Andrea L. Gilmore-Bykovskyi, Korey A. Kennelty, Eva DuGoff, Amy J. H. Kind

Transitions to sub-acute care are regularly complicated by inadequate discharge communication, which is exacerbated by a lack of clarity regarding accountability for important follow-up care. Patients discharged to sub-acute care often have complex medical conditions and are at heightened risk for poor post-hospital outcomes, yet many do not see a provider until 30 days post discharge due to current standards in Medicare regulations. Lack of designation of a responsible clinician or clinic for follow-up care may adversely impact patient outcomes, but the magnitude of this potential impact has not been previously studied. We examined the association of designating a responsible clinician/clinic for post-hospital follow-up care within the hospital discharge summary on risk for 30-day rehospitalization and/or death in stroke and hip fracture patients discharged to sub-acute care. This retrospective cohort study used Medicare Claims and Electronic Health Record data to identify non-hospice Medicare beneficiaries with primary discharge diagnoses of stroke/ or hip fracture discharged from one of two urban hospitals to sub-acute care facilities during 2003-2008 (N = 1130). We evaluated the association of omission of the designation of a responsible clinician/clinic for follow-up care in the hospital discharge summary on the composite outcome of 30-day rehospitalization and/or death after adjusting for patient characteristics and utilization. We used multivariate logistic regression robust estimates clustered by discharging hospital. Patients whose discharge summaries omitted designation of a responsible clinician/clinic for follow-up care were significantly more likely to experience 30-day rehospitalization and/or death (OR: 1.51, 95% CI 1.07-2.12, P = 0.014). The current study found a strong relationship between the omission of a responsible clinician/clinic for follow-up care from the hospital discharge summary and the poor outcomes for patients transferred to sub-acute care. More research is needed to understand the role and impact of designating accountability for follow-up care needs on patient outcomes.