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Right outside of my office door is one of the workstations where our medical technicians perform one of their practice activities. They do what we call "post-visit calls".

This is essentially our scripted telephone calls done the day after an office visit, where they check on a patient, find out how everything is going, whether all their questions were answered, if there was anything they forgot to mention at their doctor's visit.

Ideally, this serves as a continuation of the care they received in our office, and an effort to ensure that what we wanted to have happen at the office visit actually ends up happening.

What our practitioners have told me, however, is that this effort really seems to just create more work for them. It feels like lip service, and the med techs really hate doing this, they feel like they are just reading a script, checking off boxes, not really providing much additional care.

And when something does come up, it's almost always more work for the doctors. "I forgot to talk to Dr. Pelzman about my back pain, my knee pain, my stomach pain", and so on, and thus a message gets sent to me asking me to call the patient back about some "additional issues" uncovered by the post-visit call.

The same seems to be what's happening with our inpatient-to-outpatient or emergency room-to-outpatient transitions of care. Ideally, these are designed to help smooth the road, to make sure that things don't get dropped between the two different worlds, that appropriate follow-up and timely follow-up occur, and that our patient's health will continue to improve as they move from one setting to the next.

The templated visit note created for the entire interdisciplinary team to work on is a whole lot of not moving care forward.

When Medicare created the framework for the transitional care management appointment, they imposed enormous requirements in terms of what needs to be done to bill for this visit, and so in fact, most providers avoid this and just end up doing a routine office visit.

What I want to happen is that someone tells me what I need to do next. Help me help them and the rest of the team get the patient better still.

I heard of one patient followed by our care managers who has had 28 hospital admissions at our institution in the past 3 years. He frequently goes to the emergency room after episodes of presyncope, and due to his underlying medical conditions, about half the time he gets admitted. His cardiologist has done intensive evaluations to try and find out what's going on, but from what I can tell the latest assessment seems to be that they think he just falls asleep on the subway, wakes up and is not sure where he is, thinks he may have passed out, so he goes to the emergency room.

Every hospitalization is followed by an intensive discussion with the care manager he has been assigned to, who has done a fairly good job of trying to keep up with him and keep ahead of his admissions. But all of the notes that they write are starting to sound very much the same. In the description, they say that he is not sure why he ended up in the hospital and not sure what he can do to avoid it in the future; they encourage him to keep his follow-up appointments, and then they say they'll call him back later.

I'm not sure what this contact with the healthcare system accomplishes, nor am I sure what they could do differently that would help better accomplish the goal of keeping him out of the hospital, out of the emergency room.

At each visit to the emergency room, he was given a follow-up appointment in primary care and cardiology, but more often than not he breaks his appointments, despite multiple attempts to ensure that he is coming.

Perhaps we need to think about some sort of care he can receive at the time of these episodes, to which he may be better suited than hospitalization or an emergency room visit.

Our emergency room has a new telehealth program, and we are working on instituting one in our practice as well, in the hopes that we are able to have our patients reach out to us, where we could take a look at them and see how they're doing, talk them through the issue, and maybe keep them out of the emergency room.

In a situation like his, it might be reassuring to know that he's being monitored, maybe even telephonically check his implantable loop recorder and see that nothing happened, and have him come in to the primary care office.

Maybe a dedicated office visit with his primary care provider to talk about what's worrying him, what he is afraid of, because I can't believe that he really wants to spend all this time in the emergency room or in the hospital. Maybe these visits are a marker of something else, something we are missing, something that we somehow are failing him about.

Rather than just having the post-visit call, or the transitional care management note, simply be a reflection a collection of more work for the provider, perhaps this could all be tasked to other people -- ways to help the patient get better care as they await appointments with us, or return to their home to continue living their life after an admission or ER visit.

It always seems to fall back on the provider, but perhaps these care managers really need to become the managers; they need to be the ones ensuring that the stuff that needs to happen, happens.

Has a patient picked up the prescriptions from the pharmacy, are they taking them, do they have the food resources they need, is transportation arranged, are they keeping their follow-up appointments? These are the things that make for a successful discharge or after visit, and if this all comes back on us as providers, it seems like we are already too busy to make sure that these non-clinical things happen.

So, if after discharge, if there are clinical things that I need to do, help me set it up so they happen, help me make sure that a patient gets timely follow-up of lab results, things that were pending at time of discharge. Help them make sure they get to their cardiology appointment after they have an admission to the CCU for congestive heart failure or an acute MI. Help me make sure that they have adequate social support, community support, food support, prescriptions that they need to stay healthy.

Send the doctoring things to the doctor, and non-clinical things to others who could help us get the stuff done.

Otherwise, don't bother calling.

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