Pictured (left to right): Lerzan S. Kizilay, MD; Robert N. Nace, MD; Lisa M. Simonian, NP; Cheme Dolma, NP; Jonathan H. Schwartz, MD; Namrata Patil, MD, MPH.

Over a decade ago, the Brigham and Women’s Hospital Division of Thoracic Surgery faced a conundrum.

“We’d discharge patients to rehab, but sometimes they’d come back here, and we’d have no idea what happened,” says director of the Brigham’s Thoracic Intermediate Care Unit Namrata Patil, MD, MPH. “Why did the patient get this sick? Did they not get the care they were supposed to get in rehab? We were at a loss for information about the patient’s condition.”

The division’s chief, the late David J. Sugarbaker, MD, and associate chief, Raphael Bueno, MD, gave Dr. Patil an assignment: Find out why this was occurring, and fix it.

Dr. Patil devised a solution in partnership with the team at Spaulding Rehabilitation, which is also part of the Mass General Brigham system. Launched in 2011, the care continuum collaborative is still going strong today, backed by Dr. Bueno, current division chief, and Jonathan H. Schwartz, MD, chief medical officer at Spaulding Hospital Cambridge.

“After a major thoracic surgical procedure, you normally have some communication with the patient if they’re discharged to the home,” Dr. Patil says. “But if they’re discharged to rehab, you don’t always know what’s happening there. With this model, we stay involved in the patient’s continued recovery. We communicate with the rehab team to ensure the patient gets the right care and progresses as they should.”

Keeping Up With the Progress of Thoracic Surgical Patients

The first iteration of the collaborative was an arrangement between Dr. Patil and Christopher Hardy Fanta, MD, a pulmonologist at the Brigham and the medical director at Spaulding. Whenever a thoracic surgical patient was discharged from the Brigham to Spaulding, the pair would stay in touch about the patient’s progress.

Gradually, Spaulding team members who cared for the patient became involved. Dr. Patil stressed to all that she would be available for consultation 24/7/365. She has since taken calls at all hours and from locations around the country and the world—but it has all been worth it.

“Some patients have such complex needs that it’s extremely hard for the rehab team to care for them,” she says. “By always being available, I can explain what care will benefit the patient—for example, why the tracheotomy tube can’t be removed yet and what milestones still need to be achieved. Additionally, I can stay abreast of what’s happening to the patient, such as whether certain medications did or did not work.”

Dr. Patil adds that she and the Spaulding team frequently make decisions on issues such as fine-tuning medication or whether to readmit the patient to the Brigham.

‘Really Become a Part of the Rehab Team’

Though no detailed outcomes data are available on the care continuum collaborative, Dr. Patil reports that the model has given the Brigham’s thoracic surgery division greater insight into patient progress at Spaulding. It has also enabled the division to make better-informed decisions about the timing of discharge to rehab and take steps to decrease the likelihood of unnecessary readmission.

“It’s comforting for patients and their families to know that their previous team [at the Brigham] is in touch with the rehab team and involved in their care,” Dr. Patil says. “If they’re uncertain about something rehab suggests, they know they can always talk to me.”

Dr. Patil is proud that the collaborative won the 2013 Partners in Excellence award, which acknowledged staff members for their “above and beyond” efforts to support the system’s mission. She is also pleased that it has become a model for other specialty services across Mass General Brigham, including medical ICU, with two more on the horizon. Moving forward, she hopes the model will expand across more specialties and other Mass General Brigham institutions.

As for thoracic surgeons who may want to start a similar collaborative at their institution, Dr. Patil has one overriding piece of advice: “Make yourself available to the rehab team, the patient, and the family, no matter what their questions or concerns are,” she says. “Really become a part of the rehab team.”