Hospital medicine leaders have long acknowledged the disconnects in medical care that occur at discharge. The demand for greater efficiency in hospital-based care is what has driven the hospitalist movement and its inexorable growth the past two decades.
Efforts to overcome discontinuity of care have included more timely discharge summaries, phone calls to primary care physicians (PCPs) and specialists at the time of discharge, and hospitalist-staffed post-discharge clinics. In a 2002 article, Robert Wachter, MD, MHM, and Steven Pantilat, MD, SFHM, of the University of California San Francisco (UCSF), suggested that PCPs make continuity visits to the hospital once or twice to maintain their involvement and help coordinate the care of their patients.1
A new “Perspectives” piece in The New England Journal of Medicine proposes that PCPs act as medical consultants to the hospitalist team while their patients are in the hospital, making a consulting visit “within 12 to 18 hours after admission to provide support and continuity to them and their families.”2 Authors Allan Goroll, MD, MACP, and Daniel Hunt, MD, propose that the PCP be asked to write a succinct consultation note in the hospital chart, highlighting key elements of the patient’s history and recent tests—with the goal of complementing and informing the hospitalist’s admission workup and care plan—while being paid as a consultant.
“It’s a fairly straightforward proposal,” says Dr. Hunt, chief of the hospital medicine unit at Massachusetts General Hospital (MGH) in Boston. “We’re not looking for PCPs to take care of every aspect of inpatient care. It’s really just to bring in the PCP’s expertise and nuanced understanding of the patient at a vulnerable time for the patient.”
The idea might seem a little ironic given the fact that hospitalists were created in part to relieve busy PCPs from having to visit the hospital. But some see it as a way forward.
“I wouldn’t call it a step backward,” says Joseph Ming Wah Li, MD, SFHM, FACP, director of the hospital medicine program at Beth Israel Deaconess Medical Center (BIDMC) in Boston and a former SHM president. “Is it feasible? Realistically, in most settings today, I don’t think it is. But I would love it. I don’t really know enough about the patients I take care of in the hospital.”
The Barrier of “Not Enough Time”
Dr. Hunt says the biggest barrier to this proposal is the time that PCPs would have to carve out to make physical trips to the hospital.
“That ultimately comes down to reimbursement,” he says.
MGH, which is well situated with medical practices in or near the main hospital building, has piloted an approach similar to the NEJM proposal with a primary care group that comes in to see its patients in the first day or two after admission and then again on the day before discharge.
“But they are essentially doing it out of the goodness of their hearts,” Dr. Hunt explains. “What we’ve seen from this experiment are much better transitions of care and much better decision making around big decisions, such as end-of-life care or surgical interventions.”
Hospitalists at MGH and the PCPs spent a year and a half talking through the specifics of how their arrangement would work.
“We made a commitment, as hospitalists, to communicate directly by phone with the PCPs,” he says. “That commitment lasted about a week, and then we quickly converted to a daily e-mail. That works, because both parties are communicating substantial information in these e-mails.”
Dr. Hunt says the key is recognizing the “huge” value PCPs bring to an inpatient stay. And, while physical trips to the hospital or e-mails might not work for every hospitalist or PCP, the connecting of information and insight is often worth the investment.
“There are other ways [to communicate], such as video conferencing and Skype, where doctors could participate more efficiently in the care of their hospitalized patients,” he says, adding that hospitalists should reach out to PCPs, both when a patient enters the hospital and as part of a larger discussion about how to improve communication and continuity of care.
The PCP Perspective
Boston internist Gila Kriegel, MD, might seem like a throwback. She says she wants to visit her patients when they are in the hospital, if at all possible. In fact, hospitalists in Boston say Dr. Kriegel allows them to take care of her patients “almost begrudgingly.”
“She is so involved in their care,” Dr. Li says. “She tells me everything I need to know about them. She’d be here every day if she weren’t juggling other responsibilities.”
A PCP since 1986, Dr. Kriegel’s story illustrates the complexities of an evolving healthcare system. She’s based in an academic setting, which she calls a “kind of ivory tower.”
“But I was fortunate in 1989, after my first son was born and I went part-time, to have a colleague who offered to see my inpatients on the days I wasn’t working,” she explains. “Then a woman colleague of mine also went part-time, and we agreed to cross-cover for each other.”
Eventually, Dr. Kriegel was approached by Dr. Li’s hospitalist group, which offered to manage her hospitalized patients.
“For the first six months to a year, I’d go see my patients in the hospital on a social visit. I’d even write notes in the chart, until they told me, ‘You are not responsible for the care in the hospital. The hospitalist is,’” she recalls. “For me, it was a big loss to stop going to the hospital. Most PCPs I know like seeing their patients through the course of the illness.”
Then again, she also admits how difficult it is to see her patients in the hospital.
Still, she managed to stay connected. “When I stopped going to see my patients, I asked the hospital staff to give me the patient’s bedside phone number, and I’d call them in the hospital to let them know I was up on what was happening,” she says.
Technology, coincidentally, inserted a barrier: She wasn’t able to access hospitalists’ daily notes in the BIDMC electronic health records. That’s when Dr. Kriegel began e-mailing the hospitalists. In the end, even that form of communication wasn’t fully satisfying.
“The current system requires me to do the outreach,” she explains. “If you ask hospitalists about communication, they’d say they’re already doing it. But a discharge summary isn’t the same as knowing in real time what’s happening with my patients.”
“I’d love to make virtual visits to the patient in the hospital, by phone or computer link—even more so if I could get paid for my time. But I want to stay involved.”
Ripe for Innovation
Dr. Wachter, chief of hospital medicine at UCSF, who writes an HM-focused blog [wachtersworld.com], says the continuity visit is a good idea but also understands the difficulties in the new healthcare paradigm.
“It’s not easy to work out the logistics, and it depends on the geography,” he says. “We also need to be considering telemedicine. But something to enhance continuity is ripe for innovation.”
He says consultation or continuity visits offer ways to improve care with a relatively small expenditure.
“We still see a few PCPs come in when their patients are hospitalized. It’s very reassuring to their patients,” he says. “For the complicated cases where an ongoing relationship matters, those encounters are fabulous.”
Larry Beresford is a freelance writer in Alameda, Calif.