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Sealing Up the Cracks in the Healthcare System

Falling through the cracks, when it comes to healthcare, is a bad thing, but the way things are going, it’s getting harder and harder to avoid.

Providers in every setting are bombarded on all sides with data, results, messages, and things crying out — screaming — for our attention. Take, for instance, the conundrum that appears when a patient is being discharged from the hospital, but some test results are still pending. Who gets these results, who communicates them to patients, and who’s responsible for seeing that they are appropriately acted upon?

The Post-Discharge Visit

Just recently, one of our residents here in practice saw a patient on her schedule for a templated appointment type called “Post-Discharge Visit.” These appointments were created for us to squeeze patients in after a hospital admission, a rapid response to make sure they got timely and appropriate follow-up, once the inpatient team had decided that the patient was ready for discharge but needed some close-eyes-on and tender-loving-care very soon after going home.

We designed this system so that patients sent home on an antibiotic could be seen to ensure that their cellulitis or pneumonia was continuing to improve, that their heart failure exacerbation was going in the right direction and that we weren’t over-diuresing them, or to follow up on any one of a number of other issues that go into making a safe discharge plan.

This particular patient, it turns out, had been sent home from the hospital about 3 weeks earlier, and she’d never been a patient in our practice.

The resident did an outstanding job of digging through the mass of data available to her, in our electronic record and in the separate system that our inpatient teams use, as well as in the discharge summary and notes, to figure out what was going on and why she was seeing this patient. Looking back, the patient had been admitted for one specific complaint, but as often what happens in cases like this, what we think is going on in the beginning is often not what ultimately comes to light.

Delivering the Bad News

Tests led to more tests, investigations begot investigations, lines of inquiry led to more questions, and on and on, and before they knew it, the overall picture was one consistent with metastatic badness.

A diagnostic procedure was performed. At that point, the patient was felt to be stable for discharge, and she was sent home, with an appointment to follow up here in our practice 3 weeks off in the future.

Unbeknownst to her, or to us, one week after she went home her pathology report resulted in the system, confirming what had been suspected. But nothing happened after that. The inpatient teams who had been taking care of her had gone off service. The result didn’t come to us because she wasn’t a patient of ours yet. And the patient never looked on the hospital portal system to see her results, which, in the end, was probably a good thing.

So the resident ends up meeting this new patient for an appointment, unsure if this patient is going to be continuing her care here or is just here to get her results, and she has to break this devastating news to her, the first day she meets her, within a few minutes of the patient walking into our practice.

The patient and her family who were accompanying her had been suspecting something like the news she got, and all in all they handled it incredibly well. And the resident taking care of her quickly formed what appears to be a wonderful bond with the patient, and was able to expedite her into the care she needed.

But wouldn’t it have been better if this wasn’t a surprise? Neither to the patient, nor to the provider who was tasked with seeing her for an initial visit and giving life-changing, devastating news? Somewhere down the line, the chain-of-custody of this information got left unattended to, and hearing about this case made me realize this is probably happening far too often in the overwhelming cacophony of information that we’ve allowed this healthcare system to create.

The people who took care of her in the hospital are outstanding clinicians — caring and dedicated doctors who of course had no intention of having this happen in this way. If we asked them, they would say they never would have wanted to have this resident saddled with the responsibility of passing on this potentially terminal diagnosis, this piece of life-altering news about her health which will change her world forever moving forward.

But in the world of healthcare transitions, and the pressures to get patients out of the hospital, once the patient was stable, it was time for her to go. And more than likely, once they got the results back, they knew that the patient had a follow-up here, and therefore that was the most appropriate venue for that information to be conveyed to the patient.

But was it? Perhaps the road could’ve been smoothed a bit — the hospitalists could have contacted the resident in our practice and told her about the diagnosis, and that they’d discussed with the patient that this was a possible/likely outcome of the biopsy, but none of that took place.

Designating the Right Post-Discharge Provider

Long, long ago when I was a resident (and dinosaurs roamed the hospital halls), part of the discharge planning was figuring out who was going to become the primary care provider for those patients going home if they didn’t already have somebody. The person who had been taking care of them the longest, who knew them best, and who had been there getting them through this critical illness, was the choice to become their new primary care provider.

It started with the intern as first choice, then the resident on the team, and finally the attending, and we always loved giving the patients our business card (we have business cards that say “Fred N. Pelzman, MD” on them!) on the day of discharge, and telling them that we’d set up an appointment to see us for follow-up in 2 weeks in the clinic.

On this particular morning, I asked the resident if she had participated in the care of this patient in the hospital and therefore knew her, and she said no, the patient had been on the PA service, and several different hospitalists had taken care of her during her fairly brief admission, a time that overlapped with two changes of service. Since none of the hospitalists see patients in the outpatient setting, there can be no continuity there; someone else needs to take over once the patient goes home.

We’re happy to do it; that’s what we love, and that’s what we’re here for. But when things slip through the cracks, when someone’s blindsided with having to give devastating news without any context, without any relationship with the patient, then it shows us how fraught the system is with potential for things to go terribly wrong.

What if that patient had just decided that they weren’t coming to that appointment the other day? What if the thought process went something like this: “Well, I had the biopsy, but no one called me, so it must not have been anything too bad, and I’m still really tired from being in the hospital, so maybe I’ll just skip the appointment today …”

It reminds me of the way patients often think about their lab and other test results. We see people in the office, and ask when they had their mammogram and what it showed, and people would say, “Well, I never heard back from anybody, so I guess everything was okay.”

Our hospital has a wonderful new initiative called “No News is No News,” which seeks to educate patients that the loop on their healthcare is never closed until everything has been communicated to them — what we found, what it means, what to do next.

We owe this to our patients, and we owe this to our providers, to build a system where this can happen more easily, with all of the support we need to get to all of this, to communicate with patients, to build a follow-up plan, to make sure everybody knows everything about what’s going on with their health.

And nothing falls through the cracks.


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