Positive Outlook – Jan 2013-3

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Positive Outlook – Issue 1.0 – Jan 2013

Lost in Transition – Coordinating Care Between Inpatient and Primary Care Physicians
By: Renee H. Martin, JD, RN, MSN- Counsel to Positive Physicians Insurance Exchange

Hospital discharge is the most frequent type of care transition, occurring 39.5 million times each year. Research shows that 19% of discharged patients experience an adverse event, such as an emergency department (ED) visit or readmission, within three weeks of discharge.

A 2003 study published in the Annals of Internal Medicine found that more than half of all preventable adverse events occurring soon after hospital discharge have been associated with poor communication among care professionals. The declining presence of primary care providers in hospitals has not been adequately accompanied by systems to ensure that patient data are transferred to subsequent caregivers. Given that more than half of all preventable adverse events occurring soon after hospital discharge have been associated with poor communication among providers, the need for physicians to communicate effectively with each other cannot be over emphasized.

Over the last 10 to 15 years, hospitalists have become a familiar presence in the health care system. A recent article in the New England Journal of Medicine describes the growth of hospitalist care, estimating that in 2006, 19% of general internists were hospitalists. Also in 2006, 47% of all hospitals and 84% of teaching hospitals had at least three hospitalists. The number of practicing hospitalists is expected to grow from approximately 20,000 to 40,000 within 10 years. No matter what the balance of benefits versus adverse effects related to hospitalists, the economic and practical forces that promoted the growth in the care of patients by hospitalists are intensifying, not lessening, and hospitalists are here to stay.

While there are distinct advantages to adopting the hospitalist model to a variety of specialties and care situations, there remains one complicating factor. Although hospitalists provide important benefits, their involvement disrupts the continuity of care provided by the patients’ primary care physicians, resulting in potential adverse effects for both patients and doctors. With the increasing burden of chronic illness and complexity of medical care, coordinating care across settings and providers has become equally important.

This article will address three areas of risk commonly associated with coordinating care between inpatient physicians and primary care physicians, and will discuss considerations for reducing these risks.

Areas of risk

Hospital discharge is the most frequent type of care transition, occurring 39.5 million times each year. Research shows that 19% of discharged patients experience an adverse event, such as an emergency department (ED) visit or readmission, within three weeks of discharge.

Although there is a finality associated with discharge, many patients’ illnesses actually have not fully resolved by the time they leave the hospital. During a period of convalescence that may last days, weeks, or even months, patients must manage new medications, adopt lifestyle changes, and perform appropriate outpatient follow-up. Increasingly, evidence shows that during that time after hospital discharge, the patient is more prone to medical errors, adverse events, and rehospitalizations.

A study published in the Annals of Internal Medicine found that of the 19% of patients who experienced adverse events within three weeks of discharge, 61% of these events could have been prevented or ameliorated. Adverse drug events were the most common postdischarge complication, followed by hospital-acquired infections, and procedure-related injuries.

Another study found that 41% of patents are discharged with laboratory and radiologic test results still pending, of which, 9.4% of these results were potentially “clinically actionable.” Additionally, 27.6% of patients were discharged with a plan to complete a diagnostic work-up as an outpatient. Of the recommended work-ups, 35.9% were not completed.

These disturbing but common patient safety threats can be attributed to several problems in discharge planning and postdischarge care. Discontinuity between inpatient and outpatient providers is common, and studies have shown that traditional communication systems (such as the dictated discharge summary) generally fail to reach outpatient providers in a timely fashion and often lack essential information.

Discharge communication

Good communication between inpatient and outpatient physicians is essential for patient safety. A 2003 study published in the Annals of Internal Medicine found that more than half of all preventable adverse events occurring soon after hospital discharge have been associated with poor communication among care professionals. The declining presence of primary care providers in hospitals has not been adequately accompanied by systems to ensure that patient data are transferred to subsequent caregivers.

The traditional dictated discharge summary is of limited value for patient safety purposes because it generally does not reach the outpatient physician before the patient follows up, and does not necessarily contain the information outpatient physicians need to ensure continuity of care.

Primary care physicians (PCPs) have related the following information as important for providing follow-up care:

• main diagnosis;
• pertinent physical findings;
• results of procedures and laboratory tests;
• discharge medications with reasons for changes to previous medications;
• details of follow-up arrangements;
• information given to the patient and family; and
• test results pending at discharge.

Pending test results and postdischarge follow up

Another area of concern in the hand-off between inpatient physicians and PCPs involves test results that return after discharge and completion of outpatient workups.

Studies have found that 54.1% of all the discharge summaries fail to document the recommended outpatient workup, though these workup recommendations were clearly documented in the patients’ hospital charts. There was an association between the availability of discharge summaries documenting recommended outpatient workups and higher completion rates of workups. Therefore, it is not sufficient for outpatient PCPs to simply receive patients’ discharge summaries; the discharge summaries must document pertinent details about patients’ discharge plans to ensure inpatient-to-outpatient continuity of care.

Medication errors

Multiple studies demonstrate that medications are often changed or new medications prescribed without a clear indication upon admission, at transitions during hospitalization, and at discharge. Patients frequently receive new medications or have medications changed during hospitalizations. Lack of medication reconciliation results in the potential for medication discrepancies and adverse drug events, particularly for patients with low health literacy, or those prescribed high-risk medications or complex medication regimens.

Medication reconciliation is the process “of avoiding such inadvertent inconsistencies across transitions in care by reviewing the patient’s complete medication regimen at the time of admission, transfer, and discharge and comparing it with the regimen being considered for the new setting of care.”

Medication reconciliation was named as a National Patient Safety Goal by the Joint Commission in 2005. Accredited organizations are now required to implement “a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient” and to communicate “a complete list of the patient’s medications…to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within our outside the organization.” The Joint Commission does not mandate specific ways for this process to occur.

Risk management considerations

Individual physicians have a critical role to play. The following risk management considerations may help inpatient physicians and PCPs minimize risk and enhance patient safety.

Considerations for hospital-based physicians in mitigating risk exposure

• Establish rapport. In general, inpatient physicians have a shorter period of time to establish rapport with the patient. It is also a good idea to tell the patient that their care will be turned over to their primary care physician when they leave the hospital.

• Implement steps to improve the discharge communication process.

• Clearly communicate when the patient is to follow up with more than just his or her primary care physician. Who will be following the patient for ongoing labs and anticoagulant therapy? Who is to manage the patient’s diabetes regimen? If it is not the primary care physician, make sure the patient knows who to see for management of these conditions.

• Reconcile patient medications at admission and discharge, in compliance with Joint Commission standards. Ensuring that primary care physicians receive a single, shared, updated, and reconciled medication list can enhance patient safety.

Considerations for primary care physicians

• Make sure your patients understand that you will not be treating them in the hospital, but that you will resume their care once they are discharged. If possible inform all your patients that an inpatient team will be responsible for their care in the hospital. Explain also that the team members are capable and current on hospital care, that they have all my records available to them, and that they communicate regularly with you.

• Be responsive to requests from hospitalists for information about your patients. Hospitalists cite admission as a time of serious risk for poor coordination, because of reportedly limited information on patients’ medical histories from outpatient providers, especially regarding current medications.

• Ask hospitalist to communicate with you. Tell the hospitalist that you are available to talk about any issues that may arise while your patient is in the hospital and that you welcome participation in your patient’s care. • Alerting inpatient physicians when a patient needs to be admitted can avoid the “scramble for information when the patient presents in the emergency department.”

• When you receive discharge summaries on your patients, review, initial and date the report. This will provide documentation that you received and reviewed the discharge summary. Establish a policy in your office that no report is filed in a patient’s record (electronic or paper) unless it has been reviewed.

• If a patient who has been recently hospitalized comes for a follow-up visit and you have not received any information on the hospitalization, contact the hospitalist or the hospital and request a copy of the discharge summary.

• Records medication changes with the patient and in the medical record. Also assess the patient’s understanding of the new medication regimen and confirm with the patient that the medications are being taken. Using open-ended statements such as, “Tell me which medications you are taking” will likely provide the best feedback regarding the patient’s understanding of their medication regime.

Conclusion

Given that more than half of all preventable adverse events occurring soon after hospital discharge have been associated with poor communication among providers, the need for physicians to communicate effectively with each other cannot be over emphasized. Communication between inpatient and primary care physicians should be considered a two-way information exchange.