Pri-Med Southwest: How to Improve Handoffs between Primary Care Physicians and Hospitalists

Miscommunication, medication errors, and lack of follow-up during handoffs can lead to rehospitalization and other poor outcomes.

At the 2011 Pri-Med Southwest Conference, Victor Narcisse, MD, an assistant professor in the Department of Medicine at Baylor College of Medicine, talked about safety issues and methods to improve patient care handoffs between primary care physicians and hospitalists.

During his presentation, “Optimal Interactions between Primary Care Physicians and Hospitalists to Enhance Patient Care,” Narcisse noted that hospitalists have played an emerging role in health care over the last two decades. In 2006, over 40% of hospitalized patients were seen by a doctor they didn’t know. This scenario can disrupt the continuity of care provided to these patients. Around 50% of patients readmitted within 30 days after discharge have not been seen by an outpatient physician since their previous hospitalization. Unplanned rehospitalizations accounted for 17% of the $102.6 billion that Medicare paid to hospitals in 2004.

Hospital discharge is a handoff prone to passive or active failures. There is very little information exchanged between primary care physicians and hospitalists upon discharge. Discharge processes that lead to rehospitalization include: lapses in communication, inadequate patient education, medication errors, lack of timely follow-up, and lapses in home services.

Elements of effective handoff communication

The Health Quality and Patient Safety Committee of the Society for Hospital Medicine developed a tool called the Ideal Discharge for the Elderly Patient: A Hospital Checklist. It itemizes handoff elements important to the transition of elderly patients.Many of these practices can be generalizable to other populations as well. Key elements include:

• Patient education -- Patients should be provided with general and medication-specific education. Patient instructions should be written at a 6th-grade reading level and should address anticipated problems and suggested interventions. Medication education should include a written schedule of medication, as well as the purpose of each medication and associated cautions. Teach-back methods should always be employed to confirm patient understanding. Patients should be given a call-back number to call for assistance 24 hours a day, 7 days a week.
• Provider notification -- Referring and receiving providers should be contacted to communicate immediate follow-up issues.
• Medication list -- Should include indications required for continuing care and designate discontinued medications, new medications, modified medications, and unchanged medications.
• Code status -- Should specify stipulations discussed with patient and include one of the following designations: full code (unrestricted full therapy), DNR (do not resuscitate), hospice-type care, or “comfort measures only.”
• Disease-specific checklist -- Should include a record of core measure compliance with evidence-based practice.

The handoff documentation should also include a discharge summary, which should be written with the receiving caregiver in mind and ideally include:

• Name and contact information of referring and receiving providers
• Diagnoses and presenting problems that precipitated hospitalization
• Key findings and test results, as well as pending labs or tests
• Brief hospital course
• Discharge medication reconciliation
• Cognition at discharge (use practical descriptions, such as “lucid, forgetful, dementia”)
• Anticipated problems and suggested interventions
• Discharge destination, follow-up plan, and suggested management plans
• Subspecialty consultant recommendations
• Documentation of patient education and confirmation of patient understanding

Can communication between hospitalists and PCPs make a difference?

Jack, et al evaluated the effect of a systematic approach to hospital discharge among patients on the general medicine service (N=749) of an academic medical center. The results, published in the February 2009 issue of Annals of Internal Medicine, showed a 30% reduction in hospital utilization within 30 days of discharge among the intervention group. More of these patients saw their PCP for follow-up within 30 days and they self-reported better preparedness for discharge. The intervention required about 1.5 hours of a dedicated nurse’s time and 30 minutes of a pharmacist’s time, per participant. The total cost savings for the intervention group was nearly $150,000, a reduction of about one-third compared to the control group.

What can PCPs do?

Provide feedback to the inpatient physician—tell them when handoff worked well and when it didn’t. Offer suggestions on what could improve the process for you.