Passing Beyond a Wing and a Prayer after Hospital Discharge

Excerpt

There is an anxious moment in American football, when a trailing team with seconds left in the game may attempt to win by throwing a long pass down the field, hoping for a last-second touchdown. As a spectator, it is thrilling but frustrating—if only the trailing team had worked better together, had been a better team, this high-risk and low-yield strategy might have been avoided. Such a gambit has been termed the “Hail Mary” pass, and the analogy can be made between it and the often disappointing approach to handoffs of care following hospitalization. In recent years, with impetus for change provided by the Hospital Readmission Reduction Penalty within the Affordable Care Act, as well as interest across diverse payors to reward value in healthcare, the standard of care at hospital discharge is changing. Post-discharge callbacks, pharmacist-guided medication reconciliation, and timely ambulatory follow-up after discharge are examples of tactics that are proliferating in an attempt to provide post-discharge care that can guarantee wellness following hospitalization. And while there is evidence of improvement in rates of rehospitalization,1 the evidence is also mixed, with many of these pillars of high-quality care transitions failing to reliably demonstrate effectiveness.2 ^– 4 Despite intense research attention on care transitions in recent years, our understanding of readmission risk and how to remedy risk with interventions generalizable across socioeconomic spectra and care settings is remarkably limited. Is poor teamwork across the discharge transition limiting the effectiveness of our interventions and continuing to leave only “Hail Mary” options? …