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Frustrations With Hospitalist Care: Need to Improve Transitions and Communication

The Editors
[+] Article and Author Information

Potential Conflicts of Interest: None disclosed.

Requests for Single Reprints:Annals of Internal Medicine, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.


Ann Intern Med. 2010;152(7):469. doi:10.7326/0003-4819-152-7-201004060-00013
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This issue includes several letters that comment on “Three Degrees of Separation” (1), Howard Beckman's sobering essay about hospitalist care. Dr. Beckman's personal recounting of adverse changes in hospital-based care over the past 2 decades raised several concerns about the burgeoning hospitalist movement in the United States. With great nostalgia, he described his early days as a generalist who managed both outpatient and inpatient care. The flow of information across these settings was relatively seamless, in part because the same physician cared for the patient. But Beckman encountered multiple logistical challenges that, over time, impeded his ability to meet the needs of his hospitalized patients: traveling from practice to hospital, competing responsibilities, less interaction with other physicians caring for mutual patients, and keeping up with the fast-changing protocols and technology of inpatient medicine. Recognizing these limitations, he reluctantly relinquished his inpatients to the care of hospitalists. Subsequent experiences troubled him deeply, as he sometimes observed poor communication between physicians and patients; loss of continuity due to transitions from one clinician to another; depersonalized care that was no longer patient-centered; and erosion of long-term, trusting relationships.

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Hospitalists and Transitions of Care
Posted on April 28, 2010
Randall Krakauer
Aetna
Conflict of Interest: None Declared

To the Editor: In an editorial in the April 6, 2010 issue, Frustration with Hospitalist Care: Need to improve Transitions and Communication (1), the editors comment on Beckman's previously published essay (2) and letters published in the same issue, and discuss the difficulty in determining or even defining not only the potential value of Hospitalist Care, but the possibility of damage it might engender through further fragmentation of health care. Inadequate and ineffective care coordination or care management is extant throughout the US health care system, and transition of care from inpatient to outpatient (or skilled nursing facility) is only one facet of the problem. There may have been a time in which most people were cared for by a single family physician, who served as caregiver and care manager. My father (RSK) was such a physician. His patients rarely obtained care elsewhere except in emergencies, or on his recommendation. This is not always, or even not frequently the case today. Proposed "solutions" have included case management, disease management, electronic health records, and, more recently, Accountable Care Organizations (3) or patient-centered medical homes (3). As the shortage or primary care worsens (4), the problem and the need for ways to address it may become more urgent. Hospitalist Care may, in some instances, have the potential to improve the quality and possibly the cost of inpatient care. Success would require not only an improved inpatient experience and outcomes, but successful transition to the next care setting, including effective communication with the patients, the next care providers, care managers and care givers. There is considerable evidence such communication is frequently lacking (5), but it is not clear whether the problem is better or worse depending on who the inpatient physician might be. It is also not clear that maintaining the same physician through the transition will resolve the most serious care coordination problems responsible for avoidable admissions and readmissions. Ineffective transitions occur for a variety of reasons including limited patient and family caregiver education, inadequate post-discharge follow-up and monitoring, and narrow perceived accountability among the health care team for the experience of patients once they are discharged (6). These breakdowns in care can occur when the physician remains the same across all settings. Evidence-based approaches to care such as the Transitional Care Model (TCM) have been shown to improve the quality of discharge planning and home follow-up enhance patient satisfaction with care, and reduce readmissions and other avoidable adverse events (7). We are implementing such programs (8), and have and will do so for patients under care of Hospitalists, their own physicians, and others. Though we do not have comparative statistics to compare these, our experience strongly suggests that the TCM can improve results in both situations. The important issue of effective transitional care transcends the hospitalist vs. PCP as admitting physician question.

References

1. The Editors. Frustration with Hospitalist Care: Need to improve Transitions and Communication. Ann Intern Med April 6, 2010 152:469.

2. Beckman H. Three degrees of separation. Ann Intern Med. 2009;151:890- 1. [PMID: 20008765]

3. MedPAC. Report to the Congress: Improving Incentives in the Medicare Program. June 2009. Available at: http://www.medpac.gov/chapters/Jun09_Ch02.pdf

4. National Committee for Quality Assurance (NCQA). Physician practice connections' patient-centered medical home. 2009. Available at: http://www.ncqa.org/tabid/631/Default.aspx.

5. Bodenheimer T. The future of primary care: transforming practice. N Engl J Med. 2008;359(20):2086, 2089.

6. National Priorities Partnership. National Priorities and Goals: Aligning Our Efforts to Transform America's Healthcare. Washington, DC: National Quality Forum; 2008.

7. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital- based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297:831-41.

8. Greenwald JL, Denham CR, Jack BW. The hospital discharge: a review of a high risk care transition with highlights of a reengineered discharge process. J Patient Saf. 2007;3:97-106.

Conflict of Interest:

RSK and LR are Aetna employees

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