• Richard B Balaban, Joel S Weissman, Peter A Samuel, and Stephanie Woolhandler.
• Department of Medicine, Cambridge Health Alliance, Cambridge, MA, USA. rbalaban@massmed.org
• J Gen Intern Med. 2008 Aug 1; 23 (8): 1228-33.

BackgroundPatients are routinely ill-prepared for the transition from hospital to home. Inadequate communication between Hospitalists and primary care providers can further compromise post-discharge care. Redesigning the discharge process may improve the continuity and the quality of patient care.ObjectivesTo evaluate a low-cost intervention designed to promptly reconnect patients to their "medical home" after hospital discharge.DesignRandomized controlled study. Intervention patients received a "user-friendly" Patient Discharge Form, and upon arrival at home, a telephone outreach from a nurse at their primary care site.ParticipantsA culturally and linguistically diverse group of patients admitted to a small community teaching hospital.MeasurementsFour undesirable outcomes were measured after hospital discharge: (1) no outpatient follow-up within 21 days; (2) readmission within 31 days; (3) emergency department visit within 31 days; and (4) failure by the primary care provider to complete an outpatient workup recommended by the hospital doctors. Outcomes of the intervention group were compared to concurrent and historical controls.ResultsOnly 25.5% of intervention patients had 1 or more undesirable outcomes compared to 55.1% of the concurrent and 55.0% of the historical controls. Notably, only 14.9% of the intervention patients failed to follow-up within 21 days compared to 40.8% of the concurrent and 35.0% of the historical controls. Only 11.5% of recommended outpatient workups in the intervention group were incomplete versus 31.3% in the concurrent and 31.0% in the historical controls.ConclusionsA low-cost discharge-transfer intervention may improve the rates of outpatient follow-up and of completed workups after hospital discharge.

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