From Admission to Discharge: How Hospitalists Can Bridge System Gaps

Hospitalists often care for patients at their most vulnerable, admitted with acute issues while managing multiple chronic conditions. Yet the journey from admission to discharge is riddled with gaps: fragmented communication between teams, delays in care transitions, and missed opportunities to optimize long-term outcomes. Each gap represents not just inefficiency, but potential harm for patients. 

A prospective cohort study in Annals of Internal Medicine found that early readmissions (0 to 7 days after discharge) were significantly more likely to be preventable than later readmissions (8 to 30 days), with 36.2% versus 23.0% deemed preventable (1). This underscores that interventions during hospitalization and at discharge can meaningfully influence patient trajectories, and hospitalists are uniquely positioned to identify risks early and implement solutions that extend beyond the inpatient stay. 

Proactive medication reconciliation. Polypharmacy is common, particularly among older adults and those with multiple comorbid conditions. A patient admitted with heart failure, diabetes, and chronic kidney disease may already be taking over a dozen medications. Without careful review, duplications or harmful interactions may go unnoticed. By reconciling medications at admission and revisiting them throughout the stay, hospitalists can reduce adverse drug events and improve adherence. Educating patients and caregivers about medication changes empowers them to safely manage treatment at home. A commentary in Annals of Internal Medicine highlights how hospitalists can lead improvements in medication reconciliation both at the individual care team level and at the organizational level (2). 

Coordinated care transitions. Effective handoffs are critical. Discharge summaries often reach primary care providers several days after the patient leaves the hospital, delaying follow-up care. Involving patients and families in discharge planning, scheduling timely outpatient appointments, and ensuring clear communication with home health or post–acute care facilities can prevent confusion and avoidable readmissions. For example, a patient discharged with new insulin therapy may struggle without structured teaching that includes the patient, caregiver, and outpatient nurse. 

Targeted patient education. Hospital stays offer valuable opportunities for patient education, yet time constraints often limit meaningful counseling. Short, focused sessions on disease management, warning signs, and follow-up appointments can help reduce preventable readmissions. For example, discussing early warning signs of infection in a patient with diabetes or emphasizing adherence to diuretics in a patient with heart failure can prevent complications. Patients typically retain practical, contextual advice better than abstract discharge instructions. 

Interdisciplinary collaboration. Hospitalists are at the center of patient care but do not work alone. Engaging pharmacists, nurses, case managers, and social workers during daily rounds ensures comprehensive assessment and continuity. Interdisciplinary collaboration can identify barriers, such as medication affordability, transportation, or home safety, that might otherwise lead to readmission. For example, a pharmacist’s review may reveal that a patient cannot obtain a critical medication, prompting timely intervention before discharge. 

Bridging system gaps. Hospitalists are uniquely positioned to observe both micro-level patient details and macro-level system inefficiencies. By integrating these perspectives, they can implement actionable solutions that improve outcomes, reduce preventable readmissions, and strengthen the health care system. From ensuring accurate medication lists to delivering meaningful patient education, small, consistent interventions can have a lasting impact. 

Final thought. Hospitalists play a key role in connecting all parts of patient care. Even small steps like reviewing medications, teaching patients, and coordinating care can make a big difference. By bridging gaps in the system, hospitalists help patients leave the hospital healthier and better prepared for life at home. 

References

1. Graham KL, Auerbach AD, Schnipper JL, et al. Preventability of early versus late hospital readmissions in a national cohort of general medicine patients. Ann Intern Med. 2018;168:766-774. [PMID: 29710243] doi:10.7326/M17-1724
2. Schnipper JL. Annals for Hospitalists Inpatient Notes - improving medication reconciliation in hospitals. Ann Intern Med. 2022;175:HO2HO3. [PMID: 35969870] doi:10.7326/M22-1954

Shirisha Kamidi, MD

Dr. Shirisha Kamidi, MD, is an internal medicine hospitalist dedicated to enhancing patient care and hospital efficiency. She is actively involved in quality improvement initiatives and enjoys mentoring medical trainees to foster the next generation of health care professionals.