Continuity of Care is Driven by Prompt Communication Upon Hospital Discharge

Discharge summaries are critical to primary care providers (PCPs) as a key source of reference about the most up to date care their patients receive following their inpatient hospital stays. The hospital discharge summary is the key source for this information to support the continuity of care for all members. Blue Cross Blue Shield of New Mexico (BCBSNM) Provider satisfaction survey results from PCPs and Specialists are audited annually to note the receipt of timely hospital discharge summaries and those providers who are not receiving them. It is important to communicate timely and ensure continuity of care for our members, their family, and the transition home or the next level of treatment. The discharge summary is not only used to improve coordination and quality of care, but ultimately to reduce the number of preventable readmissions.

We want to remind you about some important information to help you when discharging Federal Employee Program® (FEP®) members after inpatient hospital stays. Use of Electronic Health Records (EHRs), including wider acceptance of member portals, when available, ensures smooth flow of information from hospital to the member’s next level of care. Supporting the member’s transition includes providing culturally appropriate member instructions, medication reconciliation and educating caregivers.

Studies have shown that providing timely, structured discharge summaries to PCPs helps reduce readmission rates, improves patient satisfaction, and provides an updated medication summary upon discharge, which all support continuity of care. One study found that, at discharge, approximately 40 percent of patients typically have test results pending and 10 percent of those results require action. PCPs and patients may be unaware of these results.1,3 This demonstrates the need for timely discharge summaries after hospitalization for both members and providers.

A prospective cohort study found that one in five patients discharged from the hospital to their homes experienced an adverse event (defined as an injury resulting from medical management rather than from the underlying disease) within three weeks of discharge. This study found 66 percent of these were drug-related adverse events.2,3

As a reminder, please include the following information in every discharge summary:

  • Course of treatment
  • Diagnostic test results 
  • Follow-up plans
  • Diagnostic test results pending at discharge
  • Discharge medications with reasons for changes and most commonly known side effects

Communication between the inpatient medical team and the PCP helps ensure continuity and a smooth transition of the FEP patient to the next level of care. FEP Case Management staff also are available to work with members and providers and collaborate with the medical team while inpatient and post discharge to facilitate and reinforce discharge planning instruction. BCBSNM and FEP applaud PCPs who have adopted the best practice of utilizing written discharge summaries along with medication reconciliation from their inpatient admission.

1Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005;143(2):121–8.

2Forster AJ, Murff HJ, Peterson JF, et al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161–7.

3Snow, V., MD. (2009). 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. Journal of Hospital Medicine, 4(6), 364-370. doi:10.1002

The information in this article is being provided for educational purposes only and is not the provision of medical care or advice. Physicians and other health care providers are to their own best medical judgment based upon all available information and the condition of the patient in determining the best course of treatment. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations, and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.