Navigating the handoff from hospital to community care
By Edward Doyle
SAN DIEGO—How can hospitalists and internists work together to avoid problems during the sometimes thorny period when patients go from hospital to community care?
During a presentation in late March at the annual meeting of the Society for Hospital Medicine (formerly the National Association of Inpatient Physicians), Winthrop F. Whitcomb, ACP Member, put most of the onus on hospitalists to improve that transition. At the same time, however, he said that primary care physicians must step up and take some responsibility for making the process work.
Dr. Whitcomb, one of the founders of the hospitalist movement, used the term "black hole" to describe the period after patients are discharged from the hospital but have not yet seen their primary care physician. He said that he is confident about the care hospitalists give their patients in the hospital, but he has "a lot of concerns about quality during the black hole period."
According to data published in a 1999 Annals of Internal Medicine article, other hospitalists agree with that assessment. When asked about the transition between hospital care and care from a community-based physician, 79% of surveyed hospitalists said there are "occasionally" problems, 8% said there are "regularly" problems, and 1% said there are "always" problems. (Twelve percent said there are never problems.)
Building the team
What can hospitalists do to help prevent handoff problems? A big part of the solution, Dr. Whitcomb said, is strengthening the ties between the hospital team and primary care physicians before handoffs ever occur.
While patients are still in the hospital, for example, he urged hospitalists to keep community-based physicians in the loop about their patients' care. His rule of thumb? Inform primary care physicians at any point you think that they would feel blindsided if a family member told them about the patient's situation.
"Primary care physicians don't want to have a patient come into the office and tell them that they just spent a week in the hospital recuperating from pneumonia and provide a list of the medications they are taking," he said.
Dr. Whitcomb suggested getting in touch with the primary care physician early on in the patient's hospitalization. Primary care physicians should receive updates not only at a patient's admission, he said, but whenever the patient's status changes significantly.
To address the question of exactly when primary care physicians want to hear from hospitalists caring for their patients, Dr. Whitcomb cited data from an article in a supplement published with the American Journal of Medicine in 2001.
Of the 1,000-plus primary care physicians surveyed, most said it was "very important" to talk to hospitalists upon admission (73%) and discharge (78%). More than half of the physicians said they wanted to be notified when the patient's status changed (54%) and before a major intervention (50%).
Once the handoff occurs, what information do primary care physicians want? Not surprisingly, most physicians in the American Journal of Medicine survey said they wanted information on discharge medications (94%), discharge diagnoses (93%), results of procedures (80%) and lab test results (73%).
Physicians aren't the only ones who can benefit from a phone call after discharge. Dr. Whitcomb urged hospitalists in the audience to consider calling patients themselves after discharge. "This is a great idea," he said. "Patients love it, and it's good for maintaining rapport."
Dr. Whitcomb cited another study from the supplement to the American Journal of Medicine to back up that statement. Researchers found that when hospitalists called patients after discharge, patient satisfaction scores went up and medication problems were better resolved. Patients also made fewer return visits to the emergency room.
Hospitalists who cringe at the time they'll have to spend trying to reach either a primary care physician or patient by phone need to rely on team members to help make this happen. Dr. Whitcomb said that a good clinical coordinator can spend the 10 or 15 minutes it typically takes to track down a primary care physician, then pass the phone to the hospitalist.
Primary care's role
While the hospitalist's team members are a critical part of the handoff, Dr. Whitcomb said that primary care physicians also have an important role to play.
"Primary care physicians' role is equal to hospitalists'," he explained. "They need to be accountable."
For example, Dr. Whitcomb said that primary care physicians need to take responsibility to explain to their patients how hospitalists function—and how they fit into patient care.
He also called on primary care physicians to work closely with hospitalists. He said that as soon as outpatient physicians receive a report from a hospitalist notifying them that one of their patients has been admitted to the hospital, for example, they should quickly fax pertinent office records to the hospitalist.
Finally, he called on primary care physicians to maintain a presence in their patients' hospital care—even when hospitalists provide the day-to-day care.
"Patients need to feel that their primary care physicians are involved during hospital stays—even if the physicians just visit occasionally," Dr. Whitcomb explained. "It just doesn't feel right for patients when their primary care physician disappears."
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