Should You 'Tuck in' Your High-Risk Patients?

Greg A. Hood, MD


January 13, 2015

In This Article


From our first days on the wards as medical students, we're trained to sign out our patients to the on-call team. Even before the term was coined, there was an implicit recognition that the "transition-of-care" responsibility was of integral importance for optimal patient outcomes. More specifically, we were taught that good communication was essential to avoid gaps in care that patients could fall into, to their detriment.

Costly Gaps Still Exist

For decades, much has been written, deservedly, about the gaps in transition-of-care communication between primary care practices and hospitalists and vice versa. Vast sums of money are expended on redundant and unnecessary testing every year, not to mention other costs such as the unnecessary radiation exposure from duplicative testing and medical errors made because of the lack of effective communication between providers. Especially in this era of focus upon ambulatory care sensitive conditions, such as diabetes mellitus, chronic obstructive pulmonary disease, and congestive heart failure, some sick and about to become sick patients remain in a very expensive communication vacuum. This vacuum itself is a black hole into which vast sums of money are wasted each year.

Recognizing that there's a lot of this type of waste, some accountable care organizations (ACOs), such as the one of which I'm a medical director, are experimenting with patient "tuck-in" calls. These organizations are hoping to make progress in several areas of inefficient care, including:

  • The old pattern of "no news is good news" (for instance, if we don't hear of a problem from the patient, then the patient must be fine); and

  • The lack of a coordinated, systematized approach that could prevent certain emergency department (ED) visits, hospitalizations, and urgent care visits.

Patients who have ambulatory care sensitive conditions are naturals for inclusion in such programs, as are patients who are complex by virtue of having multiple chronic conditions. In addition, without regard to disease complexity, patients who have visited the ED three or more times in the preceding 12 months should be signed up as well. These patients may have needs (unrecognized conditions or unappreciated complexity) that can be met in less-intensive, less-expensive manners.

In spite of our complex, ever-changing armada of medications, tests, electronic records, and other resources—or perhaps sometimes specifically because of them—patients and their families are often unsure or confused about the current degree of a patient's illness(es), the stability of the condition(s), or when or where to turn should questions arise. For example, some hospital systems have an extremely high rate of admissions for Medicare patients who visit their EDs. A phone call that successfully addresses a complex or chronically ill patient's concerns and renders an ED visit unnecessary also prevents potential hospitalization. A coordinated effort of this nature could head off costly visits to urgent care clinics as well.


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