Climbing Out of the Black Hole of Subacute Care

Abstract

A black hole is an accumulation of mass so dense and compact that nothing, even light, can escape its gravitational force. The edge of the black hole is where space and time stop. Some theorize that wormholes exist in black holes, which make it possible to travel nonlinearly through time. What does the theory of black holes have to do with medicine? Unfortunately, subacute care facilities often become the informational black hole of medicine. Frail patients who are not well enough to discharge to their independent homes nor ill enough to remain in the hospital are transferred to a skilled nursing facility (SNF) and, to the rest of the health care community, disappear. At some point in the future, after a series of vague and confusing events, they reappear. Small chunks of information may precede or follow the patient’s discharge but most is lost in the black hole, leaving vulnerable patients at high risk of reentering the hospital. Recently, safety at transitions has come to the forefront as a topic of great interest, largely in part to the greater use of subacute care1 and the cost of recurrent hospital admissions. If not performed correctly, transitions between care settings can lead to adverse events.2e4 Unplanned rehospitalizations are a significant financial burden to Medicare.5,6 In addition to the financial burden, the hospital environment can be a significant cause of morbidity7,8 and errors tend to occur more frequently as patients shift between providers and/or care sites.9e11 Furthermore, long term care residents experiencing frequent transitions are often excluded from quality indicator measurements, which results in skewed epidemiologic data.12 Several health care provider societies have endorsed position papers calling for improved education, communication, policy, and clinical care at transitions.3,13e16 Medical education at both the undergraduate and graduate levels that includes formal teaching on hand-offs and care transitions17e21 is becoming more common, although there continues to be a significant gap.22 Inaddition, quality improvement initiativeshavebeendeveloped to reduce rehospitalizations, improve patient care outcomes, and increase patient and provider satisfaction.23e32 However, there is a significant lag in the health care system as awhole to adopt universal strategies to reduce the burden of rehospitalizations and enhance the care at transitions.33 Furthermore, historically, care transition interventions focused primarily on hospital-to-home transfers.18e21,24,27,31 Care transition programs and policies that are cost-effective, pragmatic, and universally applicable are desperately needed to enhance patient safety during these critical transfers between all sites of care.