Evaluation of the Discharge Care Coordination Process for Elderly Patients

Coordination of discharge care is critical to reducing hospital readmissions and ensuring optimal patient outcomes, particularly among the elderly demographic. This is a pressing issue for health care delivery in both Japan and the US, where aging trends coincide with high rates of inpatient care utilization, increasing complexity of medical care, and shifting family structures with diminishing ability to provide appropriate care for elderly family members. The overall objectives of this project are to conduct an international comparison of the discharge coordination process for older patients at two large academic medical centers in Japan and the US: Tokyo Medical and Dental University Hospital of Medicine in Tokyo and Massachusetts General Hospital in Boston. A combination of patient demographic analysis, clinical observation sessions, stakeholder interviews, and patient interviews enabled process charting of the discharge coordination process for geriatric patients, from admission through discharge. This study highlights interesting case management roles that have evolved at each center while also demonstrating the need for greater institutional engagement to support a streamlined, patient-centered approach to discharge coordination. This project provides a foundation for understanding the broader opportunities, obstacles, and future trends facing discharge coordination services at large academic medical institutions in Japan and the US.

Evaluation of the Discharge Care Coordination Process for Elderly Patients
International Comparison of Two Large Academic Medical Centers in Tokyo, Japan and Boston, Massachusetts

Alisa Yamasaki (Harvard Medical School, Class of 2015)
Advisors: H. Thomas Aretz, MD, VP of Global Programs at Partners HealthCare International; Jeffrey Schnipper, MD, MPH, Director of Clinical Research, BWH Hospitalist Service