February Spotlight: Hospital Medicine: Transitions in Care, Part II


Submitted by Reem Habboushe, MD


As hospital medicine becomes central to our national health care fabric, the necessity to connect hospitalist with outpatient physician/PCP and other post-acute settings becomes increasingly important. Our evolving context includes changes at the national level and the system level. As our roles in medicine continue to evolve, the need to increase communication between different providers at all levels and in all settings grows, and our responsibility to address these issues becomes increasingly vital to patient-centered care.


“Transitions in care” presents a situation which is highly amenable to collaborative teams and to our imperative, as members of the health care sector, to work together effectively. As hospitalists, our day-to-day operations include involvement of physicians, nurses, care managers, social workers, patient care facilitators and others to create a comprehensive and inclusive network of patient-centered care. As such, our context is ideal as a model for elaboration beyond our hospitals and to other settings. Undoubtedly, strong communication skills are the hallmark of strong transitions in any context, and hospital medicine–an intrinsically collaborative model of medicine– provides a fertile setting for growth in these areas. By extension, a sturdy discharge framework can greatly enhance our ability to prevent unnecessary readmissions.


Clearly, communication at all levels plays an integral role in the success of care transitions as the above imperatives require involvement of multidisciplinary teams. Some approaches include strong discharge summaries and face-to-face meetings with PCPs and SNF/rehab directors. MLH hospitalists continue to work on strong, adequately detailed, and timely discharge summaries. At Paoli Hospital, hospitalists meet regularly with our area PCP partners. Hospitalists and PCPs are invited to attend and participate in each other’s meetings in order to discuss evolving issues and come to satisfactory modes of communication. Directors of some of our area SNFs have met directly with our hospitalists in conjunction with our SW and CM teams in order to increase connectivity at that interface. Face-to-face communication helps to mend the basic rift in our current systems by allowing for a more robust, personal connection.


Looking forward, future goals may include a questionnaire for PCPs, further expansion of our collaborative meetings, and utilization of nationally-available tools such as the JHACO Targeted Solutions Tool and SHM Post-Acute transitions toolkit. Work on risk adjustments for readmissions may help separate issues under our control from those over which we have no purview. The development and growth of post-discharge clinics staffed with knowledgeable providers will likely contribute to improvement. In addition, further involvement of patients and family members may make a large contribution to reaching our goals. Our patient-centered model of care allows for patient/family empowerment, and increasing this involvement will help to not only improve transitions but also decrease readmissions as these various interfaces are further refined.

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