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.
“We made a commitment, as hospitalists, to communicate directly by phone with the PCPs. 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
“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.