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Thursday Review: “Moving Beyond Readmission Penalties: Creating an Ideal Process to Improve Transitional Care”

As a quantitative metric, write Dr. Robert E. Burke et al., readmisssions can be problematic. In the Journal of Hospital Medicine, the authors write that one difficulty is the lack of an intentional process of discharging a patient to avoid readmission.

The authors lay out an ideal process for a care transition. I’d like to look briefly at how this idealized transition is like and unlike a story, and comment on how story can intervene at a few key points.

If any communication is going to be effective, the recipient has to perceive it as relevant. To be relevant, a story has to solve a problem the listener has or could envision themselves having. A long narrative string of “this happened, then this happened, then this happened” is usually uninteresting. The storyteller’s job is to make the listener understand that everything that happens is related in some way to what the hero of the story is trying to overcome. Put as briefly as possible, narratives have to be transformed into stories.

With that in mind, here are the ten transitional “domains”:

  1. Discharge Planning
  2. Complete Communication of Information
  3. Availability, Timeliness, Clarity, and Organization of that information
  4. Medication Safety
  5. Patient Education and Promotion of Self-Management
  6. Enlisting the help of Social and Community Supports
  7. Advanced Care Planning
  8. Coordinating Care Among Team Members
  9. Monitoring and Managing Symptoms After Discharge
  10. Outpatient Follow-Up with appropriate post-discharge providers

Burke et al. don’t see this as a step-by-step process. The only two domains which definitely happen after hospitalization are numbers 9 and 10. Every other item happens during or before discharge, at least in part. Instead, the authors use the metaphor of these being ten pillars supporting a bridge:

This … highlights key domains and suggests that lack of a domain makes the bridge weaker and more prone to gaps in care and poor outcomes. It also implies that the more components are missing, the less safe is the “bridge” or transition. Those domains that mainly take place prior to discharge are placed closer to the “hospital side” [the beginning] of the bridge, those that mainly take place after discharge are placed closer to the “community side” [the end] of the bridge, while those that take place both prior to and after discharge are in the middle.

Often, a hospital discharge feels like a release from prison, rather than a step toward health. (The word “recidivism” is used for both!) Patients are given paperwork with detailed instructions and told, “You’re being released on parole for two weeks, check in with us then.”

One simple way to begin to correct this is to talk through each of these ten domains with patients. There’s a whole story providers can clearly communicate about what’s going to happen next, using these ten domains as touchpoints.

Taken as a whole, the bridge model is also a wonderful reminder for everyone, from patients to physicians to nurses to administrators, that there is more at stake than one individual interaction with a patient. These ten domains include information sharing with the patient, other providers, and patient caregivers. Any method which lifts medicine from a siloed, factory mentality to a reminder that the patient keeps on living outside of clinic walls can be used for good.

I also think it’s impressive that the authors took pains to separate the completeness and accuracy of medical information (domain 2) from its clarity to the patient (domain 3). Burke et al. provide almost a checklist in domain 3: in order for a patient to benefit from medical information, it must be

  • available,
  • timely,
  • clear, and
  • organized.

Stories can help with this, as well as with patient education (domain 5), and communicating safety concerns with regard to medication (domain 4). As mentioned above, we perceive information as most relevant when we understand that what we’re being told is connected to our problems.

When information is communicated to the patient in a bullet point list, there’s sometimes no clear understanding of why the information is relevant. Contrast that with information presented in even the simplest of problem-first story structure:

  • One of the things we’re most concerned about in cases like yours is…
  • While you’ve been in the hospital, there have been problems with… so this medication does this: …
  • Once patients in your condition leave the hospital, they sometimes find that… and if that happens, it’s important that you…

In other words—just like transforming a narrative into a story—a list of stuff that happens has to be made into an obvious cause-and-effect string directly relating to the patient’s health.

Overall, that’s the one thing left to chance in this model: what does the patient themselves consider to “health” to look like after all this treatment? What do they want the life they return to to look like?

This process doesn’t explicitly mention establishing goals of care until domain 7, Advanced Care Planning. The authors seem to discuss the patient’s goals within the framework of end-of-life care. Both citations the authors use in their discussion of domain 7 explicitly research palliative care.1, 2

It’s certainly not wrong to discuss how a terminally- or seriously-ill patient would like to receive treatment. We shouldn’t reserve discussions about how a patient would like to live for those who are dying, though.

Going back to story and narrative, we understand a story in light of what the main character is struggling against. If a narrative is just a list of one thing after another, it seems aimless and, at worst, irrelevant. Knowing the patient’s goals for transitioning out of the hospital transforms everyone caring for that patient into characters in that patient’s story. If the goal of leaving the hospital is explicit and known, every action and domain in the process has a purpose which can be understood and acted on by everyone.

If we viewed the ten domains like a story with a problem and a goal, we could give a patient the care they need and want. The end game wouldn’t just be to keep them out of the hospital, but to help them live for something.


The article reviewed: Burke, Robert E., Sunil Kripalani, Eduard E. Vasilevskis, and Jeffrey L. Schnipper. “Moving beyond Readmission Penalties: Creating an Ideal Process to Improve Transitional Care.” Journal of Hospital Medicine 8, no. 2 (February 1, 2013): 102–9.

1 Pace, Andrea, Cherubino Di Lorenzo, Alessandra Capon, Veronica Villani, Dario Benincasa, Lara Guariglia, Maurizio Salvati, et al. “Quality of Care and Rehospitalization Rate in the Last Stage of Disease in Brain Tumor Patients Assisted at Home: A Cost Effectiveness Study.” Journal of Palliative Medicine 15, no. 2 (February 17, 2012): 225–27.

2 Nelson, Craig, Pushkar Chand, Julie Sortais, Joseph Oloimooja, and Gina Rembert. “Inpatient Palliative Care Consults and the Probability of Hospital Readmission.” The Permanente Journal 15, no. 2 (2011): 48–51.

Featured Image: Pedestrian Bridge at Sunset, by Flickr user Jonathan Cutrer under a CC BY 2.0 license.