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PCPs Come Home


Hospitalists have been concerned about the entire continuum of care from the early days of the hospital medicine movement. We have tried to look at the system of healthcare from the patients’ viewpoint, where an admission to the hospital is rare in the larger scheme of their healthcare and their interaction with a variety of physicians and health professionals.

Hospitalists will always need to rely on our professional relationships with surgeons and specialists, as well as with the primary care physicians (PCPs) who refer their patients for admission to the hospital and who partner with us to resume patient care at discharge.

With this fundamental backdrop, two interesting trends in the PCP world—the patient-centered medical home (PCMH) and PCPs’ use of performance measurements to drive referrals to hospitals and specialists—will have a profound effect on hospitalists, the patients we treat, and the systems of care in which we work.

PCMH and Hospitalists

For many years, the problems in primary care have been virtually ignored and dismissed by the insurance industry—and even by most of organized medicine. As if a light has suddenly been turned on, everyone now wants to “do something” to save primary care.

One of the latest “solutions’ is the PCMH. As we all know, ideas without funding are just ideas. It’s time to take note of PCMH. Why? Because insurance companies and Medicare are paying for a variety of pilot and demonstration projects to see how PCMH might play out in real-life interactions among patients and physicians.

The main new characteristics in the PCMH (as opposed to the traditional PCP) are a more robust information system and the commitment of personnel and organization within the PCP practice to allow proactive coordination of the patient’s care. The hope on the performance side is that patients will receive better care that will lead to better patient satisfaction and better outcomes. On the payment side, the PCP must receive significant monetary support to pay for the staff and equipment to coordinate and manage their patient’s journey through an increasingly complex series of tests, referrals, and treatments.


SHM has tried to raise the issues of how the PCMH would relate to hospitalists at key junctures in the hospitalization continuum. Hopefully this will lead to a dialogue with the PCP community about how PCMH proposals would meet the goals of defining accountability and responsibility for the PCMH and for hospitalists. In turn this would lead to a better, safer system for our patients.

While discussions have specifically focused on the PCMH-hospitalist interface, many of the same tenets of accountability, responsibility, timeliness, and information transfer would apply to the PCMH-specialist interfaces.

Time of Admission

Accurate, timely information is crucial at the time of acute illness. It would be expected that at the time of the patient’s arrival at the hospital the following set of data elements would be available to the hospitalist (and/or emergency department physician or specialist). These elements are lifted directly from the joint SHM-ACP-SGIM Transitions of Care Consensus document from 2007 (available at principle diagnosis and problem list; medication list (reconciliation), including over-the-counter and herbal products, allergies, and drug interactions; emergency plan and contact number and person; treatment and diagnostic plan; prognosis and goals of care; test results/pending results; clearly identifies medical home and/or transferring coordinating physician/institution; patient’s cognitive status; advance directives, power of attorney, consent; planned interventions, durable medical equipment, wound care; and assessment of caregiver status.

Time of Discharge

While it is clear that the hospitalist is responsible for overseeing the patient’s care while hospitalized, it is essential for patients and their families to know who will be accountable at the time of discharge. SHM proposes that the PCMH:

  • Assume the primary role of caring for the patient as of the time of discharge from the hospital;
  • Provide a timely first post-discharge office visit consistent with the acute illness as documented in the discharge summary; and
  • Ensure a handoff formally confirmed and documented by the hospitalist and PCMH.

The hospitalist should provide to the PCMH:

  • An accurate and timely discharge summary; and
  • The availability to the PCMH to answer questions about the hospitalization.

Further, discharge summaries should include:

  • Primary and secondary diagnoses;
  • Pertinent history and physical findings;
  • Dates of hospitalization, treatment provided, brief hospital course;
  • Results of procedures and abnormal laboratory tests;
  • Recommendations of any subspecialty consultants;
  • Information given to the patient and family;
  • The patient’s condition or functional status at discharge;
  • Reconciled discharge medication regimen, with reasons for any changes and indications for newly prescribed medications;
  • Details of follow-up arrangements made;
  • Specific follow-up needs, including appointments or procedures to be scheduled, and tests pending at the time of discharge; and
  • Name and contact information of the responsible hospital physician.1

Other Considerations

Obviously other aspects of the PCMH-hospitalist relationship must be considered, including when the PCMH would like to be informed (or involved) during their patient’s hospitalization, as well as how to manage the handoff of responsibilities and information when the patient leaves the hospital but does not go directly home (e.g., when they are sent to a skilled nursing facility or rehabilitation center). If we continue to look at solutions from the patient’s and family’s points of view, we can come up with a workable solution.

Performance-driven Referral

Part of the result of the growth of the hospital medicine movement is that, increasingly, PCPs are not directly managing their patients for acute illnesses. That said, the PCP still has a significant role in determining whether their patients get the best care available—even if other physicians (e.g., hospitalists, surgeons, subspecialists) deliver the actual care.

We are just at the beginning of performance measurement and reporting. Today, PCPs and their patients can log on to and look at any hospital’s performance for pneumonia, acute coronary syndrome, and heart failure. The era of disease-specific and institution-specific—even physician-specific—reporting grows on a seemingly monthly basis.

Armed with this information, the PCP’s role shifts from managing the acute illnesses of their patients to understanding the report cards on their local hospitals and specialists and using this information to direct their patients to the hospitals and physicians who have the best outcomes. The expanding role of the PCP as the informed guide for their patients further will drive hospitals and all physicians who rely on referrals to improve their feedback and communication with PCPs.

We will begin to see that best-of-breed hospitals not only will have excellent clinical outcomes but will be pushed to have better patient-satisfaction and PCP-satisfaction scores. This is an opportunity for enlightened PCPs to use their medical background and hands-on understanding of local healthcare to be a vital resource to their patients.

By the same token, this is an opportunity for product differentiation for hospitals and their hospitalists to reshape a healthcare referral world traditionally built more on geography and familiarity than on information and performance, and replace it with strong communication and better outcomes. The best thing about this approach is the patient wins. TH

Dr. Wellikson is the CEO of SHM


  1. Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007 Feb 28;297(8):831-841.

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