Transition Talk
Charles A. Crecelius, MD, of Saint Louis, has experienced best- and worst-case scenarios when his frail elderly patients have been admitted and discharged by local hospitalists.
Best case, he says: “My patient is admitted. I get a call. I’m told what is going on. I’m notified of meaningful changes, and at discharge, I get another call [from the hospitalist].”
But there are wide variations in hospitalist/nursing home relationships, notes Dr. Crecelius, a long-term care physician and president-elect of the American Medical Director’s Association (AMDA).
This was brought home by the case of a patient with a well-documented history of dystonic reaction to toxic lithium levels. The patient was later misdiagnosed as having tardive dyskinesia, a movement disorder. Her much-needed medication was discontinued, and the hospital transferred the patient back to the nursing home in worse condition than before.
“We wasted an entire hospitalization,” Dr. Crecelius recalls ruefully.
The above scenario underscores the importance of a thorough transfer of information when elderly patients move from facility to facility. Interaction between hospitalists and nursing home staff will become increasingly important in light of the growing frail elderly population and the Joint Commission on Accreditation of Health Care Organization’s (JCAHO) push for improved discharge communications.1
By applying a customer service model and continually upgrading transfer documentation, hospital medicine groups can “keep the level of communication where it needs to be,” says Susan S. Cumming, MD, associate medical director of Marin Hospitalist Medical Group at Marin General Hospital in Greenbrae, Calif.
Running a Risk
Dan Osterweil, MD, CMD, is familiar with the hospitalist model through his medical training in Israel during the late 1970s and early 1980s. Hospitalists there routinely handled inpatient care.
Dr. Osterweil, a clinical professor of medicine/geriatric medicine at UCLA, research associate with the UCLA Borun Center for Gerontological Research, and former medical director of the Jewish Home for the Aging in Reseda, Calif., has the opportunity to observe hospitalists deal with nursing homes in his current capacity as a consultant for managed care corporations in Southern California.
“Hospitalists have an excellent understanding of acute care management,” he says. “They do a good on-site job of dealing with immediate problems of the individual, and they’re very efficient and very responsive. But while hospitalists are providing higher competency in the management of intra-hospital care, I think that those I’ve interfaced with fall short on the transitions of care, which is so critical with the nursing home patient.”
Dr. Osterweil recalls one patient who had in place do not resuscitate (DNR) and do not intubate (DNI) orders. But when he was hospitalized, the patient was intubated. “If [the hospitalist] had asked one question of the individual or the caregiver—‘What is the goal of care?’—they would have been able to plan a much smoother transition for that person back to the facility.”
At Lower Bucks Hospital in Bristol, Pa., where long-term care physician Daniel Haimowitz, MD, CMD serves as chairman of internal medicine and chairs the utilization committee, the surrounding community of physicians has responded in a mostly positive way to a new hospitalist program.
However, Dr. Haimowitz has concerns that transitioning admissions of nursing home patients to hospitalists can hinder continuity of care.
Different hospitalists work each shift, and unless the patient has been on the hospitalist service in the past, the admitting hospitalist may know nothing about the patient—and most probably has no relationship with the patient’s family (as the primary care physician would have).
