In the era of quality-of-care improvement and healthcare reform, transitional care has been the focus of increased scrutiny. There is a large body of evidence suggesting that current medical care is not coordinated with quality problems for patients undergoing transitions across sites of care.¹ For obstetric and gynecologic (OB/GYN) hospitalists’ patients, and medical patients in general, multiple transitions of care occur frequently: by shift within the same level of care, by level of care within the same location, and between locations, including the patient’s home. In general, transitions of care are defined as a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location.² In other words, it involves the movement of patients between healthcare practitioners, settings, and home as their condition and care needs change. The current fragmentation of care in our healthcare system makes transitions a vulnerable period for patients.^3,4

The OB/GYN hospitalist model is no exception.⁵ Although the hospitalist may help improve the quality and safety of OB/GYN services and reduce the incidence of adverse events, poor coordination of care may lead to delays in diagnosis and treatment, increased length of stay, increased risk of readmission, and increased costs.^2,6 Consequently, a fundamental component of the OB/GYN hospitalist program is the establishment of a well-structured program of transitions of care, with clear communication between OB/GYN hospitalists and primary healthcare providers, effective patient handoffs, regular updates on progress, and detailed follow-up instructions.⁷

The impact of poor coordination across the healthcare continuum has been clearly documented. Multiple deficiencies have been identified in the transition process: barriers in communication, lack of accountability by providers, poor or inexistent medication reconciliation, and incomplete, inaccurate, or delayed information transfer, among others.² In addition to significant patient safety and satisfaction, poor transitions have a significant economic impact on patients, insurers, and taxpayers. For instance, hospital readmissions, which are frequently linked to poor transitions, cost the US healthcare system approximately $15 billion a year.⁸ Further costs occur as a result of unnecessary physician visits; the use of medication for preventable conditions; duplication of laboratory, imaging, or other tests; loss of productivity; and other aspects. The immediate implementation of strategies to improve the transition of care is needed.

A prospective cohort study assessing the safety of transitions found that one in five patients discharged from the hospital experienced adverse effects related to medical care.⁴ In approximately two-thirds of these cases, the adverse events were considered preventable or ameliorable. Drug issues were the most prevalent; they comprised 66% of all adverse events. A total of 50% of patients reporting an adverse event in this study required the use of additional health services, such as supplementary visits, laboratory monitoring, Emergency Department visits, or readmission to the hospital in 24% of cases.⁴ Interestingly, system problems contributed to all the preventable adverse events, with poor communication between inpatient and outpatient providers as the most frequent deficit identified.

Four system aspects at time of discharge were identified as key for improvement: communication of unresolved problems, patient education about medications, monitoring of drug therapies, and monitoring of overall condition. In a large systematic review including 22 studies, errors in prescription medications occurred in up to 67% of cases.⁹ In 10% to 61% of cases, an omission error was reported (deletion of a drug used before admission), and in 13% to 22% of cases, a commission error occurred (the addition of a drug not used before admission). In 60% to 67% of cases, both types of errors were reported. This study also found that between 27% and 54% of patients had at least one medication history error, and that 19% to 75% of the discrepancies were unintentional. In six of the studies included in this systematic review (n = 588 patients), the investigators estimated that 11% to 59% of medication history errors were clinically important.⁹

Another study among patients aged 65 years or older found that slightly over 14% of recently discharged patients experienced one or more medication discrepancies; close to 40% of these patients had two or more discrepancies.¹⁰ One concerning aspect is that 14.3% of the patients affected by any medication discrepancy required readmission to the hospital, as compared to only 6.1% of those without discrepancies. Another study, done in a large, academic setting, found that 49% of patients had at least one medication error on postdischarge clinic follow-up, and that these patients were 6.2 times more likely to be readmitted to the hospital within three months of discharge.¹¹

Interestingly, the transition itself from one level of care to another may increase the rate of medication errors, even if the outpatient and inpatient physicians are the same. In a retrospective chart review, patients admitted to the hospital and followed by their same outpatient physician were less likely to have medication discrepancies at admission (8.7% vs. 12.9%) and discharge (14.3% vs. 19.5%) than were patients admitted to the hospital with in-patient management by a different physician.¹² As expected, patients prescribed more than ten medications in this study were more likely to have a medication discrepancy than those on fewer medications.¹² These findings highlight the relevance of medication reconciliation during patient transitions in general; however, the OB/GYN hospitalist faces additional challenges due to pregnancy and lactation in many of these patients.

Healthcare fragmentation increases the need for timely and accurate communication among healthcare providers. Poor communication between hospitalists and primary care providers may negatively affect patients’ health, safety, and satisfaction; continuity of care; use of resources; and provider satisfaction. Detailed recommendations to improve communication have been suggested.^6,13 Lack of coordination and communication between inpatient and outpatient providers was highlighted in a large cross-sectional study, which found that over 40% of recently discharged patients had test results pending, but outpatient providers were not aware of over 60% of these results; 37% of these were actionable and over 12% required urgent action.¹⁴

A large, systematic review assessing communication after hospital discharge found that direct communication between hospital physicians and primary care providers occurred in only 3% to 20% of discharges.¹⁵ Furthermore, only 12% to 34% of cases had a discharge summary at the first follow-up visit. Even when there was a discharge summary, the study found that it often lacked relevant and sometimes critical information, such as diagnostic test results (not present in 33% to 63% of cases), treatment or hospital course (7%–22%), discharge medications (2%–40%), test results pending at discharge (65%), and even follow-up plans (2%–43%). Previous research has shown that the risk of readmission to the hospital may decrease when patients are assessed following discharge by physicians who have received the discharge summary¹⁶ and that completeness of patient information do impact patients’ health.¹⁷

Several models of ideal transfer of care have been published. The Institute of Medicine, in its landmark publication Crossing the Quality Chasm: A New Health System for the 21st Century, describes the ideal transfer of care as safe, effective, timely, patient-centered, efficient, and equitable.¹ The American Geriatrics Society (AGS) has provided general guidelines for a transfer of care that can apply to all patients.² The AGS report emphasizes preparation of the patient and receiving caregivers by the referring physician, bidirectional communication, the creation of systems of care and policies that promote high-quality transitional care, and continuous education to healthcare providers about the transition process.

The Transitions of Care Consensus Conference (TOCCC), sponsored by multiple organizations, including the Society of Hospital Medicine (SHM) and the American College of Physicians, developed principles aimed at improving the quality of care gap for transitions from the inpatient to the outpatient settings. These included accountability, communication and timely interchange of information, involvement of patient and family, respect for the hub or coordination of care as well as nationwide implementation of quality of care during transition standards and use of standardized metrics to assess its effectiveness.

Multiple single and multimodal interventions have been shown to improve specific outcomes of the transition process; however, the results have been equivocal,^18–21 The field of transitions in care is very broad, so inconsistent intervention results may reflect heterogeneous populations, intervention characteristics, outcomes measured, and settings. A study of 17 systematic reviews across different patient populations, representing a variety of intervention types, found that there were no patient population or intervention type categories in which transitional care interventions were uniformly successful.²² However, several patterns emerged. For instance, multimodal interventions may be better than interventions that address only one of a few components. Also, successful interventions were more likely to include the means to assess and respond to individual immediate discharge needs. Further, the authors found little support for the effectiveness of interventions isolated to either the predischarge or postdischarge setting or successful interventions that bridged settings with components such as home visits, a single point of contact, or telephone calls. However, it is not clear to what extent and in what populations postdischarge home visits may be a necessary component of healthcare transitions.²² Successful interventions in this review usually targeted populations at high risk for hospital readmission. Based on these findings, multimodal interventions covering multiple settings and targeting high-risk populations may be more cost effective.²³

Lessons for improved transitions of care in OB/GYN patients can be drawn from the current literature. Project RED (which stands for “reengineered discharge”) is an example of a multifaceted transition intervention that has been shown to decrease hospital readmission rates.²⁴ In this procedure, a nurse discharge advocate works with patients during their hospital stay to arrange follow-up appointments, confirm medication reconciliation, and conduct patient education, with an individualized instruction booklet sent to their primary care provider as well. A clinical pharmacist called patients two to four days after discharge to reinforce the discharge plan and review the list of medications. Project RED decreased hospital utilization (combined Emergency Department visits and readmissions) within 30 days of discharge by about 30%.

Another successful similar intervention is Project BOOST (short for “Better Outcomes for Older adults through Safe Transitions”), which targeted hospital discharge care transitions.²⁵ This multifaceted intervention showed a 30-day readmission decrease from 14.7% prior to implementation to 12.7% 12 months later, reflecting an absolute reduction of 2% and a relative reduction of 13.6%.²⁵ The potential effectiveness of these and other interventions highlights the feasibility of decreasing readmission rates.