By Deborah J. DeWaay, MD, FACP
Medical University of South Carolina,
Dr. DeWaay reports no financial relationships relevant to this field of study
SOURCE: Jones C, Vu M, O’Donnell C, Anderson M, Patel S, Wald H, Coleman E, DeWalt D. A Failure to communicate: A Qualitative Exploration of Care Coordination Between Hospitalists and Primary Care Providers Around Patient Hospitalizations. Journal of General Internal Medicine. 2014; 30(4): 417-24.
Many problems occur after a patient is discharged that are a direct result of poor coordination of care between hospitalists and primary care providers (PCPs). These issues include, but are not limited to, missed test results, medication errors, inadequate follow up, and harm to the patient. PCPs are frequently unaware that their patient was hospitalized and they often do not receive a copy of the discharge summary. The authors of this paper did a qualitative study to analyze the barriers and solutions to care coordination between hospitalists and PCPs in North Carolina.
This exploratory qualitative study involved both hospitalists and PCPs from North Carolina practices, and consisted of eight focus groups between February and May 2013. Three were comprised entirely of PCPs. Four were comprised of hospitalists and one was a hybrid of both PCPs and hospitalists. Each group met and talked for 45 minutes. The discussion was taped and transcribed in its entirety.
The authors purposefully sampled practices from diverse settings. A common theme among the recruits was their active involvement in quality improvement projects regarding care transitions. Only one eligible practice declined to participate because of scheduling issues.
The interview questions were based on the Agency for Healthcare Research and Quality (AHRQ) Care Coordination Measurement Framework and includes the following themes: care coordination, information exchange, follow-up, medication management, and accountability. The research team developed and used a framework-based code book to code the comments made in the focus groups. A main coder coded all of the transcripts, and a group of additional team members coded portions of the transcripts. The team members and main coder would meet to reconcile any discrepancies. In addition, the members of the focus groups were able to check the key discussion themes from their group.
The eight focus groups included 58 total participants: 34 hospitalists, 22 outpatient PCPs, and two physicians who practiced equally in both settings. Academic and private practices were represented, as were rural and urban areas. All of the participants used an electronic medical record (EMR). The hospitalists were more often male, whereas the PCPs were more often female.
Both hospitalists and PCPs described having a lack of time to communicate with each other. They said that it was often difficult to get the correct phone number in order to speak with the right physician. Discharge summaries were also a stress point. The hospitalists’ systems struggled to share the discharge summaries with the PCPs and to coordinate a follow-up appointment after hours or on the weekends, thus leaving patients responsible to schedule an appointment. Discharge summaries were also often incomplete, not adequately describing the expectations for the follow-up visit, leaving both PCPs and patients in a bad situation.
Both groups had concerns about missing tests with results pending. The PCPs felt that hospitalists should be accountable for hospitalist-ordered tests unless expressly described in the discharge summary or via a phone call. The hospitalists expressed that PCPs should be responsible for follow-up tests that are required after hospitalization. For example, a PCP should order the CT needed 6 months after finding a lung nodule. In addition, there was unclear accountability dispute regarding home health services. Both groups agreed that the hospitalists should oversee the initial order set, but there was a difference of opinion regarding follow-up orders.
The hospitalists and PCPs agreed that a greater effort is needed from both sides with high-risk patients. There was a shared sentiment regarding the benefits of a personal relationship between the two physicians and sharing an EMR. The hospitalists wanted a centralized scheduling system for PCP follow-up appointments or to have a hospitalist-run follow-up clinic, while the PCPs wanted follow-up appointments to be scheduled before discharge.
This study found that both types of physicians had similar concerns regarding the important transition from inpatient to outpatient care. Often, the discrepancies in opinions had to do with issues that clinicians in the opposite setting didn’t realize were a problem. Both groups envision improving personal relationships between physicians and using the EMR would be helpful. Further studies need to be performed to see if more formal accountability with pending tests, future tests, and home health would be helpful.
The discharge process is more complex than ever. This paper outlines some good starting places for hospitals and physicians to begin their quality improvement processes regarding inpatient to outpatient transitions of care.
This study’s biggest limitation was its generalizability. All participants were from North Carolina and the authors chose groups that were very active in quality improvement within their systems. Thus, these findings may not represent experiences elsewhere. Discharge planning and transitions of care will continue to be a major issue that hospitals and physicians must address as payments change to be based on quality measures. The discharge process is very complex and trying to improve the transition proves daunting. Creating better phone directories and increased access to paging systems would be a great place to increase PCP/hospitalist communications. Increased automation with respect to EMRs will be helpful, especially regarding the sending of discharge summaries and laboratory and imaging studies. More automation and earlier arrangement of PCP appointments might also be helpful.