Lost in Transition — Coordinating Care Between Inpatient and Primary Care Physicians
Over the last 10 to 15 years, hospitalists have become a familiar presence in the health care system. A recent article in the New England Journal of Medicine describes the growth of hospitalist care, estimating that in 2006, 19% of general internists were hospitalists. Also in 2006, 47% of all hospitals and 84% of teaching hospitals had at least three hospitalists. (1) The number of practicing hospitalists is expected to grow from approximately 20,000 to 40,000 within 10 years. (2)
"No matter what the balance of benefits versus adverse effects related to hospitalists, the economic and practical forces that promoted the growth in the care of patients by hospitalists are intensifying, not lessening, and hospitalists are here to stay." (3)
The dramatic growth of hospitalist care has led to the use of inpatient physicians in other specialties. A recent article in the journal Hospitalist reported on the increased subspecialization in hospital medicine. "There are now surgicalists, laborists, psychiatric hospitalists — even hepa-hospitalists." (4)
Recently, hospitals have been hiring "laborists" or OB hospitalists who manage patients in labor "without worrying about an office full of patients." (5) Laborists can also evaluate patients for obstetric problems, make patient rounds, and care for patients in labor who do not have an ob-gyn. "The American College of Obstetricians and Gynecologists calls the use of OB hospitalists widespread, but does not have a formal opinion on the practice." (6)
Surgeons have also begun relying on hospitalists to comanage uncomplicated presurgical and postsurgical care. "In both academic and community settings, comanagement by a hospitalist offers advantages of consistent availability and proactive perioperative expertise, both in diagnosing and treating relevant problems and in recognizing the need for subspecialty involvement, thus improving efficiency of care." (7)
The hospitalist model may also be a viable solution to one of the most challenging problems in emergency medicine: finding specialists to take call. Having specialist hospitalists (such as orthopedic surgeons or general surgeons) on staff can address two of the obstacles to specialists taking call: financial issues and work-life balance.
"Because hospitalists by definition are on-site 24/7, the lifestyle issue becomes moot. Also, because they are being paid for the time they spend in the hospital, there is no need for a stipend or other remuneration for being 'on call'" (8)
While there are distinct advantages to adopting the hospitalist model to a variety of specialties and care situations, there remains one complicating factor. "Although hospitalists provide important benefits, their involvement disrupts the continuity of care provided by the patients' primary care physicians, resulting in potential adverse effects for both patients and doctors. With the increasing burden of chronic illness and complexity of medical care, coordinating care across settings and providers has become equally important." (3)
This article will address three areas of risk commonly associated with coordinating care between inpatient physicians and primary care physicians, and will discuss considerations for reducing these risks.
AREAS OF RISK
Hospital discharge is the most frequent type of care transition, occurring 39.5 million times each year. (9) Research shows that 19% of discharged patients experience an adverse event, such as an emergency department (ED) visit or readmission, within three weeks of discharge. (10)
"Although there is a finality associated with discharge, many patients' illnesses actually have not fully resolved by the time they leave the hospital. During a period of convalescence that may last days, weeks, or even months, patients must manage new medications, adopt lifestyle changes, and perform appropriate outpatient follow-up. Increasingly, evidence shows that during the time after hospital discharge, the patient is more prone to medical errors, adverse events (AEs), and rehospitalizations." (11)
A study published in the Annals of Internal Medicine found that of the 19% of patients who experienced adverse events within three weeks of discharge, 61% of these events could have been prevented or ameliorated. Adverse drug events were the most common postdischarge complication, followed by hospital-acquired infections, and procedure-related injuries. (10)
Another study found that 41% of patients are discharged with laboratory and radiologic test results still pending, of which, 9.4% of these results were potentially "clinically actionable." (12) Additionally, 27.6% of patients were discharged with a plan to complete a diagnostic work-up as an outpatient. Of the recommended work-ups, 35.9% were not completed. (13)
"These disturbing but common patient safety threats can be attributed to several problems in discharge planning and postdischarge care. Discontinuity between inpatient and outpatient providers is common, and studies have shown that traditional communication systems (such as the dictated discharge summary) generally fail to reach outpatient providers in a timely fashion and often lack essential information." (14)
Good communication between inpatient and outpatient physicians is essential for patient safety. A 2003 study published in the Annals of Internal Medicine found that more than half of all preventable adverse events occurring soon after hospital discharge have been associated with poor communication among care professionals. (10) "The declining presence of primary care providers (PCPs) in hospitals has not been adequately accompanied by systems to ensure that patient data are transferred to subsequent caregivers." (15)
A systematic review of discharge communication, conducted by the Continuity of Care Task Force of the Society of Hospital Medicine/Society of General Internal Medicine, found that discharge summaries were often unavailable at the time of the patient's first follow-up contact with a primary care physician. Patients or their families "were often the first source of information about the hospitalization," and this adversely affected care in about 24% of cases. Additionally, 25% of discharge summaries never reached the primary care physician. (16)
The review also found that discharge summaries frequently lacked information that would be essential for providing thorough follow-up care, such as discharge medications (missing from a median of 21% of discharge summaries), pending test results (missing from a median of 65% of discharge summaries), and specific follow-up plans (missing from a median of 14% of discharge summaries). (16)
"The traditional dictated discharge summary is of limited value for patient safety purposes because it generally does not reach the outpatient physician before the patient follows up, and does not necessarily contain the information outpatient physicians need to ensure continuity of care." (17)
Primary care physicians have rated the following information as important for providing follow-up care:
- main diagnosis;
- pertinent physical findings;
- results of procedures and laboratory tests;
- discharge medications with reasons for changes to previous medications;
- details of follow-up arrangements;
- information given to the patient and family; and
- test results pending at discharge. (16)
The Continuity of Care Task Force published the following recommendations to improve discharge communications.
- "On the day of discharge, a summary document should be sent to the primary care physician by email, fax, or mail. If a complete discharge summary cannot be sent on the day of discharge, then an interim discharge note should be sent. At minimum, it should include the diagnoses, discharge medications, results of procedures, follow-up needs, and pending test results."
- A detailed discharge summary should be delivered in a week. This summary should include diagnoses, pertinent history and physical findings, dates of hospitalization, hospital course, results of procedures and abnormal studies, consultant recommendations, information given to the patient and family, functional status, reconciled medication regimen (with reasons for changes and indications for new medications), details of follow-up arrangements made, specific follow-up needs (appointments or procedures that need to be scheduled, tests pending at discharge), and name and contact information of the hospital physician.
- "Discharge summaries should be structured with subheadings to organize important information." (16)
- "Hospitals should use information technology to aid in the completion of discharge summaries." (16)
- "Patients should be given a copy of the discharge summary or note and told to take it to their follow-up visit." (16)
PENDING TEST RESULTS AND POSTDISCHARGE FOLLOW UP
Another area of concern in the hand-off between inpatient and primary care physicians involves test results that return after discharge and completion of outpatient workups.
A study published in the Archives of Internal Medicine found that at discharge, 27.6% of patients had at least one outpatient workup recommended by a hospital physician. However 35.9% of the workups were not completed. Common recommended workups not completed included CT scans of the chest to further evaluate pulmonary nodules; outpatient stress tests to rule out myocardial infarction in patients experiencing chest pain; and colonoscopies for patients found to have heme-positive stool specimens. (13)
The study also found that 54.1% of all the discharge summaries failed to document the recommended outpatient workup, though these workup recommendations were clearly documented in the patients' hospital charts. "In our study, there was an association between the availability of discharge summaries documenting recommended outpatient workups and higher completion rates of workups. Therefore, it is not sufficient for outpatient PCPs to simply receive patients' discharge summaries; the discharge summaries must document pertinent details about patients' discharge plans to ensure inpatient-to-outpatient continuity of care." (13)
Regarding pending test results, Roy et al found that 41% of patients are discharged with laboratory and radiologic test results still pending, of which, 9.4% of these results were potentially "clinically actionable." The most common test results that required urgent action were lab tests that would require starting or changing antibiotic treatment. Many nonurgent actionable results were from radiologic studies or serologic tests. "Surveyed physicians were unaware of almost two thirds of these potentially actionable results; more than a third of these would change the patient's diagnostic or therapeutic plan, and 12.6% required urgent action." (12)
This study also found that most inpatient physicians surveyed expressed dissatisfaction with their current ability to follow up on results returning after discharge, and agreed that electronic health records could make this follow up easier. (12)
"Given the high volume of results returning after discharge and the potential for patient harm if even a few results are overlooked, a highly reliable system for ensuring follow-up seems warranted. Electronic results-management systems are being evaluated to solve the problem of timely and reliable test follow-up in the outpatient setting, and such technology may be useful to hospitalists in tracking results returning after discharge. Such systems could highlight important results and filter out normal results to avoid overwhelming busy clinicians." (12)
Multiple studies demonstrate that medications are often changed or new medication prescribed without a clear indication upon admission, at transitions during hospitalization, and at discharge. Patients frequently receive new medications or have medications changed during hospitalizations. Lack of medication reconciliation results in the potential for medication discrepancies and adverse drug events, particularly for patients with low health literacy, or those prescribed high-risk medications or complex medication regimens. (18)
The findings from a study published in the Journal of Hospital Medicine found that 7.2% of patients reported problems obtaining or taking prescription medications in the 48 to 72 hours after discharge. In 79.8% of cases, the problem was failure to pick up discharge medications. (19) "Medication-related problems after hospital discharge, which include patients not filling or refilling their prescriptions, not understanding how to take medications, showing discrepancies between what they are and what they should be taking, and having adverse drug events, are a major cause of morbidity and mortality." (19)
Medication reconciliation is the process "of avoiding such inadvertent inconsistencies across transitions in care by reviewing the patient's complete medication regimen at the time of admission, transfer, and discharge and comparing it with the regimen being considered for the new setting of care." (18)
Medication reconciliation was named as a National Patient Safety Goal by the Joint Commission in 2005. Accredited organizations are now required to implement "a process for obtaining and documenting a complete list of the patient's current medications upon the patient's admission to the organization and with the involvement of the patient" and to communicate "a complete list of the patient's medications . . . to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization." The Joint Commission does not mandate specific ways for this process to occur. (20)
Research into the best ways to achieve medication reconciliation is ongoing. A 2006 study published in theArchives of Internal Medicine demonstrated that medication review, discharge counseling, and telephone follow-up by pharmacists were associated with a lower rate of preventable adverse drug events 30 days after hospital discharge. (21) Solutions that integrate medication reconciliation into electronic health records are also being investigated. (18)
"Interventions should also focus on minimizing unnecessary changes from preadmission regimens to discharge medication orders. After discharge, interventions should focus on identifying discrepancies between discharge medication orders and patients' self-reported regimens. Additional follow-up interventions may be necessary to provide sustained benefits in medication adherence and discrepancies and improve detection of ameliorable ADEs." (21)
The Agency for Healthcare Research and Quality (AHRQ) has created toolkits to help health professionals ensure a single, shared, updated, and reconciled medication list during the transition from inpatient to outpatient care. Experts in patient safety research developed the toolkits based on the examination of best practices in a variety of health care settings. For more information, please visit the AHRQ web site at www.ahrq.gov/qual/pips.
Several systems-based interventions have been suggested to prevent adverse events during care transitions, including using discharge checklists to standardize the process, placing postdischarge phone calls to patients, setting up "discharge appointments" with patients, and employing "transition coaches."
A "transition coach" is a health care professional (generally an advanced practice nurse) who meets with patients before and after discharge to reconcile medications, instruct patients and caregivers in self-care methods, and facilitate communication with the patient's primary care physician. A study published in the Archives of Internal Medicinefound that the use of a "transition coach" reduced 30-day hospital readmission rates. (For more information on transition coaching, please visit www.caretransitions.org/.) (22)
Another intervention currently being studied is a protocol called Project RED (Re-Engineered Discharge). Through qualitative analysis, process mapping, root cause analysis, and other techniques the Project RED team developed 11 components for effective hospital discharge.
These components were used to create a standardized discharge intervention that includes patient education, comprehensive discharge planning, and postdischarge telephone contact. The RED intervention reduced hospital readmission rates and ED visits together by 30%, according to the results from a study published in the Annals of Internal Medicine. Patients who participated in the intervention also reported a higher rate of follow up with a primary care physician within 30 days. (15) More information on Project RED, including tools and training manuals, is available at the Project Red web site.
RISK MANAGEMENT CONSIDERATIONS
While the use of the systems-based interventions described in this article can improve care transitions, individual physicians also have a critical role to play. The following risk management considerations may help inpatient physicians and primary care physicians minimize risk and enhance patient safety.
Considerations for hospital-based physicians
- Establish rapport. In general, inpatient physicians have a shorter period of time to establish rapport with the patient. "When you introduce yourself to the patient, hand the patient your business card and tell that patient what your role will be," says Jane Holeman, vice president of risk management at TMLT. "It is also a good idea to tell the patient that their care will be turned over to their primary care physician when they leave the hospital."
- Implement steps to improve the discharge communication process. Is the information necessary to ensure continuity of care included in the discharge summary? Has the discharge summary been completed and sent in a timely manner? "The Joint Commission considers discharge summaries to be part of the hospital record and requires that they be completed within 30 days of discharge. This is far too permissive, considering that patients often contact the PCP within 7 to 14 days of discharge." (11)
- Clearly communicate when the patient is to follow up with more than just his or her primary care physician. Who will be following the patient for ongoing labs and anticoagulant therapy? Who is to manage the patient's diabetes regimen? If it is not the primary care physician, make sure the patient knows who to see for the management of these conditions.
- Reconcile patient medications at admission and discharge, in compliance with Joint Commission standards. Ensuring that primary care physicians receive a single, shared, updated, and reconciled medication list can enhance patient safety.
- Follow up on pending test results. "Test results are the responsibility of the physician who ordered them," says Holeman. "The ordering physician, whether a subspecialist or a hospitalist, has the responsibility to relay the results to the patient's primary care physician."
Considerations for primary care physicians
- Make sure your patients understand that you will not be treating them in the hospital, but that you will resume their care once they are discharged. "I now tell all of my patients that my colleagues on the inpatient team will be responsible for their care in the hospital. I explain that the team members are capable and current on hospital care, that they have all my records available to them, and that they communicate regularly with me." (23)
- Be responsive to requests from hospitalists for information about your patients. Hospitalists "cited admission as a time of serious risk for poor coordination, because of reportedly limited information on patients' medical histories from outpatient providers, especially regarding current medications." (24)
- Ask hospitalists to communicate with you. "Even though a primary care physician may not physically be able to see the patient in the hospital, the physician can always request to be kept informed of the patient's condition," says Holeman. "Let the hospitalist know that this communication works both ways. Tell the hospitalist that you are available to talk about any issues that may arise while your patient is in the hospital."
- Alerting inpatient physicians when a patient needs to be admitted can avoid the "scramble for information when the patient presents in the emergency department." (24)
- When you receive discharge summaries on your patients, review, initial and date the report. This will provide documentation that you received and reviewed the discharge summary. Establish a policy in your office that no report is filed in a patient's record (electronic or paper) unless it has been reviewed.
- If a patient who has been recently hospitalized comes for a follow-up visit and you have not received any information on the hospitalization, contact the hospitalist or the hospital and request a copy of the discharge summary.
- Reconcile medication changes with the patient and in the medical record. "It is also a good idea to assess the patient's understanding of the new medication regimen and confirm with the patient that the medications are being taken," says Holeman. "Using open-ended statements such as, 'Tell me which medications you are taking,' will likely provide the best feedback regarding the patient's understanding of their medication regime."
Given that more than half of all preventable adverse events occurring soon after hospital discharge have been associated with poor communication among providers, the need for physicians to communicate effectively with each other cannot be over emphasized. Communication between inpatient and primary care physicians should be considered a two-way information exchange.
"Many primary care physicians are not routinely notified about patient admissions or complications during the hospital course. Conversely, some primary care physicians may not provide sufficient information to hospitalists at admission, visit or call hospitalized patients, participate in discharge planning, or contact patients who have missed postdischarge follow-up appointments." (16) Two-way dialogue between inpatient physicians and primary care physicians can ensure that important information is not lost during care transitions.
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