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Idea Portal to manage transitions from hospital to rehabilitation settings

By Zvi Frankel | 08 Dec, 2014

Idea submitted by: Zvi Frankel

There's a plethora of published research establishing the dramatic decrease of re-admissions and complications when patients receive optimal post-discharge rehabilitation. At the same time, the unfortunate reality is that a very high percentage of patients never end up receiving the critical benefits of attending an appropriate post-discharge rehabilitation program.

I propose an idea to break this trend, by creating a portal to bridge the transition period between hospital discharge, and admission to an appropriate in-patient (or outpatient) rehabilitation program.

The development of a user friendly “post-discharge to rehab admission” bridge portal, accessible to the team of treating physicians from the hospital (including the primary physician), the patient, and finally the chosen rehab team, would engage all parties to facilitate admission into an appropriate rehab program. The idea would be to keep all parties continuously engaged and updated, and to “hold the patient’s hand” until the successful admission to an appropriate rehab program. I think that a “physician/patient transition to rehab engagement bridge" concept will dramatically increase the number of patients receiving appropriate post-hospital rehab.


Hisham Yousif Advisor Replied at 2:44 PM, 9 Dec 2014

Zvi, thanks for submitting this idea. Curious indeed-- and I most certainly agree that post-discharge rehabilitation is optimal for many patients after hospitalization. I am wondering if you could flesh out a little more on where exactly you see this bridge taking form? Would you want the inpatient medical team to be responsible for patients until they are admitted to rehabilitation centers? Or rather, would you want care coordination staff to ensure that there is an adequate bridge from discharge to rehabilitation admission? Or perhaps, both, in different capacities? In my experience, attending inpatient physicians, care coordination staff, and PCPs (would be great if PCPs were ALWAYS involved, but this isn't always possible) work together to have a patient placed in an appropriate rehabilitation facility before they are discharged if deemed necessary by inpatient occupational therapy/physical therapy staff. What would this bridge platform contain/look like that would enhance communication/ability to do that. Furthermore, are you focusing on direct hospital to rehabilitation admission, or outpatient rehabilitation?

In summary, I think your idea is great but want more information to see how you see it taking form.

Zvi Frankel Replied at 2:40 PM, 10 Dec 2014

Hisham, thank you for your important questions.

Regarding inpatient rehabilitation, I think the portal would create an important bridge for communication between the treating hospital physicians, the PCP, the rehabilitation team, and the patient. To illustrate with a practical example: A post-op patient is transferred from a hospital to an in-patient rehabilitation facility, with a number of new medications which need to be carefully monitored. The portal would enable the new team of physicians at the in-patient rehabilitation facility to easily communicate any questions and/or updates (e.g. dosage adjustment, etc.) directly with the treating physicians from the hospital/PCP, and vice versa. At the same time, the patient would have easy access to the portal to remain fully engaged.

Likewise, regarding outpatient rehabilitation, the portal would act as an unprecedented bridge for communication and engagement between the treating hospital physicians, the PCP, the rehabilitation team, and the patient. To give one example how the portal would have a major impact specifically in terms of outpatient rehabilitation: Upon discharge, physicians would enter a chosen outpatient rehabilitation program into the portal, with the anticipated date when the program would begin. There would be automatic customized reminders via the portal sent out to the physicians and patient when the scheduled date to begin the rehab program approaches (the patient would be able to choose whether they wish to be reminded by email, SMS, or phone). If a patient fails to confirm/begin attendance, the treating physicians would receive an alert, reminding them to personally follow-up with the patient (and then confirm when they did so). The follow-up reminders/alerts would repeat until it is confirmed that the patient began the rehabilitation program. As mentioned above, the portal would also enable the rehabilitation team, to easily communicate any relevant questions directly with the other treating physicians, and vice versa. Such an approach would insure that everyone remains "on the same page."

The following passage from a study regarding cardiac rehabilitation after PCI, is one of the many examples which crystalizes the serious problem that I think my idea would dramatically impact: "...Overall participation in CR was 40% after PCI over the length of our study. Using 3 different analytical techniques aimed at reducing potential sources of bias, we found that CR participation was associated with a 45% to 47% reduction in 5-year all-cause mortality rate compared with nonparticipation..." (Impact of Cardiac Rehabilitation on Mortality and Cardiovascular Events After Percutaneous Coronary Intervention in the Community. Circulation. 2011;123: 2344-2352)

Maxim Topaz Advisor Replied at 10:01 PM, 11 Dec 2014

Thanks Zvi, great idea with many important implications! One thing for you to consider- in a recent study we did in Philadelphia, we found that about 30% of patients who are offered post acute services, refuse them. Not surprisingly, we found that those who refuse were younger, healthier and better ensured ... but to our surprise, we found that they were almost two times more likely to be readmitted (this study is in press in AJMC).
I would suggest you to think of the important implications from this study and expand your portal thinking to get people interested/knowledgeable about the post acute setting so they accept services more. Just a thought and thanks again.

Zvi Frankel Replied at 12:02 AM, 12 Dec 2014

Thank you Maxim for your great point. I think that a key to increasing the patient interest/knowledge that you noted, is the execution of adequate patient education. It would seem that an effort to properly educate patients regarding the sharp differences in outcomes when appropriate rehabilitation is accepted, would naturally increase the number of patients interested in receiving it. Did your study explore the variable of adequate patient education? In other words, whether properly educating patients (well in advance to hospital discharge) regarding the significant impact of acute services on mortality/complications/re-admissions, would increase the number of the younger and healthier patients that you mentioned, to accept acute services?

Zvi Frankel Replied at 12:07 AM, 12 Dec 2014

[Sorry for the typo: "acute" should read "post-acute"]

A/Prof. Terry HANNAN Advisor Replied at 2:05 AM, 12 Dec 2014

Zvi, this is a good extnesion of this discussion. I do (and I hope it is a move in the right direction) GIVE THE PATIENT a copy of thier record and try and explain to them in most cases, what is the content of the record. This is part of their "educations".
They also have email contact with me where possible or hyperlinks to educational sites on the web.
For non-web users I try and provide Summary Educational materials. I have not measured the effects of this but have the impression that I reduce the number of "healthg care facility encounters".

Zvi Frankel Replied at 1:50 PM, 12 Dec 2014

Thank you Terry, your patients are clearly fortunate. To add another component to this discussion, I would like to highlight an interesting article published in 2011, which presented a remarkable discrepancy in the amount of patients attending cardiac rehabilitation, depending on the referral technique utilized (Effect of Cardiac Rehabilitation Referral Strategies on Utilization Rates: A Prospective, Controlled Study. Grace SL, Russell KL, Reid RD, et al. Arch Intern Med. 2011;171(3):235-241).

Attached resource:

Maxim Topaz Advisor Replied at 9:21 AM, 13 Dec 2014

Great discussion Zvi and Terry! We are working on a study to continue this work and better understand the reasons for care refusal. From the nurses notes in our previous work, it seemed that many patients have already established caregiver circles- they would say "my daughter will take care of me". However, their caregivers were probably less prepared than expected which lead to higher readmission rates.... This is probably one of the common reasons but we are not sure about the rest at this point.

Joaquin Blaya, PhD Advisor Replied at 2:59 PM, 13 Dec 2014

Very interesting indeed and I think Zvi that there is a lot of data to back up your idea of having a large impact in reducing readmissions doing post discharge follow for example this article.
Receipt of a discharge call was associated with reduced rates of readmission; intervention group members were 23.1% less likely than the comparison group to be readmitted within 30 days of hospital discharge (P = 0.043).

I found this amazing, 23% less readmissions with 1 PHONE CALL, this seems to blatanly obvious to do, that it begs the question why isn't it being done now? and I have to admit I don't know the answer, but if a simple phone call isn't being done, how could this bridge work? To me this seems the key, because I think there are good technologies to implement what you've mentioned, some of which have been mentioned on GHDonline before for example
My Open Notes
Automated phone call follow up systems or
Call Centers

A/Prof. Terry HANNAN Advisor Replied at 6:39 AM, 16 Dec 2014

Joaquin, I was on a plane at the weekend looking for something to read and came across the attached article which you co-authored. What I liked was the way you and your co-authors addressed the end-user needs which is why I am posting this here.

Attached resource:

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