Background: 1 in 4 patients on the Acute Care of the Elder (ACE) unit at a tertiary care center state that their physicians do not communicate well “all of the time.”

Purpose: To enhance physician-patient communication on the ACE unit by writing personalized letters to patients regarding their care.

Description: We asked attending physicians to write a letter directly to their patient explaining the reason for their hospitalization, plan of care for the day, and anticipated discharge date. Letters, labeled “treatment plan” in our EMR, were written on day two of the patient’s hospitalization, printed out, and given to patients to read and share with their family. Attendings also provided a one-line attestation to the resident note on the day they wrote a letter to fulfill billing and regulatory documentation requirements. Letters were not provided if patients lacked cognitive capacity to understand the letter, were medically unstable, or if the attending thought the letter would not improve communication. 23% of ACE patients received a letter from their attending during the first month of the intervention.
Our letter writing initiative was the result of user-centered design (often called “design thinking”) event meant to explore creative opportunities for improving patient communication. The idea was generated out of an interprofessional rapid process improvement event on the ACE Unit and iteratively implemented and tested using the IHI “Model for Improvement” methodology. The original idea was rapidly prototyped by a single physician who solicited feedback from 3 patients who received letters. Based on feedback, the letter format was fine-tuned with that single physician before being incorporated into the practice of all ACE attendings. Feedback was sought from physicians, patients, and family to inform additional iterations.

A survey assessing clarity, knowledge, language/style and overall impression of the letters was delivered to 8 patients and 3 family members. All surveyed patients and/or family members felt that the letters increased satisfaction with communication. In addition, two independent clinicians and a non-clinician reviewed letters for content and clarity. The non-clinical reviewer agreed or strongly agreed that 84.4% of the letters clearly communicated events of the hospital stay and was easy to read and comprehend. On pre and post surveys with 6 physicians, attendings generally thought that the letters increased patient engagement but found it challenging to minimize jargon and that the letters were time consuming.

Conclusions: This form of written communication has been well received by patients and their family members. Time has been the critical limiting factor, in particular distributing letters to all potential ACE patients. Creating a streamlined workflow that better integrates clinical documentation with patient-facing written communication might serve to make letter writing sustainable for broader dissemination.