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Continuity of Care: Meeting the Challenge

When hospitalists hand off information and recommendations regarding recently diagnosed patients to offi cebased primary care physicians (PCP), the process is usually neither as smooth nor as comprehensive as it should be.

When hospitalists hand off information and recommendations regarding recently diagnosed patients to office-based primary care physicians (PCP), the process is usually neither as smooth nor as comprehensive as it should be. Unfortunately, hospitalists and PCPs often end up playing hot potato, with each seeking to avoid getting stuck with tests and referrals left undone. But they work in a healthcare system in which incentives are not aligned for inpatient and outpatient physicians to facilitate continuity of care, making it diffi cult for patients to get the care they need.

The continuity of care problem stems from physicians and hospitals pursuing shrinking pools of dollars. Hospitals, squeezed by declining reimbursement and a fl ood of uninsured patients, look to save money by cutting length of stay and curtailing expensive testing. Office-based PCPs, struggling with soaring offi ce overhead, malpractice premiums, and shrinking reimbursement, are busy keeping their practices afl oat. With hospitalists on the scene, PCPs don’t get reimbursed for visiting their hospitalized patients, so they have less incentive to visit and have a smaller stake in the care provided there. Operating in increasingly separate spheres, hospitalists and PCPs have little common ground. An exception to this can be found in the minority of hospitalists and PCPs who work for the same medical group. The Society of Hospital Medicine’s 2005-2006 survey of hospitalist group structures found that 14% of hospitalists belong to multi-specialty/primary care medical groups, 12% to local hospitalist-only groups, and 2% to emergency/critical care physician groups. The latter two group types tend to be formed and sometimes staff ed by local doctors hankering to return to the intensity of inpatient medicine.

Aligned Incentives

When hospitalists belong to a multi-specialty group, there are more incentives for inpatient and outpatient doctors to coordinate care. As Purnima Joshi, MD, Chief of Medicine and a hospitalist in Kaiser-Permanente’s Mid-Atlantic Region, succinctly puts it, “I don’t do billing. I just do what I love, which is to treat patients.” Kaiser physicians are salaried and use a sophisticated electronic medical record (EMR) system in inpatient and outpatient settings, improving communication and care quality. Medical groups that practice in growing geographical areas also have incentives to deploy their own member physicians as hospitalists. Foundation Medical Partners, a 130+ physician group in Nashua, NH, started a hospitalist group, as its physicians, scattered in 22 suburbs, were hard-pressed to drive to South New Hampshire Medical Center to make rounds and cover calls.

The well-established Brockie Medical Center in fast-growing York, PA started a hospitalist program to make its practice pattern offi cial, says Jonathan Whitney, a Brockie hospitalist. Several physicians who were already spending 60-70% of their time in the hospital became hospitalists, collaborating easily with their office-based peers. Catonsville, MD-based Erickson Retirement Communities has taken hospitalist/PCP integration to another level; its 57 full-time physicians practice solely at Erickson’s 18 campuses and are employed by the Erickson Health Medical Group. Physicians work both in the hospital and in their campus-based offices. Each physician is a ‘hospitalist’ for one week per month, rounding daily, covering weekend calls, and rotating calls with colleagues during the week. Another 41 providers—nurse practitioners, physician assistants, and mental health workers—augment the group. Commenting on Erickson’s novel approach to continuity of care, Dr. Matthew Narrett, Erickson Retirement Communities’ executive vice-president and chief medical officer, says, “We need to care for our patients when they are sickest, in the hospital.

There is clear and tangible relief from patients and families when they see their own doctors at the hospital.” Although the majority of hospitals that Erickson works with have their own hospitalists, they readily back off when Dr. Narrett explains his group’s practice model and the physicians’ willingness to care for their hospitalized patients. A Web-based EMR is a key component that enables Erickson’s physicians to collaborate from their offi ces and in the hospital. Although it took time to get all physicians up-to-speed, they now use the system in both inpatient and outpatient settings. Dr. Narrett says that the EMR is essential to continuity of care because it allows Erickson physicians to share data seamlessly across settings. Perhaps the major systemic obstacle to continuity of care is the lack of EMR interoperability. Without national standards for EMRs, organizations often fi nd their systems are incompatible with those used by other providers. For hospitals and outpatient physician groups, no interoperability means badly inhibited communication.

To address the interoperability issue and to share data completely between the Charlestown, MD campus and the hospital used most frequently by Erickson’s Charlestown residents (St. Agnes), the two organizations set up a health information exchange. Dr. Narrett says that an investment of about $100,000 in consulting and technology enabled the two locations to make their EMRs compatible. “This allows the ER physician to instantly access the patients’ medications, lab results, allergies, and history.”

Erickson has established a similar exchange with a large cardiology group used by its patients. “It used to take us 10 days to get a cardiologist’s hospital notes or discharge summary,” explains Dr. Narrett. “Now it’s in our EMR within 24 hours, and we’re ready for the first posthospitalization patient visit.” Despite this progress, not every Erickson

The Track Record

Despite the growing number of hospitalists and hospital medicine programs, the thorny continuity of care issue is far from resolved. For the most part, peer-reviewed literature has outpatient physicians giving hospitalists low marks for continuity of care. Defi cits in information transfer between hospitalists and outpatient physicians are common and potentially dangerous. In short, physicians are not satisfi ed with the timeliness and quality of hospitalist discharge summaries. In a survey of 226 outpatient physicians, researchers at the Northwestern University Medical School-Division of General Internal Medicine found that only 19% said discharge summaries were timely; only 32% were satisfi ed or very satisfi ed with the quality of such summaries. Overall, 41% believed that at least one of their hospitalized patients experienced a preventable adverse event related to poor information transfer at discharge.

A retrospective cohort study of 693 hospital discharges from NYC’s Mount Sinai Hospital indicated that 35.9% of follow-up recommendations weren’t completed. That included diagnostic procedures (47.9%), referrals to subspecialists (35.4%), and laboratory tests (16.7%). The study also showed that increasing time to the initial post-discharge primary care physician visit decreased the likelihood that a recommended workup was completed. A 2007 JAMA review of 55 studies of continuity of care by researchers at Emory University School of Medicine, Division of General Medicine, showed an overall lack of such continuity. Direct communication between hospitalists and PCPs occurred infrequently (3%-20%); the availability of a discharge summary at the fi rst post-discharge visit was low (12%-34%), affecting the quality of care in 25% of follow-up visits and contributing to PCP dissatisfaction with hospitalist communication. Discharge summaries often lacked important information, such as diagnostic test results (missing from 33%-63% of summaries), and hospital course (7%-22%).

The Society of Hospital Medicine and Continuity of Care

  • Set up a good communication system from the beginning
  • Use technology - fax, voicemail, e-mail, EMRs
  • On admission, notify PCP that responsibility for care has been taken over
  • During hospitalizations, notify the PCP only of transfer to the ICU or surgery, and resuscitation with survival
  • At discharge, fax/e-mail a dictated summary of the hospitalization to the PCP before the patient’s first follow-up visit

Source: physician is connected; the missing link is between the cardiologist and ER. “If the cardiologist raised the medication dosage, the ER doesn’t know it immediately,” he adds.

Improving Continuity of Care

In any organization or process, technology is only a means to an end. Communicating information about patients smoothly between hospitalists and offi ce-based physicians remains an unmet goal because of technical and corporate culture obstacles. Until all EMRs conform to a universal standard, probably set by the government, hospitalists will continue to send discharge summaries by fax, voicemail, and e-mail—hardly 21st-century technology. Beyond that, it’s imperative for hospitalists to see that, far from being a waste of time, continuity of care puts dollars in their pockets. A major result of Erickson’s commitment to continuity of care between hospital and offi ce is that their health outcomes beat the norms. Hospital length of stay (LOS) is 3.8 days versus the Medicare average of 5.9 days. Dr. Narrett says Erickson’s average LOS for chronic heart failure is 4.1 days vs. Medicare’s 5.24 days; the diagnosis-related group payment is $5,473, with hospitals losing about $1,000 because the average daily cost is $1,236. Dr. Narrett puts it in a nutshell: “If we decrease LOS by one day, we help the hospital make money. Through our model, the patient, provider, hospital, and payer win.”

Marlene Piturro is a freelance medical writer.