Hospital Report Card – Care Transitions

Project Timeframe: October, 2012 – ongoing


Hospital care is usually a brief, intensive intervention in a patient’s overall health and well being. However hospital care is seldom the only intervention a patient needs. For most patients there is a need for follow-up care with their Primary Care Physician. For some there is also the need to follow-up with a specialist, such as a Cardiologist. Many patients, especially those on anticoagulation therapy, need lab work shortly after they leave the hospital to make sure their medication remains at a therapeutic level.

For too long many hospitals, including BMH, have been long on advice, but perhaps a little short on action in helping patients get this follow-up care. We’ve told patients to call their doctor and get an appointment soon; to call the specialist and get that appointment for further assessment. But we’ve had no way of knowing if the patient actually makes those calls or gets that care. Without that continued care the patient’s health may deteriorate to the point that they need to be hospitalized again.

We recognized that there are many factors that keep a patient from making those calls: they are relaxed to be home and feel they can wait a while, or they may be busy getting back to life as usual and making those appointments gets further and further down their “to do” list.

We recognized that while we could not control the behavior of our patients and get them to make those calls, we did have control over what we did. We made a commitment to change.


To schedule after care appointments with Primary Care Physicians and specialists as needed for each patient prior to discharge, and to communicate this information to the patient before they left the hospital.


In October, 2012, we put together a multidisciplinary Task Force including the Medical Director of the Hospitalist Program, the VP of Patient Care Services, The Executive Director of Quality and Care Management, a unit Nurse Manager, Care Managers and an IT Specialist to strategize who we could best accomplish our goals and document our efforts.

The team developed the following plan:

  • On admission Care Management staff notify the patient’s Primary Care Physician that the patient has been admitted, share basic clinical information with that physician, and invite their collaboration with the Hospitalist or Surgeon treating physician throughout the patient’s stay.
  • Care Managers verify the patient’s choice of pharmacy
  • When discharge is planned a Care Manager: phones the patient’s Primary Care Physician to schedule an appointment within a week and to update the physician on the patient’s hospital course of care and immediate needs as they transition back home; schedules appointments with any specialists and schedules any needed tests; phones in prescriptions for any new medicines to the patient’s pharmacy of choice. If the patient does not have a Primary Care Physician we get them one and schedule an appointment.
  • When discharge is imminent the Attending Physician: makes a complete medication reconciliation, indicating medicines to be continued, those to be stopped, and new ones prescribed.
  • Care Manager and Physician document their efforts in the electronic medical record
  • On the day of discharge the Care Manager prints one report which includes the medication reconciliation, details about appointments made and summarizes the education that has been provided to the patient and their care givers during the hospital stay. This form is given to the patient and their care givers and reviewed with them to check understanding.
  • On the day of discharge this form is faxed to the patient’s Primary Care Physician


Measuring three months after beginning this program we found that 80% of all patients had after care appointments made for them and received the one-report summary of aftercare plans.

Next Steps:

Having achieved success with in-patients we will next roll out this process in our Emergency Department. Initial plans call for the Unit Secretary to set up appointments for patients prior to their discharge. We have begun training and established a clear process flow, and hope to report on this extension of this imitative next year.

Contact Information
Michele Rowland, RN, LICSW
Executive Director, Quality, Utilization and Care Management
Brattleboro Memorial Hospital
17 Belmont Avenue, Brattleboro, VT 05301