Leaders: Care Doesn't Stop at the Hospital Door

Dr. Lauren Doctoroff, an academic hospitalist at Beth Israel Deaconess Medical Center in Boston, is part of a small but growing number of hospitalists who are seeing patients after they leave the hospital. Dr. Doctoroff, who is also an instructor of medicine at Harvard Medical School, Boston, is the medical director for the post-discharge clinic run jointly by Beth Israel and the hospital’s primary care practice, HealthCare Associates. The clinic, which opened its doors in September 2009, provides follow-up care to patients who have been recently discharged from the hospital or the emergency department.

In an interview with Hospitalist News, Dr. Doctoroff explained what led to the opening of the clinic and how working there has helped to make her a better hospitalist.

Hospitalist News: What drove the decision to open the post-discharge clinic at Beth Israel?

Dr. Doctoroff: The clinic was started as a joint venture between the hospitalist program and the general medicine department, which includes the faculty primary care practice, HealthCare Associates. There was a feeling from the hospitalist side that we could not get adequate and timely follow-up for our hospitalist patients at discharge. From the primary care perspective, I think they wanted to expose hospitalists to the outpatient work in the clinic and help us better organize the post-discharge planning that we do.

HN: Did you get push-back from primary care physicians in the community, and if so, how did you deal with that?

Dr. Doctoroff: Our clinic only sees patients who are affiliated with the primary care practice here. We do not have a stand-alone clinic where we see any patient that we discharge from the hospital. We have had some push-back from primary care doctors within the practice who feel that having us see a patient after a traumatic hospital admission is essentially another transition. And so they prefer to see their own patients after discharge. We developed processes to ensure that a primary care physician can know when their patient is scheduled in our clinic. But the effect of having us in the clinic has pushed the bar a little bit, so the primary care physicians seem to be scheduling their patients sooner, rather than having them come back to see them in a more haphazard way.

HN: Have you measured any outcomes since opening the clinic, such as the effect on readmissions?

Dr. Doctoroff: We were started essentially to help improve and create open access into this clinic. The main outcome that we started to look at was our impact on open access for patients after discharge. I have only preliminary data, but it shows that we really do see patients after discharge much more quickly than the primary care practice as a whole. Readmissions are what everyone is talking about these days, but our clinic wasn’t really established to reduce readmissions. It might be a secondary effect. But there are conflicting data about whether seeing a doctor actually reduces your risk of being readmitted. If you come to the doctor and you’re feeling poor, then you’re more likely to get readmitted than if you’d stayed home. But in those cases, being readmitted isn’t necessarily a bad outcome for the patient. It’s hard for me to think that seeing a doctor soon after discharge doesn’t help improve, if not readmissions, certainly quality of care.

HN: Do you enjoy the work in the discharge clinic, or does it detract from your inpatient responsibilities?

Dr. Doctoroff: I think that working in the discharge clinic has very much enriched my inpatient perspective. I think it really is invaluable to see the impact of discharge planning. You may think your discharge plan is good when you’re in the hospital, and then when you see the patient in the clinic, you think, "How was this ever considered to be a good plan?" For instance, why does a patient have four different appointments on different days with different specialists all in the 2 weeks after discharge? It’s really opened my eyes about what a good discharge plan and a good discharge summary are. I also feel more empathy for primary care physicians, as their job is definitely not an easy one.

HN: Do you think this clinic is a model for hospitalists in other parts of the country?

Dr. Doctoroff: The next stage of hospitalist medicine is going to include looking at our role as being a little broader than just being in the hospital. We as hospitalists are being held responsible for what happens to patients after discharge, whether it’s readmissions or other outcomes. I’m not sure that for every hospitalist group or every hospital, it will make sense to start a discharge clinic. I think there are models for discharge clinics in many different practice settings, both staffed by hospitalists and staffed by primary care doctors. But I do think that whether it’s a discharge clinic, whether it’s a post-discharge phone calling program, whether it’s just establishing better relationships with the primary care practices that you serve as a hospitalist, that this sort of connection is what’s going to be required to succeed as a hospitalist and in the new world of accountable care organizations and global payments.

This column, "Leaders," regularly appears in Hospitalist News, an Elsevier publication. Dr. Doctoroff had no disclosures to report.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to m.schneider@elsevier.com. Read previous columns at ehospitalistnews.com.

Dr. Lauren Doctoroff, an academic hospitalist at Beth Israel Deaconess Medical Center in Boston, is part of a small but growing number of hospitalists who are seeing patients after they leave the hospital. Dr. Doctoroff, who is also an instructor of medicine at Harvard Medical School, Boston, is the medical director for the post-discharge clinic run jointly by Beth Israel and the hospital’s primary care practice, HealthCare Associates. The clinic, which opened its doors in September 2009, provides follow-up care to patients who have been recently discharged from the hospital or the emergency department.

In an interview with Hospitalist News, Dr. Doctoroff explained what led to the opening of the clinic and how working there has helped to make her a better hospitalist.

Hospitalist News: What drove the decision to open the post-discharge clinic at Beth Israel?

Dr. Doctoroff: The clinic was started as a joint venture between the hospitalist program and the general medicine department, which includes the faculty primary care practice, HealthCare Associates. There was a feeling from the hospitalist side that we could not get adequate and timely follow-up for our hospitalist patients at discharge. From the primary care perspective, I think they wanted to expose hospitalists to the outpatient work in the clinic and help us better organize the post-discharge planning that we do.

HN: Did you get push-back from primary care physicians in the community, and if so, how did you deal with that?

Dr. Doctoroff: Our clinic only sees patients who are affiliated with the primary care practice here. We do not have a stand-alone clinic where we see any patient that we discharge from the hospital. We have had some push-back from primary care doctors within the practice who feel that having us see a patient after a traumatic hospital admission is essentially another transition. And so they prefer to see their own patients after discharge. We developed processes to ensure that a primary care physician can know when their patient is scheduled in our clinic. But the effect of having us in the clinic has pushed the bar a little bit, so the primary care physicians seem to be scheduling their patients sooner, rather than having them come back to see them in a more haphazard way.

HN: Have you measured any outcomes since opening the clinic, such as the effect on readmissions?

Dr. Doctoroff: We were started essentially to help improve and create open access into this clinic. The main outcome that we started to look at was our impact on open access for patients after discharge. I have only preliminary data, but it shows that we really do see patients after discharge much more quickly than the primary care practice as a whole. Readmissions are what everyone is talking about these days, but our clinic wasn’t really established to reduce readmissions. It might be a secondary effect. But there are conflicting data about whether seeing a doctor actually reduces your risk of being readmitted. If you come to the doctor and you’re feeling poor, then you’re more likely to get readmitted than if you’d stayed home. But in those cases, being readmitted isn’t necessarily a bad outcome for the patient. It’s hard for me to think that seeing a doctor soon after discharge doesn’t help improve, if not readmissions, certainly quality of care.

HN: Do you enjoy the work in the discharge clinic, or does it detract from your inpatient responsibilities?

Dr. Doctoroff: I think that working in the discharge clinic has very much enriched my inpatient perspective. I think it really is invaluable to see the impact of discharge planning. You may think your discharge plan is good when you’re in the hospital, and then when you see the patient in the clinic, you think, "How was this ever considered to be a good plan?" For instance, why does a patient have four different appointments on different days with different specialists all in the 2 weeks after discharge? It’s really opened my eyes about what a good discharge plan and a good discharge summary are. I also feel more empathy for primary care physicians, as their job is definitely not an easy one.

HN: Do you think this clinic is a model for hospitalists in other parts of the country?

Dr. Doctoroff: The next stage of hospitalist medicine is going to include looking at our role as being a little broader than just being in the hospital. We as hospitalists are being held responsible for what happens to patients after discharge, whether it’s readmissions or other outcomes. I’m not sure that for every hospitalist group or every hospital, it will make sense to start a discharge clinic. I think there are models for discharge clinics in many different practice settings, both staffed by hospitalists and staffed by primary care doctors. But I do think that whether it’s a discharge clinic, whether it’s a post-discharge phone calling program, whether it’s just establishing better relationships with the primary care practices that you serve as a hospitalist, that this sort of connection is what’s going to be required to succeed as a hospitalist and in the new world of accountable care organizations and global payments.

This column, "Leaders," regularly appears in Hospitalist News, an Elsevier publication. Dr. Doctoroff had no disclosures to report.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to m.schneider@elsevier.com. Read previous columns at ehospitalistnews.com.

Dr. Lauren Doctoroff, an academic hospitalist at Beth Israel Deaconess Medical Center in Boston, is part of a small but growing number of hospitalists who are seeing patients after they leave the hospital. Dr. Doctoroff, who is also an instructor of medicine at Harvard Medical School, Boston, is the medical director for the post-discharge clinic run jointly by Beth Israel and the hospital’s primary care practice, HealthCare Associates. The clinic, which opened its doors in September 2009, provides follow-up care to patients who have been recently discharged from the hospital or the emergency department.

In an interview with Hospitalist News, Dr. Doctoroff explained what led to the opening of the clinic and how working there has helped to make her a better hospitalist.

Hospitalist News: What drove the decision to open the post-discharge clinic at Beth Israel?

Dr. Doctoroff: The clinic was started as a joint venture between the hospitalist program and the general medicine department, which includes the faculty primary care practice, HealthCare Associates. There was a feeling from the hospitalist side that we could not get adequate and timely follow-up for our hospitalist patients at discharge. From the primary care perspective, I think they wanted to expose hospitalists to the outpatient work in the clinic and help us better organize the post-discharge planning that we do.

HN: Did you get push-back from primary care physicians in the community, and if so, how did you deal with that?

Dr. Doctoroff: Our clinic only sees patients who are affiliated with the primary care practice here. We do not have a stand-alone clinic where we see any patient that we discharge from the hospital. We have had some push-back from primary care doctors within the practice who feel that having us see a patient after a traumatic hospital admission is essentially another transition. And so they prefer to see their own patients after discharge. We developed processes to ensure that a primary care physician can know when their patient is scheduled in our clinic. But the effect of having us in the clinic has pushed the bar a little bit, so the primary care physicians seem to be scheduling their patients sooner, rather than having them come back to see them in a more haphazard way.

HN: Have you measured any outcomes since opening the clinic, such as the effect on readmissions?

Dr. Doctoroff: We were started essentially to help improve and create open access into this clinic. The main outcome that we started to look at was our impact on open access for patients after discharge. I have only preliminary data, but it shows that we really do see patients after discharge much more quickly than the primary care practice as a whole. Readmissions are what everyone is talking about these days, but our clinic wasn’t really established to reduce readmissions. It might be a secondary effect. But there are conflicting data about whether seeing a doctor actually reduces your risk of being readmitted. If you come to the doctor and you’re feeling poor, then you’re more likely to get readmitted than if you’d stayed home. But in those cases, being readmitted isn’t necessarily a bad outcome for the patient. It’s hard for me to think that seeing a doctor soon after discharge doesn’t help improve, if not readmissions, certainly quality of care.

HN: Do you enjoy the work in the discharge clinic, or does it detract from your inpatient responsibilities?

Dr. Doctoroff: I think that working in the discharge clinic has very much enriched my inpatient perspective. I think it really is invaluable to see the impact of discharge planning. You may think your discharge plan is good when you’re in the hospital, and then when you see the patient in the clinic, you think, "How was this ever considered to be a good plan?" For instance, why does a patient have four different appointments on different days with different specialists all in the 2 weeks after discharge? It’s really opened my eyes about what a good discharge plan and a good discharge summary are. I also feel more empathy for primary care physicians, as their job is definitely not an easy one.

HN: Do you think this clinic is a model for hospitalists in other parts of the country?

Dr. Doctoroff: The next stage of hospitalist medicine is going to include looking at our role as being a little broader than just being in the hospital. We as hospitalists are being held responsible for what happens to patients after discharge, whether it’s readmissions or other outcomes. I’m not sure that for every hospitalist group or every hospital, it will make sense to start a discharge clinic. I think there are models for discharge clinics in many different practice settings, both staffed by hospitalists and staffed by primary care doctors. But I do think that whether it’s a discharge clinic, whether it’s a post-discharge phone calling program, whether it’s just establishing better relationships with the primary care practices that you serve as a hospitalist, that this sort of connection is what’s going to be required to succeed as a hospitalist and in the new world of accountable care organizations and global payments.

This column, "Leaders," regularly appears in Hospitalist News, an Elsevier publication. Dr. Doctoroff had no disclosures to report.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to m.schneider@elsevier.com. Read previous columns at ehospitalistnews.com.