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 www.hospitalmedicine.org): 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: