Hospitalists and primary care clinicians aren't always clear on their respective roles when it comes to patient care transitions. The resulting lack of communication can contribute to confusion about admissions, discharges, lab results, and medications as patients hang in the balance.
A qualitative study, published in the October 2014 Journal of General Internal Medicine, interviewed 58 hospitalists and physicians and physician assistants working in primary care (PCPs) about their perceived barriers to care coordination. In general, hospitalists maintained that, after discharge, PCPs should be responsible for home health care and any recommended tests. PCPs expressed frustration over being unaware their patients were discharged and not receiving information on pending tests. Both groups agreed on many points, including lack of time and difficulty reaching other clinicians.
Lead author Christine D. Jones, MD, spoke with ACP Hospitalist about her findings. Dr. Jones is an assistant professor of medicine at the University of Colorado, where she is director of care transitions for the hospital medicine group.
Q: What led you to explore this issue?
A: I was working with my primary mentor during my primary care research fellowship, Darren DeWalt [MD, FACP], and he was leading a study to try to improve care transitions from the primary care perspective, to help clinics be prepared to receive patients after a hospitalization. And what we realized through this project was that, often, the PCPs had no idea their patients had been in the hospital, and it was really difficult for them to engage the hospitals in a conversation to try to make that better. I had worked as a hospitalist before, but during my fellowship, I was actually also a PCP. I had both perspectives. . . . It seems to be very widespread and systematic that the hospitalists and PCPs aren't necessarily certain how to connect around patient discharges.
Q: What were some of the more concerning communication problems you found between hospitalists and PCPs?
A: One example that comes to mind is home health care. . . . If they're brand-new services at discharge, a lot of times the PCPs don't necessarily know what was ordered [and] why it was ordered. So if there are problems that arise before the primary care follow-up, really it's kind of the hospitalist that needs to think about addressing those because the PCP often doesn't have the discharge summary and doesn't quite know what those services were ordered for. And I think the hospitalist's perception is that, “I ordered home health services, and the PCP will take over everything once the patient's out of the hospital.” . . . One of the other things that came up a lot is clearly defining accountability. . . . Who is responsible for following up on those pending tests and making sure that the patient knows about [the results] and has follow-up regarding that? I think that's still something that's still kind of unclear and not well defined as we're handing off between the inpatient and outpatient setting.
Q: Did your findings surprise you?
A: I think the home health care one really surprised me. The other thing was . . . the perceived accountability to interact with home health care providers was very different between hospitalists and PCPs. I think the PCPs felt like . . . “I don't necessarily understand why things were ordered or why they were done because I didn't get the information I needed from discharge.” Meanwhile, the hospitalists just felt like, “I think I auto-routed my discharge summary to the PCP, so they should be able to sort it out.”
Q: How do these lapses in communication affect the patients making these care transitions?
A: One example that came up . . . was that PCPs might not have a patient on, for example, an [angiotensin-converting-enzyme] ACE inhibitor because a patient has had a problem with it before. But maybe from the hospitalist perspective, we don't always see the primary care notes if they're outside of our system. So we're thinking something like, “This patient is diabetic. They really should be on an ACE inhibitor.” And so, we feel like we're good stewards of evidence-based care and might start this ACE inhibitor, and then the patient shows back up in the PCP's office with the same problems that they had.
Q: What can hospitalists do to help correct these issues?
A: One of the solutions that was proposed [by the surveyed doctors] was to have things like mixers with hospitalists and PCPs so that you know the person that you're handing off to. They felt if they had more personal relationships, they would be more likely to make extra efforts to engage in care coordination. . . . There were a couple groups that I interviewed who shared the same electronic medical record [EMR], and so they noted that there were some advantages to being able to send messages within the electronic medical record, but then even within those groups, some of them wanted the extrapersonal touch of talking in person or getting a personal page about their patients.
Q: Since this study was published, have you noticed an increase in attention to this issue?
A: I think so. I think more and more we're realizing that fragmented care between settings is a root problem that is often at the heart of a lot of adverse events that follow hospitalization and that, until we all are on same page and have a shared accountability for patient outcomes, it's very challenging to improve patient outcomes after discharge. . . . One of the bits of feedback I got as I was doing this is, “Well, aren't EMRs just going to solve all this?” And I think we're realizing that the technology is not going to solve all of these problems.