The Importance of Communication with Patient and Family During the COVID-19 Pandemic

Some elements of this article appeared in https://www.the-hospitalist.org/hospitalist/article/249749/covid-19-updates/chronically-interrupted-importance-communication-patient

Publish date:?December 9, 2021

Nichola Haddad, M.D.?1 3 5; John Halporn, M.D.?3,4,5?and Ebrahim Barkoudah, M.D., M.P.H.?2,3, 5

From the?1?Psychiatry Residency Program;?2?Hospital Medicine Unit and the Division of General Internal Medicine; 3?Department of Medicine at Brigham and Women’s Hospital?4?Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, and?5?Harvard Medical School,?all?in Boston, MA

Running Title:?Haddad et al; Chronically Interrupted: The Importance of Communication with Patient and Family During the COVID-19 Pandemic

The Importance of Communication with Patient and Family During the COVID-19 Pandemic?

Closing the loop between inpatient and outpatient clinicians:?For patients with complex medical issues or those reaching end of life, effective communication within the healthcare system is critically important. While inpatient teams are often driving the plan for the patient, they are only with their patients for a snapshot in time; therefore, they may not have had the capacity to get to know the patient on a deeper level, given that longitudinal relationship with primary care physicians (PCPs) or even specialty physicians are common. The inpatient and outpatient medical teams should communicate directly, and ideally with the patients and their family, to figure out what is best for the patient. To achieve patient-centered and goal-concordant care, inpatient clinicians must do their due diligence to fully grasp the patient’s values and help determine appropriate next steps. How do we approach complex disease management between inpatient and outpatient teams in a way that best benefits the patient? How do we bridge these gaps in care??

While the Joint Commission does not mandate verbal communication during handoffs, this type of communication offers clinicians the opportunity to ask questions and better understand the patient as a whole. Especially for medically complex patients, PCPs tend to prefer verbal handoffs compared to being sent discharge summaries electronically.[i]?In addition to physician preference, timely and reliable communication between inpatient and outpatient providers has been shown to prevent medical adverse events.?[ii]Despite this, direct communication between hospital medicine physicians and PCPs has been shown to occur infrequently, ranging from 3-20%.[iii]?Given that inpatient hospitalists serve as primary inpatient providers for most general admissions at hospitals around the world, it is their responsibility to communicate with outpatient providers, especially PCPs.?Busy hospitalist providers must prioritize their time allocation, and the inherent clumsiness in communicating with off-site providers and family is often abbreviated or curtailed. With increased burdens from PPE, remote hospital providers (social work, case managers), and increased bureaucratic duties, COVID-19 has decreased the frequency and quality of this communication.???

Prior research has supported this proposition. A study that was implemented with the goal of improving verbal handoffs from hospital medicine physicians to PCPs within 24 hours of discharge is an excellent example of effective communication.[iv]?In this study, a multidisciplinary team redesigned the process by which PCPs were contacted following patient discharge. A team pager was held by a designated resident physician who was assigned the responsibility for communication, and this was supplemented by an electronic health record-initiated process. These changes improved percentage of calls initiated from 50% to 97% and the percentage of complex verbal handoffs increased to more than 93%, an effect that was sustained for 18 months. This study is helpful in showing that communication between inpatient and outpatient clinicians is both possible and sustainable with proper measures in place.

While existing research is helpful in determining specific ways to approach effective communication between the inpatient and outpatient realms, this transmission of information should ideally occur prior to discharge.[v]?Deficits in communication, particularly at patient discharge, are extremely common and may negatively impact patient care; in fact, only 3% of PCPs report being involved in discussions about discharge.3?These deficits have negative implications related to continuity of care, patient satisfaction, and most importantly, patient safety.3

Changes during the COVID-19 era:?During the COVID-19 pandemic, patients are allowed only one visitor per day, limited visiting hours, and even limited interaction with clinicians per the implemented policies. COVID-19 has elucidated limitations in medical capacity and revealed the difficulties that clinicians face in communicating with patients and families, especially about serious illness. Communication tasks specific to this unprecedented era include facilitating virtual goodbyes between dying patients and their families, facilitating family meetings over videoconference, and discussing patient care with various members of the treatment team through virtual technologies.[vi]?While effective communication between patients, families, and clinicians is arguably even more important during a global disaster, the pandemic paradoxically restricts the physical presence of families for hospitalized patients and severely hinders effective communication.[vii]This shift in care must be urgently addressed.

The pandemic has heightened anxieties in patients and clinicians alike. Now more than ever, clinicians should continue to utilize core communication skills including building rapport, assessing patient and family perspectives and agenda, using empathy, and sharing information.[viii]?However, patient values should continue to be at the heart of medical treatment plans. Interestingly, patients tend to more frequently value functional outcomes while clinicians tend to default to treatment modalities.[ix]?Goals of care and end-of-life discussions are associated with improved quality of life, less aggressive medical interventions near death, and even increased survival.8?Given the limited resources and difficulties in communication during the COVID-19 pandemic, clinicians should place even greater emphasis on values-based shared decision-making.

How exactly do clinicians highlight patient values during COVID-19? Broadly speaking, clinicians must respect the role of family members as partners in our patients’ care, maintain family integrity through collaboration between family and the health care team, and ensure that the patient’s values are central in conversations between primary and multidisciplinary providers.?“Normal” strategies to put the patient at the forefront of care include family presence at the bedside and regular communication between clinicians, patients, and families. In pre-COVID times, one of the hardest tasks for physicians is to discuss the prospect of worsening patient prognosis and the need to readdress the goals of ongoing care.

While these strategies are more difficult to do with visitation restrictions and social distancing, it is necessary for health systems to adapt procedures and tools to circumvent these limitations. Internet-based solutions are essential and widely used, and video conferencing via tablets has been initiated at the institutional scale at many hospitals across the nation.[x]?Notably, many clinicians with little experience with videoconferencing in patient communication are broadly implementing these technologies.

Despite these technological strategies, issues still arise in how to communicate effectively in the hospital setting. Firstly, it is important to acknowledge that internet-based strategies require smartphones and/or computers, stable internet access, and technological literacy, highlighting disparities in access to quality healthcare.6?Additionally, even within families with access to these technologies, in-person visitation provides increased comfort, promotes family-driven patient advocacy, and prevents sundowning;9?some cases thus require limited family presence at bedside (i.e., in patients nearing the end of life, those with severe neurocognitive disability).?Identification and mitigation of any barriers to communication and engagement should occur early on in the hospitalization.6?Though communication barriers faced by families could be multifactorial and include access to technology, ability to travel to the hospital, risk of visiting the hospital, and length and frequency of allowed visits.

Clinicians already have challenges in conducting difficult conversations during “normal” times. Conversations during the COVID-19 pandemic will require listening, empathy, responsive action, and the acknowledgment of the social determinants of health on the behalf of clinicians.?Importantly, these conversations need to happen between clinicians and patients/families, but also between each other to ensure that patients are receiving effective multidisciplinary support.?

Proposals and considerations for improving communication and transition-of-care:?High-quality and safe patient discharge encompasses careful review of medications, follow-up discharge plans, and?a deep understanding of the transition?between inpatient and outpatient providers. These steps serve?to increase our reliance on patient compliance, communication following discharge, and the exchange of information about the global progression of disease between providers. The quantitative and qualitative steps of care transition should overcome the disconnect between teams, specifically deficit areas regarding post-discharge communication, monitoring, and understanding of prognosis around the relevance to this era of COVID-19. Multiple steps will be warranted to implement the safe transition process and improve communication:

·??????Clinicians and Providers Level:

o???Emphasize active involvement of patient, caregivers and family with global and detailed understanding of discharge elements and next steps.??

o???Stress the value of communication along with utilizing education and training resources.

o???Advocate for patients and their families within heath systems to engage further resources and infrastructure.?

o???Rework discharge protocols to add redundancy for known communication deficits, this can include making inpatient-outpatient connections between social workers, physical and occupational therapists, nurses, and nurse case managers

·??????Hospital Level:

o???Standardize discharge communications to include operational active involvement of caregivers through quality improvement initiatives.

o???Support hospital systems to apply effective hospital visiting policies.?

o???Align the resources with value-based metrics.

o???Incorporate new team structure with the redeployment of healthcare workforce (i.e., operating room providers who have work reductions with the cancellation of some elective procedures); experienced providers can focus on providing enhanced communication with families and outpatient providers when working alongside usual inpatient providers.

o???Evaluate the current processes during COVID-19 and apply a Plan-Do-Study-Act frame to improve families’ engagement.

·??????Healthcare System Level:

o???Implement?conventional and innovation tools that integrate innovative technology into solutions for communication.

o???Ensure caregiver understanding of discharge plan and contingencies such as?telemedicine or video conferencing between inpatient and outpatient doctors.

o???Utilize standardized tools such as I-PASS for objective data as vehicles for the transition of information and documentation.

o???Increase support for practitioner communication skills with in-house and outside training, and increased staffing of providers with particular expertise in communication (social work and palliative care, particularly).

·??????Policy Level:

o???Leverage health policy efforts to place the patient and family at the center of system improvement rather than focusing on mandates and liability aspects.

o???Address the current barriers of the current pandemic and identify opportunities to facilitate implementation of communication tools.

o???Align incentives with improving patient engagement and caregiver involvement in shared decision-making.

References:

[i]?Sheu L, Fung K, Mourad M, Ranji S, Wu E. We need to talk: primary care provider communication at discharge in the era of a shared electronic medical record.?J Hosp Med, 2015;10(5):307–310.

[ii]?Goldman L, Pantilat SZ, Whitcomb WF. Passing the clinical baton: 6 principles to guide the hospitalist.?Am J Med, 2001;111(9B):36S–39S.

[iii]?Kripalani S, LeFevre F, Phillips CO, Williams MV, et al. Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians: Implications for Patient Safety and Continuity of Care.?JAMA, 2007;297(8):831-841.

[iv]?Mussman GM, Vossmeyer MT, Brady PW, Warrick DM, et al. Improving the Reliability of Verbal Communication Between Primary Care Physicians and Pediatric Hospitals at Hospital Discharge.?Journal of Hospital Medicine, 2015;10(9):574-580.

[v]?Scotten M, LaVerne Manos E, Malicoat A, Paolo AM. Minding the gap: Interprofessional communication during inpatient and post discharge chasm care.?Patient Education and Counseling, 2015;98:895-900.

[vi]?Back A, Tulsky JA, Arnold RM. Communication Skills in the Age of COVID-19.?Annals of Internal Medicine, 2020;172(11):759-760

[vii]?Hart JL, Turnbull AE, Oppenheim IM, & Courtright KR. Family-Centered Care During the COVID-19 Era.?Journal of Pain and Symptom Management, 2020;60(2):e93-e97.

[viii]?Rubinelli S, Myers K, Rosenbaum M, & Davis D. Implications of the current COVID-19 pandemic for communication in healthcare.?Patient Education and Counseling, 2020;103:1067-1069.

[ix]?Simpson N, Milnes S, & Steinfort D. Don’t forget shared decision-making in the COVID-19 crisis.?Internal Medicine Journal, 2020;50:761-763.

[x]?Knopov A, Wong K, Merritt R. Communicating Through COVID-19: Keeping Patients Connected to Loved Ones.?RIMJ, 2020;103(7):10.