ACP: Making transitions better for patients

ACP: Making transitions better for patientsA guest column by the American College of Physicians, exclusive to

Many patients see multiple doctors and receive care in a variety of settings. Some patients receive care in more than one hospital. As an internist who is in the process of transforming into a patient-centered medical home, I have been taking steps to help my patients when they see other physicians.

All physicians can recount instances when they saw a patient with too little information. That works both ways. I know my patients have been seen elsewhere when additional information from me could have helped their care.

Scheduled referrals give a wonderful opportunity to share information. Hopefully, those of us making the referrals will not simply dump data from old records but will at a minimum list the pertinent issues at hand and the questions being asked in the referral. Physicians receiving referrals can then respond with their impression in a readable format and update that report if the impression changes with additional information.

When patients are seen in a hospital it often is not scheduled and poses more challenges in both directions. As an outpatient physician, I greatly appreciate notification when my patients are admitted to a hospital so that I can provide whatever information is needed, and a prompt discharge summary is always helpful to me in the first post-hospital visit.

When information flow works smoothly, it is easier for all involved in care and the patient benefits. What are the barriers to effective information flow? What are the opportunities to improve this flow? I’ll share some thoughts and would appreciate the perspective of those with other vantage points, particularly hospitalists and doctors seeing patients on referral.

As a general internist in a small town my patients are either hospitalized in our local community hospital or referred to one of two main tertiary centers. While I practice only in the office, I make “social rounds” in our local hospital and perform the handoff personally, copying records and passing along particular perspectives based on what is often many years of getting to know the patient well. I can also validate in the patient’s mind the care he or she is receiving in the hospital.

I appreciate progress reports from the hospitalist and prompt discharge summaries so that I will know where my attention needs to be directed in that first visit.

Where there is not in-person contact, the communication can vary tremendously depending on the efforts of those involved. It is helpful to get a notification when a patient is admitted to an out-of-town hospital with information on how to contact the physicians caring for the patient. I must confess that I often see the responsibility one way; after receiving that information, most physicians – myself included – could do a better job of sending relevant information to those caring for my patient.

It would be helpful to make a new expectation that part of the discharge planning process be to notify the primary care physician of discharge and make sure that proper records including a discharge summary be available before the first post-hospital visit. Most hospitals seem to have requirements for timely summaries but in many cases they are either not done or not transmitted by the time of the first outpatient visit. This would seem to be an excellent opportunity to improve patient care.

Most of us have seen data suggesting that a significant portion of patients readmitted within 30 days have not seen a physician in the outpatient setting. That should not be noted as simply another “ding” in the report cards that seem to be coming from all directions but a failure of the system to provide continuity of care.

We all try to do our best when we see a patient. The goal of excellent patient care is not met when avoidable complications occur due to a suboptimal handoff. What are your thoughts on how we can make transitions better for our patients?

Fred Ralston practices internal medicine in Fayetteville, Tennessee, and is the Immediate Past President of the American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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  • Donald Tex Bryant

    Dr. Ralston, you certainly present compelling arguments about communication in support of patients.  Implementing these recommendations is a difficult matter and will take some time to implement.  Implementation of your recommendations will be easier in situations where the PCP or outpatient physician is a hospital employee, I believe.  CMS will also probably drive this type of communication with its value based purchasing initiative.  These too trends alone will help in driving better communication.

    On the other hand, it will be difficult for some hospitals and outpatient docs to advance along with their peers in adopting new communications protocols.  The inertia of years of counterproductive patterns will be difficult to overcome without a personal commitment to improved patient care by leadership and docs.

    • WarmSocks

      Why would you think that this type of communication is difficult?  When I took my son to the ER for a broken arm, the hospital notified our family physician (who is not a hospital employee) and sent a link so our doctor could view the x-rays.  When I was admitted to that same hospital, our family physician was notified – and showed up to take over my care from the hospitalist.

      Notifying the primary doctor doesn’t seem like a difficult thing to do – with computerized medical records, it should be even easier since a good programmer could make email notification automatic.

      • Anonymous

        It’s NOT that difficult. Whether you communicate by EMR, paper, or smoke signals, all it takes is asking for the needed info. If you’re seeing a patient in consultation or for a post-hospital follow-up, train your staff to get all the info BEFORE you see the patient. It’s really not that hard. The problem seems to be either laziness or distraction by too many non-clinical tasks.

        Can’t help commenting on the author’s completely irrelevant mention of “transforming into a PCMH.” For the primary care apparatchiks, a sentence is noun + verb + PCMH.

  • Steven Reznick

    I always try to  contact the consultant by phone and discuss my concerns and reasons for the consult.My staff assist in making the appointment if the patient is older or infirm or if the patient just needs assistance. Before the appointment date I fax a cover letter with the patients last visit which also states the reason for the consult. We send labs and pertinent studies such as recent EKGs and imaging studies to the consultant so that they have the pertinent data to evaluate the question. We do the same for out of area hospital referrals to Centers of Excellence. I do my own hospital care so we do not have those type of handoff problems. Communicating verbally in person or by phone to avoid confusion or mistakes is not difficult to do especially in the smartphone era. It takes effort

  • Anonymous

    As hard as “some” providers try to coordinate care for their patients, that effort is futile in the small office fee-for-service (FFS) delivery model. The motive in FFS medicine is to do as much as possible to generate more and more revenue. It does not matter if the volume of tests and procedures produce wellness, if such volume produces increased revenues, that is how success is measured. Wellness be dammed! Consumer be dammed! What Home Depot did for home improvement and what WalMart did for retailing, is the same model needed for health care delivery. Big-box health care will force prices down. Rewarding wellness and good outcomes and ending FFS medicine will force prices down. Economy of scale will force prices down. The buying power of WalMart style health care will force the drug companies to compete and lower their prices. There’s absolutely no efficiency in having hundreds of one-doc practices in a geographical region when a WalMart style of health care delivery can do it all under one roof and offer coordination, cooperation and collaboration with a goal of wellness and good outcomes. Face it, most small office doctors don’t necessarily communicate with each other. Most hospital groups don’t necessarily communicate with each other. As long as we continue to support small office FFS health care delivery, we will have higher and higher costs with worse and worse results. The critics say ACOs under the PPACA will never work. What’s working today? We have over 50 million Americans that are uninsured. We have another estimated 25 million Americans that are underinsured. We spend 18 percent of GDP on health care, the most expensive in the world, and yet we rank 37th worldwide in efficiency and performance. America has the best health care in the world? Yeah, if you are wealthy!

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