Coordinating patient care between hospital clinicians and primary-care physicians is a significant challenge due to poor communication and gaps in information-sharing strategies, according to a study led by physicians at the School of Medicine of the University of Colorado Anschutz Medical Campus.
The inability to share timely information can increase the risk of missed test results and hospital readmissions, according to the study's corresponding author, Christine D. Jones, MD, assistant professor of medicine and director of the Hospital Medicine Group of the Care Transitions Program.
"Communication between hospitalists and PCPs [primary care providers] around patient hospitalizations occurs infrequently and is associated with scenarios involving more serious patient issues, including readmissions, following discharge," Jones and her co-authors write in the April edition of the Journal of General Internal Medicine.
Jones and her fellow researchers interviewed 58 clinicians in eight focus groups to gather perspectives on how to improve the transition of patients from hospital to home. The study focused on health care providers in North Carolina who were already actively working to improve care transitions.
The study found multiple ways that care coordination between clinicians could be improved based on the issues identified by hospitalists and primary care providers who participated in the focus groups.
Often the primary-care physicians and the hospital clinicians were not even aware of the issues faced by their counterparts. For example, some primary care physicians noted that they were frequently unaware that patients from their practices had been in the hospital.
In other cases where the issues were known, there was a lack of clarity about who was accountable for follow-up care. Examples included uncertainty about who was responsible for specific tests pending at the time of discharge from the hospital and for home health care orders in the weeks and months after a patient leaves the hospital.
"Further research would be of value in order to investigate whether establishing accountability for pending tests and home health care via formal service agreements between hospitalists and PCPs results in fewer missed test results and/or hospital readmissions," the authors conclude.