Making care transitions work as an outpatient-only physician

Many primary care physicians used to make hospital rounds, overseeing their patients’ care after they were admitted. Now, however, the growing number of hospitalists means fewer providers are juggling outpatient and inpatient duties.

For office-based physicians, this paradigm shift in hospitalized care has heightened the importance of implementing processes that maintain continuity of care for their patients across different settings.

Poor transitions can cause patient dissatisfaction. Even worse, they may precipitate adverse events, such as exacerbation of chronic medical conditions. “Regardless of which particular next site of care where they’re transitioning, it creates the opportunity for patients to fall through the cracks,” says Christopher Kim, MD, MBA, associate professor of internal medicine at the University of Michigan and program director of the Integrated Michigan Patient-Centered Alliance on Care Transitions.

Primary care physicians can have a major role in preventing transition gaps for their hospitalized patients, Kim and Charles E. Coffey, MD, MS, noted in a 2014 American Family Physician editorial. “Although these steps may require additional time and resources in an already busy practice, they are critical to keeping patients safe and healthy at home after discharge,” the authors wrote in “Transitions of Care: Optimizing the Handoff From Hospital-Based Teams to Primary Care Physicians.”

Keeping the lines of communication open

During a patient’s hospitalization, the lines of communication should remain open between hospital-based clinicians and primary care physicians. An electronic health record (EHR) system would serve as the ideal form of automated notification to a primary care practice when a patient is admitted, discharged or transferred. However, telephone calls, e-mails, text messages and facsimile also can help promote good communication, the authors say.

Related:Transition of care calls for primary care quarterback

After a patient’s discharge, a primary care physician can have the greatest influence on continuity. When the physician or a staff member with clinical knowledge of the patient’s medical home environment makes contact within 24 to 72 hours, Kim and Coffey suggest that those team members may be ideally suited to address or adjust for any unresolved symptoms and self-care plans initially devised by the hospital team.

In addition, the caller should discuss medications with the patient, especially any changes or additions to the regimen, and help with scheduling and transportation needs for the follow-up visit. If necessary, arrangements should be made for other services, such as a visiting nurse or in-home physical therapy, if those have not yet addressed by the hospital-based providers.

The follow-up visit should include an assessment of the patient’s recovery and a review of the post-discharge care plan, as well as the medication regimen, including any modifications. Patient engagement techniques such as “teach back” can facilitate understanding of self-care plans. This visit also would be the time to discuss test results not available at discharge or subsequent screenings recommended during hospitalization, Kim and Coffey advise.

Preventing hospital readmission is a major goal of these preemptive measures, says Robert Wergin, MD, FAAFP, president of the American Academy of Family Physicians. Primary care physicians often wonder, “How do you accommodate these vulnerable patients at a time when they’ve been ill enough to be hospitalized?” he says. “How do you make sure that transitions to home and follow-up care are going to be done?”

Wergin, who practices in Milford, Nebraska-a rural community with a 20-bed critical access hospital-still makes rounds regularly to see his patients when they are admitted. This helps with continuity.

Nonetheless, “many times the patients are confused” about which medicines to take afterward at home and how to adhere to the discharge treatment plan, he says. During a face-to-face conversation, he can set them straight. “I have found those visits to be very valuable,” Wergin says of the follow-up office appointment.

 

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