Is the doc available after the initial order?

AZ addresses issues with hospital-based referrals

The hospital discharge planner calls your admission department about a patient for whom the physician ordered home care. Sounds like it is just business as usual, doesn't it? Not if the physician who ordered the home care only saw the patient once, for a brief time, and is never available to sign the plan of care or answer questions about the patient.

This is the problem faced by Arizona home care agencies when the physician who ordered the home care service is a hospitalist as opposed to a primary care physician. A hospitalist is a physician whose practice is completely based in a hospital setting, such as the emergency department, explains Karen Jeselun, RN, administrator of Arizona Home Care in Phoenix.

The agency received a referral for a hip replacement patient who needed physical therapy and blood drawn to monitor anticoagulant medication, she reports. "The hospital-based physician wrote the order, but he was not available to approve the physical therapy plan of care, nor was he available to review the results of the lab work to monitor the medication's effectiveness and make changes if necessary," Jeselun says. "We had a patient who needed care, but no physician to oversee our care for her."

Because Jeselun's agency was not the only one facing this issue, a statewide task force was formed that included representatives from hospitals, home health agencies, and the state medical association. "We realized early in our discussions that there was no one, simple solution to the problem, so we've addressed it in several ways," she says.

Transient seniors

The most at-risk group of patients in Arizona was the large Medicare population, Jeselun reports. "Many of our senior citizens are a transient group of people who live part of the year in a state other than Arizona, and most of them do not have a primary care physician in Arizona," she explains.

When these people do need health care, they often enter the Arizona system through an emergency department and are treated by other hospital specialists if necessary, Jeselun adds.

In these cases, the hospital-based physician may discharge the patient with orders for home health care, but there is no community primary care physician who can follow the patient's care, approve changes in medication, or sign the initial plan of care developed by the home health nurse. Bruce Bethancourt, MD, a Phoenix physician on the task force, says, "We found that 30% of patients admitted to home health care without a primary care physician were readmitted to the hospital."

Primary care physicians always have been hesitant to take assume responsibility for a patient that they have not seen, know nothing about their medical history, and don't really know the reason for their hospitalization, Bethancourt says.

Not only is there a liability risk, but there is also the issue of being able to provide the best care for the patient, he says. "A physician needs all of the information on the patient to assume responsibility," he adds.

What wasn't fully understood by hospitals and hospital-based physicians was their liability in the discharge of a patient to home health, points out Bethancourt. "It was quite a shock to hospitals and their physicians to learn that if they discharged a patient on medication, they are responsible for that patient until the problem is resolved or the care of the patient is transferred to another physician," he says. Many hospitalists believed that once they discharged a patient to home health, the patient was no longer their responsibility, he explains.

The first step taken by the state medical association was to develop a database of primary care physicians who will take new patients when a home health agency receives a referral from a hospitalist, or when the hospitalist needs to refer a patient to a primary care physician, Bethancourt says. The association is setting up a web site to make it easy for agencies or physicians to find a primary care physician for the patient, he adds.

Jeselun's agency has developed a list of physicians who are part of a hospital-based physician group so that their admission staff will recognize the referral as coming from a hospitalist. "One of our problems had been that we did not realize the referral was from a hospitalist rather than a private physician until after we accepted the patient," she says.

By identifying the referral source early, admission personnel have an opportunity to research the patient's situation and find out if the patient does have a personal physician, Jeselun points out. "We'll actually contact the patient while he or she is still in the hospital in order to get information and put the patient in touch with a primary care physician if there is not one," she adds.

While home health agencies and hospitals in Arizona are just beginning to address this issue, Jeselun is encouraged. "There is no quick fix to this problem, but we are seeing an increased awareness among hospital-based physicians and primary care physicians that will make it easier to make sure that patients do have a primary care physician involved in their care," she says.

For more information about hospital-based physician referrals, contact:

  • Bruce Bethancourt, MD, 4400 N. 32nd St., Suite 140, Phoenix, AZ 85018. Telephone: (602) 254-4424.
  • Karen Jeselun, RN, Administrator, Arizona Home Care, 4615 S. 33rd Place, Phoenix, AZ 85040. Telephone: (602) 445-1751. E-mail: