
Primary care physicians are critical in addressing health inequities in readmissions and long-term care
Who should coordinate care transitions? The doctors with the best picture of care through touchpoints with patients and their families.
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PCPs are in a unique position to help prevent hospital readmissions. They coordinate a patient’s care, are often the first point of contact when a patient is experiencing health problems, and usually have a better picture of care journeys with more touchpoints and communication with patients or their families. They are integral to identifying deterioration and worsening of conditions and intervening to avoid readmissions or even death. PCPs are also able to leverage their knowledge, communication and position in a patient’s care journey to minimize the impact of health care inequities that continue to challenge the health care system.
Health care inequities in readmission rates
Hospital readmission rates can be greatly impacted by race, ethnicity, socioeconomic status and more.
Additionally, living in a disadvantaged neighborhood is associated with
PCPs, collaboration and communication
Transitions of care, especially when a patient is being transferred from an acute care setting to a post-acute or long-term care facility, present the greatest risks for patients, and those with chronic illnesses are most at risk. A seamless transition of care between care settings is crucial to ensuring positive outcomes and avoiding hospital readmissions or worsening conditions. The efforts of PCPs in managing complex and chronic care effectively can go a long way toward ensuring the continuity of quality care for higher-acuity patients. In fact, studies have shown that having PCPs involved and engaged in the management of
PCPs at the forefront of preventing readmissions
There is increasing recognition in the medical community about the crucial role of primary care in reducing hospital readmissions.
Utilizing technology for effective collaboration
Digital technology such as patient portals, remote patient monitoring, telemedicine platforms and advanced analytics can strengthen collaboration and communication between practices and facilities, enabling PCPs to have better visibility into patients’ health status and coordinate timely interventions as needed. These tools and better communication among hospitals, PCPs, specialists and other care team members enable PCPs to identify a care plan for post discharge, track medications and continue follow-ups with patients through telehealth or other patient monitoring software, all of which are crucial to patient progress and satisfaction.
Additionally, PCPs can provide clear and effective communication throughout the care journey, especially during care transitions, to ensure care plans and outcomes are clearly communicated to patients and their families, as well as other members of the care team. PCPs are perhaps better positioned than anyone on a patient’s care team to address the gaps in care that lead to worse patient health outcomes and higher readmission rates. Because of their direct touchpoints with patients and their families, PCPs have greater visibility into their success in treatment and condition management and can lead collaborative efforts between practices and outpatient facilities to reduce hospital readmissions and improve patient outcomes no matter a patient’s race, ethnicity or socioeconomic status.
It’s tragic when a patient with a chronic illness, such as chronic obstructive pulmonary disease, heart disease or diabetes, is discharged from a hospital to a skilled nursing facility, only to be readmitted to the hospital when their condition worsens. Yet with the right care coordination measures, real-time insights and effective communication in place, hospital readmissions are entirely avoidable, even for patients with complex care needs. Seamless, uninterrupted care when a patient is being transferred from the hospital to a skilled nursing facility is vital to keeping that patient’s health on track. As the patient’s strongest health advocate and clinician most responsible for preventive health measures, the PCP is ideally positioned to directly participate in care coordination and lead care coordination during the post-discharge process.
Ahzam Afzal, PharmD, is the co-founder and CEO of
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