Hospital Medicine

Communication with the primary care provider

I. Problem/Challenge.

Communication between Hospitalists and primary care providers (PCPs) is believed to be an essential component of high-quality, safe medical care. The rise in the number of Hospitalists nationwide and the continued increase in the number of patients for whom we care makes the issue of communication as important as ever. Inpatient-outpatient communication has received an increased amount of attention after being referred to as "the main Achilles heel of Hospitalist systems" in 2011.

In spite of increased awareness, ineffective communication between inpatient and outpatient medical providers (also referred to as inpatient-outpatient "physician discontinuity") remains alarmingly common. While estimates vary, a recent study identified successful direct communication in only approximately one-third of inpatient hospitalizations.

More is known about communication at the time of discharge as compared to admission. Elderly patients, those with multiple comorbidities and patients being discharged to acute and long-term care facilities are likely at greatest risk for adverse events at the time of hospital discharge.

Physician discontinuity has been linked with lower quality of care on follow-up. PCPs have been shown to be unaware of approximately 60% of pending test results returning after discharge, of which nearly 40% are considered actionable.

Patient perception regarding communication between inpatient and outpatient medical providers also appears to improve patient satisfaction, and patients are often mistaken about whether communication has occurred. Patients in a recent study were significantly more satisfied with care (70% vs 53%) when they perceived such communication had taken place. In addition, amongst patients for whom communication did not occur, approximately half of patients were under the impression that it had.

It has also been suggested that only about half of PCPs are satisfied with the communication they receive from Hospitalists. A qualitative study regarding communication between Hospitalists and primary care providers with respect to inpatient hospitalization found similar challenges including lack of time, difficulty reaching other clinicians, lack of personal relationships with other clinicians, lack of information feedback loops, medication list discrepancies, and lack of clarity regarding accountability for pending tests and home health. However, there were important experiential differences related to sending and receiving roles for discharges. Hospitalists note difficulties obtaining timely follow-up appointments for after-hours or weekend discharges. PCPs often did not know their patients were hospitalized, reported not having hospital records for follow-up appointments, had difficulty in locating important information in discharge summaries, and felt undervalued when Hospitalists made medication changes without them. Clearly, efforts on both the parts of the Hospitalist and PCP are indicated to address these gaps.

A shared electronic medical record has improved access to information in a diverse array of care venues, though the majority primary care physicians studied continue find this insufficient as a sole means of communication at the time of hospital discharge.

Understanding that specific circumstances have been associated with a lack of communication (house staff involvement in patient care, low expected 30-day readmission rate, and insurance with Medicaid as compared with Medicare) is also essential to identify patients with these predictors and take steps to diminish their effect.

While the means by which Hospitalists and PCPs are able to communicate are many and varied, the hospital discharge summary remains a standard instrument of correspondence. The literature is rife with information documenting that discharge summaries are often not completed, not delivered to the PCP in a timely manner, do not contain necessary information, or do not provide information in an appropriate user-friendly format. At the time of hospital discharge follow-up, discharge summaries are not present an estimated 25-75% of the time. This issue is of particular concern in patients being discharged to sub-acute care facilities, as one study approximates 32% had laboratories pending at discharge but few were documented in hospital discharge summaries.

Ongoing efforts to explore further means by which increased Hospitalist-PCP communication may mitigate the potential harms of such discontinuity remain necessary.

II. Identify the Goal Behavior

All communication between Hospitalists and PCPs must be compliant with the Health Insurance Portability and Accountability Act (HIPAA). The ultimate goal for Hospitalist-PCP communication is to tailor the content and frequency of contact to the specific needs of the patient and the involved medical providers.

Literature regarding PCP communication preferences suggests that telephone contact is the favored means of communication. A study of family practitioners in California revealed a preference for telephone communication (77% overall), with the PCPs desiring communication at admission (73%) and discharge (78%). A recent study of a shared electronic medical record found that a majority primary care physicians (61%) did not feel discharge notification plus discharge summary was adequate for a safe transition of care, and believed additional communication via telephone or email was necessary.

An initial strategy by which effective communication may occur is Hospitalist-initiated telephone contact at the time of inpatient admission, at which time PCP preferences for further communication should also be addressed. While some investigators have suggested benefits of a two-way communication model in which PCPs and Hospitalists share responsibility for initial contact, and many have anecdotal experience in being contacted first by PCPs, this is not standard practice in most cases.

It is estimated that half of PCPs prefer to be informed of significant changes in health status or necessity of major intervention that occur during hospitalization. Notification of PCPs for the following in-hospital events should therefore also occur: death, intensive care unit (ICU) transfer, goals of care discussion or change, and necessity of major intervention or procedure.

At discharge, Hospitalist-initiated telephone contact should occur, during which discharge diagnosis, medications (those added, withdrawn or changed), procedure/diagnostic testing results, pending test results, follow-up arrangements, and suggested next steps may be discussed.

A discharge summary containing information regarding diagnoses, abnormal physical findings, important test results, discharge medications, follow-up arrangements made and appointments still needing to be made, counseling provided to the patient and family, and tests still pending at discharge is also to be completed.

The discharge summary is to be part of the electronic medical record (when available), is to follow a structured template with subheadings, should be completed within 24 hours of hospital discharge, and should be delivered to the PCP prior to the patient's scheduled outpatient follow-up visit.

III. Describe a Step-by-Step approach/method to this problem.

There should be no hesitation to contact the PCP of a patient at any time for the exchange of information necessary to maximize the quality, efficiency and safety of a patient's inpatient medical care. If the PCP of a patient for whom you are caring is one with whom you have an established working relationship with known preferences regarding communication, it is appropriate to respect them unless a new or unique situation arises. However, for those PCPs who are less well known, or unknown, our recommendations are as outlined.

Step one

All communication between physicians must adhere strictly to the requirements mandated by the HIPAA.

The initial recommendation is for Hospitalist-initiated telephone contact with the PCP at the time of inpatient admission. At this time, the patient's current medical issues in the context of the PCP's longitudinal knowledge of and previous experience with the patient can be discussed.

Disease-specific patient data including prior laboratory testing and diagnostic imaging results (for example, baseline creatinine in a patient with chronic kidney disease or recent echocardiography results in a patient with congestive heart failure) can be solicited verbally or by fax to the hospital floor.

This conversation is also an excellent opportunity for the Hospitalist to obtain patient-specific information including expressed preferences regarding goals of care, communication, personal and family dynamics, and other important factors that are often not present in a written medical record.

PCP preferences regarding specialty referral patterns for new issues requiring consultation, and previously involved specialists for known problems are also important.

Goals and expectations for further triggers for communication with the PCP, means of further communication (telephone, email, other) and the desired content should also be addressed.

Step two

We recommend notifying PCPs by telephone of the following events: death, ICU transfer, goals of care discussion or change, and necessity of major intervention or procedure.

PCPs who request daily communication regardless of change in health status of the patient should be afforded this courtesy as your schedule allows. When possible, involving the PCPs in the discharge planning process and working together to formulate an appropriate follow-up plan is also encouraged.

Step three

Discharge is an appropriate time for mandatory, direct, Hospitalist-initiated contact with the PCPs. During this conversation, it is recommended the following be discussed: discharge diagnosis, medications (those added, withdrawn or changed), procedure/diagnostic testing results, pending test results, follow-up arrangements, and suggested next steps.

Making your contact information available in the event further questions arise regarding the hospitalization is also advised.

Discharge summaries should be completed in a timely fashion as well, and many hospitals have promulgated the expectation that they be completed within 24 hours of hospital discharge. In addition, all efforts should be made to ensure that the summary arrives prior to the first scheduled outpatient follow-up appointment.

Discharge summaries should contain the following: diagnoses, abnormal physical findings, important test results, discharge medications, follow-up arrangements made and appointments still needing to be made, counseling provided to the patient and family, and tests still pending at discharge.

The discharge summary is to be part of the electronic medical record (when available) and is to follow a structured template with subheadings rather than unstructured narrative summaries.

IV. Common Pitfalls.

There are many acknowledged barriers to effective communication between Hospitalists and PCPs; However, there are specific pitfalls that should be avoided.

The first is the decision not to contact a PCP based upon the assumption that they have already been called by another provider (emergency room physician, admitting physician, physician-extender) or that the PCP (the specific preferences of whom you have not directly solicited) will be "bothered" by your call. Most Hospitalists will encounter a PCP who complains of call redundancy, often at the time of admission, though this represents a minority of cases and should not prevent future calls to other PCPs.

Another common mistake is foregoing or significantly truncating direct communication when the patient's specific PCP is not available and a covering physician or partner is available.

Calling the PCP prior to your evaluation of the patient is also not advised, save infrequent acute or emergency situations. Patient discharge to a venue other than home (short-term rehabilitation or extended care facility) should also not lessen the imperative of discharge communication.

V. National Standards, Core Indicators and Quality Measures.

While there are no defined national standards for the frequency, means and content of Hospitalist-PCP communication, there are standards regarding discharge summaries. The Joint Commission promotes the following elements of a quality discharge summary: reason for hospitalization, procedures performed, care/treatment/services provided, patient condition and disposition at discharge, information provided to patient and family, and provisions for follow-up care. However, many in our field deem this standard to be incomplete.

A Transitions of Care Consensus Policy Statement from the American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society of Academic Emergency Medicine was published in 2009. Therein, five principles for effective care transitions were developed; those with specific implications for Hospitalist-PCP communication were "the clear and direct communication of treatment plans and follow-up expectations", and "timely feedback and feed-forward of information".

Recommendations are made to notify a patient's PCP at all steps in care transitions and that patient-centered approaches are to be employed.

Of particular note are additional components of an "ideal" transition record, which are as follows: principal diagnosis and problem list; medication list (reconciliation) including over-the-counter medications/herbals, allergies, and drug interactions; emergency plan and contact number and person; treatment and diagnostic plan; prognosis and goals of care; test results/pending results; clear identification of the medical home and/or transferring coordinating physician/institution; patient's cognitive status; advance directives, power of attorney and consent; planned interventions, durable medical equipment, wound care, and so on; assessment of caregiver status. We suggest including these additional components of the discharge summary when able.

VI. What's the evidence?

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