Hospitalist Home Visit Program

Postdischarge home visits may allow for early identification of medical complications after hospital discharge. The hospitalist home visit program (HHVP) was started with the intention of facilitating communication between primary care providers and hospitalists and reducing hospital utilization postdischarge by earlier identification of nonadherence to discharge treatment recommendations. During our pilot study with 15 patients, participants were visited in their homes after discharge prior to their first visit with their primary care provider. During each visit, HHVP staff performed a brief clinical evaluation, a home safety assessment, and a review of all medications being taken. At least one medication discrepancy was found among 67% of visited patients, resulting in several different interventions made by the HHVP staff. There was a nonsignificant reduction in 15-day rates of hospital readmissions and emergency department visits. Hospitalist-sponsored home visit programs may be an effective means of helping patients during their transition to outpatient care after hospitalization. During the past decade, inpatient care has been transformed by accelerated discharge planning and the increasing presence of hospitalist attending physicians. Hospitalist physicians direct inpatient medical services and coordinate discharge with the primary care provider. The potential advantages of hospitalist physicians include greater familiarity with inpatient clinical issues and greater availability on the wards as compared with primary care providers who are also engaged in running an outpatient practice [1]. Hospitalist physicians may be of particular benefit in situations where patients cared for in resident clinics are hospitalized, given the large number of competing demands residents face as primary care physicians. Several studies have shown that hospitalist physicians provide highquality treatment while decreasing length of stay and reducing cost; however, little attention has been given to examining the transition of care back to the primary care physician after discharge [1–6]. Most studies of home visits have focused on limited patient populations, such as the elderly and those with congestive heart failure (CHF). Among elderly patients, for instance, some studies and a recent meta-analysis have shown that the use of a physician or nurse specialist to perform home visits may help reduce hospital readmissions [7–15]. Home-based interventions, including visits and telephone calls, have been used in postoperative cholecystectomy patients [16]. Patients with CHF and chronic obstructive pulmonary disease have also benefited from home visits, with simple indices such as weight and peak flow reported to physicians after discharge [17,18]. Stroke patients and postpartum women have also been targeted [19–21]. The format of home visits in these studies has been heterogeneous, with visits made by nurses, primary care physicians, and other types of home care clinicians [22,23]. These findings are related to specific patient populations, however, and cannot be generalized to the broad range of medical and social problems encountered on the general medical service of an urban teaching hospital. The hospitalist group at the Brigham and Women’s Hospital (BWH) cares for a diverse group of general medical patients with a wide range of medical problems. Many patients in this urban setting are elderly, uninsured, and have no regular source of primary care or receive their care in medical resident clinics. Despite substantial efforts at discharge planning on the hospitalist service, the most vulnerable patients are at high risk for readmission within a short period of time. There is growing interest in interventions that will identify high-risk patients and streamline their transition back to From the Brigham and Women’s-Faulkner Hospitalist Program, Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA (Drs. Reese, Hicks, Britton, and McKean and Mr. McWilliams), and the Department of Health Care Policy, Harvard Medical School, Boston, MA (Dr. Hicks). outpatient care. The hospitalist group at BWH developed the Hospitalist Home Visit Project (HHVP) with the goal of improving posthospitalization outcomes of a more heterogeneous mix of patients. The HHVP targeted a racially diverse population of patients with a variety of chronic illnesses who were discharged from the general medical service. We performed a 15-patient pilot study to examine the feasibility of implementing this hospitalist home visit program. Emergency department visits, readmission rates, and the number of medication errors detected were measured.