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Hospitalists Take Care Transitions Into Their Own Hands


How can hospitalists know if the care-transition plans they’ve put in place to get their discharged patients back to their PCPs are working out? For the 18-member inpatient medicine group at Aultman Hospital in Canton, Ohio, the answer is simple: Ask the PCPs.

“It’s more important than ever for the transition from one service to the next to be smooth, with a very good handoff. That’s where our hospitalist group and what we are doing comes in,” says group leader O. George Mitri, MD, FACP, FHM.

Dr. Mitri, along with Lewis Humble, MD, the group’s designated outreach champion, and Katie Wright, MSN, RN, the group’s practice administrator, visit PCPs in their offices once or twice a month. They meet with the physicians and practice managers, sharing data and exchanging stories about care transitions.

They recently held a three-hour summit in a conference room in the hospital, where PCPs were treated to dinner and discussion about transitions of care. Annually, PCPs are sent a satisfaction survey, which, like the office visits, asks if they are getting the information they need, in the format they need, and the right amount of it in order to take care of their patients post-discharge.

“We’ve taken that feedback and implemented changes at our end to better meet the needs of the patients and PCPs,” Dr. Mitri says. “It’s a lost opportunity if you’re not visiting PCPs in their offices. You lose touch.”

Changes implemented by the hospitalist group include making the admitting hospitalist for the day responsible for forwarding to PCPs any test results for discharged patients that require immediate attention, as well as revising the group’s discharge report to include a cover sheet summarizing the most pertinent information, discharge medications, and an assessment of the patient’s risk of readmission using Project BOOST’s “8Ps” risk assessment tool.

The goal is to dictate the discharge summary within 24 hours and fax it to the PCP the next business day, Wright says. The group’s rounding nurses also schedule the patient’s first medical office visit before the discharge, even if that means finding a PCP for the patient or making an appointment with a local community clinic. Patients identified as at-risk, including those with congestive heart failure (CHF) or COPD, also get a post-discharge follow-up call.

Other hospitalist groups are employing similar techniques to close the loop with PCPs for discharged patients. Bronson Internal Medicine Hospitalist Specialist Group in Kalamazoo, Mich., just hired three phone nurses to help with care transitions, using Dr. Eric Coleman’s Care Transitions model, says practice manager Joshua Hill. The nurses also call the PCPs. Paying particular attention to new heart-failure cases, they will accompany patients to follow-up appointments with PCPs and specialists and will make home visits if needed.

“For every readmission within 60 days, we also call the PCP,” Hill says.

Listen to Dr. O. George Mitri and Katie Wright discuss improving communication with PCPs

At Aultman, the hospitalists and support staff, including nurse practitioners, rounding nurses and office staff, are employed by the health system, whereas the PCPs they work with mostly belong to small, independent groups. The changes described above mostly apply to patients managed in the hospital by the hospitalists. But if the metrics—such as a decline in readmissions to 11 percent from 13 percent since they started making follow-up appointments for patients—continue to show improvements, Dr. Mitri says they might become hospital standards.

“We’ve taken that feedback and implemented changes at our end to better meet the needs of the patients and PCPs. It’s a lost opportunity if you’re not visiting PCPs in their offices. You lose touch.”

—O. George Mitri, MD, FACP, FHM

Next on the quality hit list at Aultman is a greater focus on medication safety. “How do we get what happens in the hospital to the PCP and to the patient at home? Is it a nurse visit to address what really goes on in the home, including the shoebox full of medications in the closet?” he asks.

Wright adds that the hospitalist group has started meeting with partner specialist groups in the hospital, including cardiology, neurology, and general surgery, and is working on relationships with nursing homes. That might mean another set of regular sit-down meetings to talk about how to make transitions to post-acute care work better. TH

Larry Beresford is a freelance writer in Oakland, Calif.

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