ACP: Making transitions better for patients

A 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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