A primary care physician's ideal transitions of care—where's the evidence?

Abstract

Reducing hospital readmissions is a national healthcare priority. Most of the interventions to reduce hospital readmission have been concentrated in the inpatient setting. However, there is increasing attention placed on the role of primary care physicians (PCPs) in improving the transition from hospital to home. In this article, a primary care physician's perspective of how inpatient and outpatient providers can partner to create the ideal care transition is described. Seven steps that occur during the hospitalization are highlighted: communicate with the PCP on admission, involve the PCP early regarding discharge planning, notify the PCP on hospital discharge, complete the discharge summary at time of discharge, schedule follow‐up appointments by discharge, ensure prescriptions are available at the patient's pharmacy, and educate the patient about self‐management. Another 7 are described as the role of the PCP and clinic staff: call the patient within 72 hours of discharge, ensure follow‐up appointments with the PCP, coordinate care, repeat above until medically stable, create access for patients with new symptoms, track readmission rates, and track and review frequently admitted patients. Insights are offered on how the changing financial landscape can help support elements of this idealized transition‐of‐care program. Journal of Hospital Medicine 2013;8:472–477. © 2013 Society of Hospital Medicine

Information Transfer and the Hospital Discharge Summary: National Primary Care Provider Perspectives of Challenges and Opportunities

“…9,10 Some study of the interface between hospitalist and PCP has already taken place, confirming the importance of the HDS in this care transition. [11][12][13] To further quantify specific deficits in HDS content and delivery we designed a survey of primary care physicians in the United States. Our aim was to further explore their perceptions of the ideal HDS and deficits in the current state.…”

Care team identification in the electronic health record: A critical first step for patient‐centered communication

“…This is particularly problematic for non–unit‐based providers who try to communicate with unit‐based care team members. These providers, in particular, have valuable knowledge and insight that can aid the primary team in decision making . However, they typically do not participate in rounds, often waste time identifying responsible providers, and may communicate their recommendations directly with the patient without discussing with the primary team.…”

Evaluation of a Primary Care-Based Post-Discharge Phone Call Program: Keeping the Primary Care Practice at the Center of Post-hospitalization Care Transition

“…In fact, there is growing support for increased participation and ownership from the primary care practice to coordinate and manage care immediately after hospital discharge. 10,11 In January 2013, the Centers for Medicare and Medicaid Services (CMS) introduced two new Current Procedural Terminology (CPT) codes, 99495 and 99496, for primary care providers (PCPs) who complete two steps: (1) document discussion with a patient or caregiver about care transitions within 2 days of discharge and (2) have a face-to-face visit with the patient within 2 weeks or 1 week, respectively. 10 By adding these reimbursable codes, CMS is acknowledging the benefits of timely phone and in-person primary care contact after hospital discharge.…”