou Gehrig’s disease.⁶
• Desirudin injection (Iprivask), a direct thrombin inhibitor, has been approved by the FDA for the prevention of DVT.⁷ In clinical trials, it was superior to enoxaparin and unfractionated heparin for preventing proximal DVT and prevention of major venous thromboembolic events following elective hip replacement surgery. Desirudin is administered as a fixed subcutaneous dose. It does not cause thrombocytopenia, is relatively short-acting, and is easy to monitor. Some of the adverse reactions in clinical trials were thrombosis, hypotension, lower-extremity edema, fever, decreased hemoglobin level, and hematuria.⁸ Also known as Revasc, this medication has been available in Europe for more than 10 years.
• Doxepin tablets (Silenor) have been approved by the FDA for the treatment of short-term and chronic insomnia distinguished by difficulty with sleep maintenance in adults and elderly patients.⁹ Sleep maintenance includes difficulty staying asleep, waking up too much or too early, and not being able to fall back asleep. In clinical trials, adverse reactions were similar to placebo, there was a low-therapy discontinuation rate, and no evidence of amnesia, tolerance, or complex sleep behaviors such as sleep eating or sleep driving.¹⁰ It will be available in 3-mg and 6-mg tablets. It is not designated as a controlled substance.
• GVAX pancreas vaccine has received orphan drug status as a potential treatment for pancreatic cancer.¹¹ It also is being investigated for other cancers, including those of the breast and for leukemias.
• Ritonavir (Norvir) has been approved by the FDA in a new formulation, which is heat-stable and can be stored at room temperature rather than in the refrigerator.¹² The rate of drug absorption with the new formulation is different but does not require a dosage change.
• Somatropin [rDNA origin] prefilled injection pen (Norditropin FlexPro) has been approved by the FDA to treat adults and children with growth hormone disorders.¹³ The pen has an audible click and does not require any reconstitution or cartridge loading. After initial use, the pen can be left at room temperature for up to three weeks without worry of drug degradation.

Pipeline

• Agalsidase (Replagal) has received fast-track status from the FDA for treating Fabry disease.¹⁴ It is an enzyme replacement therapy.
• Exenatide LAR (Bydureon), the once-weekly version of exenatide (Byetta), is in final discussions at the FDA. The FDA has asked for additional information related to the product label, risk mitigation, and manufacturing, which the manufacturer is addressing.¹⁵
• Insulin powder for inhalation, ultra-rapid-acting (Afrezza), has been reviewed by the FDA, and the agency has requested additional information related to safety and labeling.¹⁶
• A combination therapy of saxagliptin/metformin has been submitted to the FDA as a once-daily treatment of Type 2 diabetes mellitus as an adjunct to diet in adults who cannot adequately control their diabetes on metformin monotherapy, or in treatment-naïve patients.¹⁷
• Vilanterol/fluticasone is a combination of the inhaled corticosteroid fluticasone and the long-acting beta-agonist (LABA) vilanterol, which is currently in Phase 3 clinical trials for treating asthma.¹⁸ The trial will compare the combination’s efficacy and safety to fluticasone/salmeterol (Advair). TH

Michele B. Kaufman, PharmD, BSc, RPh, is a freelance medical writer based in New York City and a clinical pharmacist at New York Downtown Hospital.

References

1. Cadence pharmaceuticals receives complete response letter from FDA for intravenous acetaminophen NDA. Cadence Pharmaceuticals website. Available at: http://cadx.client.shareholder.com/releasedetail.cfm?ReleaseID=444303. Accessed March 23, 2010.
2. Cadence pharmaceuticals reports fourth quarter and full year 2009 financial results. Cadence Pharmaceuticals website. Available at: http://files.shareholder.com/downloads/CADX/874963043x0x359109/1cf00f72-0872-4d4e-b27d-bde1c03d625a/CADX_News_2010_3_15_General_Releases.pdf. Accessed March 23, 2010.
3. Bayer lung infection drug gets orphan status. Forbes website. Available at: http://www.forbes.com/feeds/ap/2010/03/11/business-energy-us-bayer-healthcare-orphan-drug_7427368.html. Accessed March 23, 2010.
4. FDA grants orphan status for Bayer’s ciprofloxacin for cystic fibrosis. The Pharma Letter website. Available at: http://www.thepharmaletter.com/file/4e4fb33313eddf122cdb730e3ea71840/fda-grants-orphan-status-for-bayers-ciprofloxacin-for-cystic-fibrosis.html. Accessed March 23, 2010.
5. Burgess S. FDA approves drug to treat condition that causes elevated ammonia levels. U.S. Food and Drug Administration website. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm205150.htm. Accessed March 23, 2010.
6. UPDATE 1: Cytokinetics’ Lou Gehrig’s drug gets orphan status. Reuters website. Available at: http://www.reuters.com/assets/print?aid=USSGE6290J820100310. Accessed March 23, 2010.
7. Iprivask available for prevention of deep vein thrombosis. Monthly Prescribing Reference website. Available at: http://www.empr.com/iprivask-available-for-prevention-of-deep-vein-thrombosis/article/164779/. Accessed March 23, 2010.
8. First direct thrombin inhibitor for DVT prevention now available from Canyon Pharmaceuticals. Canyon Pharmaceuticals website. Available at: http://www.canyonpharma.com/newsexpand.aspx?id=7. Accessed March 23, 2010.
9. FDA approves Silenor. Drugs.com website. Available at: http://www.drugs.com/newdrugs/somaxon-announces-fda-approval-silenor-doxepin-insomnia-2070.html?printable=1. Accessed March 23, 2010.
10. UPDATE 1: Somaxon gets FDA nod for insomnia drug, shares soar. Reuters website. Available at: http://www.reuters.com/assets/print?aid=USSGE62H0KI20100318. Accessed March 21, 2010.
11. BioSante announces FDA orphan drug designation for GVAX pancreatic cancer vaccine. The New York Times website. Available at: http://markets.on.nytimes.com/research/stocks/news/press_release.asp?docTag=201003150755BIZWIRE_USPRX____BW5298&feedID=600&press_symbol=64917. Accessed March 23, 2010.
12. Abbott receives U.S. FDA approval for heat-stable Norvir (ritonavir) tablets. Abbott website. Available at: http://www.abbott.com/global/url/pressRelease/en_US/60.5:5/Press_Release_0820.htm. Accessed March 23, 2010.
13. Novo Nordisk receives FDA approval for Norditropin FlexPro for growth hormone treatment. Novo Nordisk website. Available at: http://press.novonordisk-us.com/index.php?s=43&item=239. Accessed March 23, 2010.
14. Dane L. Shire receives FDA fast-track designation for Replagal. FirstWord website. Available at: http://www.firstwordplus.com/Fws.do?articleid=97AF48EBA7054EF0857F055877E82B2C&logRowId=352323. Accessed March 23, 2010.
15. Amylin shares up on FDA response for diabetes drug. Forbes website. Available at: http://www.forbes.com/feeds/ap/2010/03/15/business-health-care-us-amylin-mover_7435579.html. Accessed March 23, 2010.
16. Russell J. MannKind drug fails to win FDA approval. Los Angeles Business Journal website. Available at: http://labusinessjournal.com/article.asp?aid=4998235.0597195.1894204.8500584.7421642.713. Accessed March 23, 2010.
17. U.S. Food and Drug Administration accepts NDA for once-daily fixed dose combination of Onglyza (saxagliptin) and extended-release metformin for the treatment of type 2 diabetes mellitus in adults. AstraZeneca website. Available at: http://www.astrazeneca-us.com/about-astrazeneca-us/newsroom/product/8804120?itemId=8804120#. Accessed March 23, 2010.
18. Dennis M. GlaxoSmithKline begins late-stage clinical programme for asthma drug Relovair. FirstWord website. Available at: http://www.firstwordplus.com/Fws.do?articleid=E256469FBD8F4A2F80C5DD3E844CC1E1&logRowId=356423. Accessed March 23, 2010.

New Drugs, Indications, Dosage Forms, and Approval Recommendations

• Acetaminophen intravenous (Ofirmev) received a complete response letter in February from the FDA related to facility manufacturing deficiencies. The FDA did not cite any safety or efficacy issues and is not requiring any additional studies to be done prior to approval.¹ The third-party manufacturer has submitted its response to the FDA and is ready to resubmit their new drug application (NDA) for this agent. It is being investigated to treat fever and pain in adults and children.²
• Ciprofloxacin dry powder inhaler (DPI) has received orphan drug status from the FDA for treating pulmonary infections in cystic fibrosis (CF) patients.^3,4 It is in clinical trials to determine if it can improve pulmonary function in CF patients with Pseudomonas aeruginosa infections.
• Carglumic acid (Carbaglu) has been approved by the FDA to treat the metabolic disorder N-acetylglutamate synthetase (NAGS) deficiency.⁵ NAGS deficiency is an extremely rare genetic disorder that presents shortly after birth. It results in hyperammonemia, and can be fatal if not rapidly detected and managed. Carglumic acid treats the hyperammonemia within three days, with a lowering of the ammonia level within 24 hours. In clinical trials, a small number of patients (n=23) received the drug from six months to 21 years; the majority of patients were able to maintain normal ammonia levels long-term with continued treatment. It is recommended that carglumic acid only be administered by physicians who have experience dealing with metabolic disorders. The starting dose is between 100 mg/kg/day and 250 mg/kg/day for treatment of acute hyperammonemia. Using other agents to lower the ammonia level during acute episodes is recommended. Dosing should be based on the ammonia level and the patient’s symptoms.
• CK-2017357 has received orphan drug status for treating amyotrophic lateral sclerosis (ALS), or Lou Gehrig’s disease.⁶
• Desirudin injection (Iprivask), a direct thrombin inhibitor, has been approved by the FDA for the prevention of DVT.⁷ In clinical trials, it was superior to enoxaparin and unfractionated heparin for preventing proximal DVT and prevention of major venous thromboembolic events following elective hip replacement surgery. Desirudin is administered as a fixed subcutaneous dose. It does not cause thrombocytopenia, is relatively short-acting, and is easy to monitor. Some of the adverse reactions in clinical trials were thrombosis, hypotension, lower-extremity edema, fever, decreased hemoglobin level, and hematuria.⁸ Also known as Revasc, this medication has been available in Europe for more than 10 years.
• Doxepin tablets (Silenor) have been approved by the FDA for the treatment of short-term and chronic insomnia distinguished by difficulty with sleep maintenance in adults and elderly patients.⁹ Sleep maintenance includes difficulty staying asleep, waking up too much or too early, and not being able to fall back asleep. In clinical trials, adverse reactions were similar to placebo, there was a low-therapy discontinuation rate, and no evidence of amnesia, tolerance, or complex sleep behaviors such as sleep eating or sleep driving.¹⁰ It will be available in 3-mg and 6-mg tablets. It is not designated as a controlled substance.
• GVAX pancreas vaccine has received orphan drug status as a potential treatment for pancreatic cancer.¹¹ It also is being investigated for other cancers, including those of the breast and for leukemias.
• Ritonavir (Norvir) has been approved by the FDA in a new formulation, which is heat-stable and can be stored at room temperature rather than in the refrigerator.¹² The rate of drug absorption with the new formulation is different but does not require a dosage change.
• Somatropin [rDNA origin] prefilled injection pen (Norditropin FlexPro) has been approved by the FDA to treat adults and children with growth hormone disorders.¹³ The pen has an audible click and does not require any reconstitution or cartridge loading. After initial use, the pen can be left at room temperature for up to three weeks without worry of drug degradation.

Pipeline

• Agalsidase (Replagal) has received fast-track status from the FDA for treating Fabry disease.¹⁴ It is an enzyme replacement therapy.
• Exenatide LAR (Bydureon), the once-weekly version of exenatide (Byetta), is in final discussions at the FDA. The FDA has asked for additional information related to the product label, risk mitigation, and manufacturing, which the manufacturer is addressing.¹⁵
• Insulin powder for inhalation, ultra-rapid-acting (Afrezza), has been reviewed by the FDA, and the agency has requested additional information related to safety and labeling.¹⁶
• A combination therapy of saxagliptin/metformin has been submitted to the FDA as a once-daily treatment of Type 2 diabetes mellitus as an adjunct to diet in adults who cannot adequately control their diabetes on metformin monotherapy, or in treatment-naïve patients.¹⁷
• Vilanterol/fluticasone is a combination of the inhaled corticosteroid fluticasone and the long-acting beta-agonist (LABA) vilanterol, which is currently in Phase 3 clinical trials for treating asthma.¹⁸ The trial will compare the combination’s efficacy and safety to fluticasone/salmeterol (Advair). TH

Michele B. Kaufman, PharmD, BSc, RPh, is a freelance medical writer based in New York City and a clinical pharmacist at New York Downtown Hospital.

References

1. Cadence pharmaceuticals receives complete response letter from FDA for intravenous acetaminophen NDA. Cadence Pharmaceuticals website. Available at: http://cadx.client.shareholder.com/releasedetail.cfm?ReleaseID=444303. Accessed March 23, 2010.
2. Cadence pharmaceuticals reports fourth quarter and full year 2009 financial results. Cadence Pharmaceuticals website. Available at: http://files.shareholder.com/downloads/CADX/874963043x0x359109/1cf00f72-0872-4d4e-b27d-bde1c03d625a/CADX_News_2010_3_15_General_Releases.pdf. Accessed March 23, 2010.
3. Bayer lung infection drug gets orphan status. Forbes website. Available at: http://www.forbes.com/feeds/ap/2010/03/11/business-energy-us-bayer-healthcare-orphan-drug_7427368.html. Accessed March 23, 2010.
4. FDA grants orphan status for Bayer’s ciprofloxacin for cystic fibrosis. The Pharma Letter website. Available at: http://www.thepharmaletter.com/file/4e4fb33313eddf122cdb730e3ea71840/fda-grants-orphan-status-for-bayers-ciprofloxacin-for-cystic-fibrosis.html. Accessed March 23, 2010.
5. Burgess S. FDA approves drug to treat condition that causes elevated ammonia levels. U.S. Food and Drug Administration website. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm205150.htm. Accessed March 23, 2010.
6. UPDATE 1: Cytokinetics’ Lou Gehrig’s drug gets orphan status. Reuters website. Available at: http://www.reuters.com/assets/print?aid=USSGE6290J820100310. Accessed March 23, 2010.
7. Iprivask available for prevention of deep vein thrombosis. Monthly Prescribing Reference website. Available at: http://www.empr.com/iprivask-available-for-prevention-of-deep-vein-thrombosis/article/164779/. Accessed March 23, 2010.
8. First direct thrombin inhibitor for DVT prevention now available from Canyon Pharmaceuticals. Canyon Pharmaceuticals website. Available at: http://www.canyonpharma.com/newsexpand.aspx?id=7. Accessed March 23, 2010.
9. FDA approves Silenor. Drugs.com website. Available at: http://www.drugs.com/newdrugs/somaxon-announces-fda-approval-silenor-doxepin-insomnia-2070.html?printable=1. Accessed March 23, 2010.
10. UPDATE 1: Somaxon gets FDA nod for insomnia drug, shares soar. Reuters website. Available at: http://www.reuters.com/assets/print?aid=USSGE62H0KI20100318. Accessed March 21, 2010.
11. BioSante announces FDA orphan drug designation for GVAX pancreatic cancer vaccine. The New York Times website. Available at: http://markets.on.nytimes.com/research/stocks/news/press_release.asp?docTag=201003150755BIZWIRE_USPRX____BW5298&feedID=600&press_symbol=64917. Accessed March 23, 2010.
12. Abbott receives U.S. FDA approval for heat-stable Norvir (ritonavir) tablets. Abbott website. Available at: http://www.abbott.com/global/url/pressRelease/en_US/60.5:5/Press_Release_0820.htm. Accessed March 23, 2010.
13. Novo Nordisk receives FDA approval for Norditropin FlexPro for growth hormone treatment. Novo Nordisk website. Available at: http://press.novonordisk-us.com/index.php?s=43&item=239. Accessed March 23, 2010.
14. Dane L. Shire receives FDA fast-track designation for Replagal. FirstWord website. Available at: http://www.firstwordplus.com/Fws.do?articleid=97AF48EBA7054EF0857F055877E82B2C&logRowId=352323. Accessed March 23, 2010.
15. Amylin shares up on FDA response for diabetes drug. Forbes website. Available at: http://www.forbes.com/feeds/ap/2010/03/15/business-health-care-us-amylin-mover_7435579.html. Accessed March 23, 2010.
16. Russell J. MannKind drug fails to win FDA approval. Los Angeles Business Journal website. Available at: http://labusinessjournal.com/article.asp?aid=4998235.0597195.1894204.8500584.7421642.713. Accessed March 23, 2010.
17. U.S. Food and Drug Administration accepts NDA for once-daily fixed dose combination of Onglyza (saxagliptin) and extended-release metformin for the treatment of type 2 diabetes mellitus in adults. AstraZeneca website. Available at: http://www.astrazeneca-us.com/about-astrazeneca-us/newsroom/product/8804120?itemId=8804120#. Accessed March 23, 2010.
18. Dennis M. GlaxoSmithKline begins late-stage clinical programme for asthma drug Relovair. FirstWord website. Available at: http://www.firstwordplus.com/Fws.do?articleid=E256469FBD8F4A2F80C5DD3E844CC1E1&logRowId=356423. Accessed March 23, 2010.

New Drugs, Indications, Dosage Forms, and Approval Recommendations

• Acetaminophen intravenous (Ofirmev) received a complete response letter in February from the FDA related to facility manufacturing deficiencies. The FDA did not cite any safety or efficacy issues and is not requiring any additional studies to be done prior to approval.¹ The third-party manufacturer has submitted its response to the FDA and is ready to resubmit their new drug application (NDA) for this agent. It is being investigated to treat fever and pain in adults and children.²
• Ciprofloxacin dry powder inhaler (DPI) has received orphan drug status from the FDA for treating pulmonary infections in cystic fibrosis (CF) patients.^3,4 It is in clinical trials to determine if it can improve pulmonary function in CF patients with Pseudomonas aeruginosa infections.
• Carglumic acid (Carbaglu) has been approved by the FDA to treat the metabolic disorder N-acetylglutamate synthetase (NAGS) deficiency.⁵ NAGS deficiency is an extremely rare genetic disorder that presents shortly after birth. It results in hyperammonemia, and can be fatal if not rapidly detected and managed. Carglumic acid treats the hyperammonemia within three days, with a lowering of the ammonia level within 24 hours. In clinical trials, a small number of patients (n=23) received the drug from six months to 21 years; the majority of patients were able to maintain normal ammonia levels long-term with continued treatment. It is recommended that carglumic acid only be administered by physicians who have experience dealing with metabolic disorders. The starting dose is between 100 mg/kg/day and 250 mg/kg/day for treatment of acute hyperammonemia. Using other agents to lower the ammonia level during acute episodes is recommended. Dosing should be based on the ammonia level and the patient’s symptoms.
• CK-2017357 has received orphan drug status for treating amyotrophic lateral sclerosis (ALS), or Lou Gehrig’s disease.⁶
• Desirudin injection (Iprivask), a direct thrombin inhibitor, has been approved by the FDA for the prevention of DVT.⁷ In clinical trials, it was superior to enoxaparin and unfractionated heparin for preventing proximal DVT and prevention of major venous thromboembolic events following elective hip replacement surgery. Desirudin is administered as a fixed subcutaneous dose. It does not cause thrombocytopenia, is relatively short-acting, and is easy to monitor. Some of the adverse reactions in clinical trials were thrombosis, hypotension, lower-extremity edema, fever, decreased hemoglobin level, and hematuria.⁸ Also known as Revasc, this medication has been available in Europe for more than 10 years.
• Doxepin tablets (Silenor) have been approved by the FDA for the treatment of short-term and chronic insomnia distinguished by difficulty with sleep maintenance in adults and elderly patients.⁹ Sleep maintenance includes difficulty staying asleep, waking up too much or too early, and not being able to fall back asleep. In clinical trials, adverse reactions were similar to placebo, there was a low-therapy discontinuation rate, and no evidence of amnesia, tolerance, or complex sleep behaviors such as sleep eating or sleep driving.¹⁰ It will be available in 3-mg and 6-mg tablets. It is not designated as a controlled substance.
• GVAX pancreas vaccine has received orphan drug status as a potential treatment for pancreatic cancer.¹¹ It also is being investigated for other cancers, including those of the breast and for leukemias.
• Ritonavir (Norvir) has been approved by the FDA in a new formulation, which is heat-stable and can be stored at room temperature rather than in the refrigerator.¹² The rate of drug absorption with the new formulation is different but does not require a dosage change.
• Somatropin [rDNA origin] prefilled injection pen (Norditropin FlexPro) has been approved by the FDA to treat adults and children with growth hormone disorders.¹³ The pen has an audible click and does not require any reconstitution or cartridge loading. After initial use, the pen can be left at room temperature for up to three weeks without worry of drug degradation.

Pipeline

• Agalsidase (Replagal) has received fast-track status from the FDA for treating Fabry disease.¹⁴ It is an enzyme replacement therapy.
• Exenatide LAR (Bydureon), the once-weekly version of exenatide (Byetta), is in final discussions at the FDA. The FDA has asked for additional information related to the product label, risk mitigation, and manufacturing, which the manufacturer is addressing.¹⁵
• Insulin powder for inhalation, ultra-rapid-acting (Afrezza), has been reviewed by the FDA, and the agency has requested additional information related to safety and labeling.¹⁶
• A combination therapy of saxagliptin/metformin has been submitted to the FDA as a once-daily treatment of Type 2 diabetes mellitus as an adjunct to diet in adults who cannot adequately control their diabetes on metformin monotherapy, or in treatment-naïve patients.¹⁷
• Vilanterol/fluticasone is a combination of the inhaled corticosteroid fluticasone and the long-acting beta-agonist (LABA) vilanterol, which is currently in Phase 3 clinical trials for treating asthma.¹⁸ The trial will compare the combination’s efficacy and safety to fluticasone/salmeterol (Advair). TH

Michele B. Kaufman, PharmD, BSc, RPh, is a freelance medical writer based in New York City and a clinical pharmacist at New York Downtown Hospital.

References

1. Cadence pharmaceuticals receives complete response letter from FDA for intravenous acetaminophen NDA. Cadence Pharmaceuticals website. Available at: http://cadx.client.shareholder.com/releasedetail.cfm?ReleaseID=444303. Accessed March 23, 2010.
2. Cadence pharmaceuticals reports fourth quarter and full year 2009 financial results. Cadence Pharmaceuticals website. Available at: http://files.shareholder.com/downloads/CADX/874963043x0x359109/1cf00f72-0872-4d4e-b27d-bde1c03d625a/CADX_News_2010_3_15_General_Releases.pdf. Accessed March 23, 2010.
3. Bayer lung infection drug gets orphan status. Forbes website. Available at: http://www.forbes.com/feeds/ap/2010/03/11/business-energy-us-bayer-healthcare-orphan-drug_7427368.html. Accessed March 23, 2010.
4. FDA grants orphan status for Bayer’s ciprofloxacin for cystic fibrosis. The Pharma Letter website. Available at: http://www.thepharmaletter.com/file/4e4fb33313eddf122cdb730e3ea71840/fda-grants-orphan-status-for-bayers-ciprofloxacin-for-cystic-fibrosis.html. Accessed March 23, 2010.
5. Burgess S. FDA approves drug to treat condition that causes elevated ammonia levels. U.S. Food and Drug Administration website. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm205150.htm. Accessed March 23, 2010.
6. UPDATE 1: Cytokinetics’ Lou Gehrig’s drug gets orphan status. Reuters website. Available at: http://www.reuters.com/assets/print?aid=USSGE6290J820100310. Accessed March 23, 2010.
7. Iprivask available for prevention of deep vein thrombosis. Monthly Prescribing Reference website. Available at: http://www.empr.com/iprivask-available-for-prevention-of-deep-vein-thrombosis/article/164779/. Accessed March 23, 2010.
8. First direct thrombin inhibitor for DVT prevention now available from Canyon Pharmaceuticals. Canyon Pharmaceuticals website. Available at: http://www.canyonpharma.com/newsexpand.aspx?id=7. Accessed March 23, 2010.
9. FDA approves Silenor. Drugs.com website. Available at: http://www.drugs.com/newdrugs/somaxon-announces-fda-approval-silenor-doxepin-insomnia-2070.html?printable=1. Accessed March 23, 2010.
10. UPDATE 1: Somaxon gets FDA nod for insomnia drug, shares soar. Reuters website. Available at: http://www.reuters.com/assets/print?aid=USSGE62H0KI20100318. Accessed March 21, 2010.
11. BioSante announces FDA orphan drug designation for GVAX pancreatic cancer vaccine. The New York Times website. Available at: http://markets.on.nytimes.com/research/stocks/news/press_release.asp?docTag=201003150755BIZWIRE_USPRX____BW5298&feedID=600&press_symbol=64917. Accessed March 23, 2010.
12. Abbott receives U.S. FDA approval for heat-stable Norvir (ritonavir) tablets. Abbott website. Available at: http://www.abbott.com/global/url/pressRelease/en_US/60.5:5/Press_Release_0820.htm. Accessed March 23, 2010.
13. Novo Nordisk receives FDA approval for Norditropin FlexPro for growth hormone treatment. Novo Nordisk website. Available at: http://press.novonordisk-us.com/index.php?s=43&item=239. Accessed March 23, 2010.
14. Dane L. Shire receives FDA fast-track designation for Replagal. FirstWord website. Available at: http://www.firstwordplus.com/Fws.do?articleid=97AF48EBA7054EF0857F055877E82B2C&logRowId=352323. Accessed March 23, 2010.
15. Amylin shares up on FDA response for diabetes drug. Forbes website. Available at: http://www.forbes.com/feeds/ap/2010/03/15/business-health-care-us-amylin-mover_7435579.html. Accessed March 23, 2010.
16. Russell J. MannKind drug fails to win FDA approval. Los Angeles Business Journal website. Available at: http://labusinessjournal.com/article.asp?aid=4998235.0597195.1894204.8500584.7421642.713. Accessed March 23, 2010.
17. U.S. Food and Drug Administration accepts NDA for once-daily fixed dose combination of Onglyza (saxagliptin) and extended-release metformin for the treatment of type 2 diabetes mellitus in adults. AstraZeneca website. Available at: http://www.astrazeneca-us.com/about-astrazeneca-us/newsroom/product/8804120?itemId=8804120#. Accessed March 23, 2010.
18. Dennis M. GlaxoSmithKline begins late-stage clinical programme for asthma drug Relovair. FirstWord website. Available at: http://www.firstwordplus.com/Fws.do?articleid=E256469FBD8F4A2F80C5DD3E844CC1E1&logRowId=356423. Accessed March 23, 2010.