Enhancing Communication Between Inpatient Hospital Teams and Outpatient Primary Care Physicians

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Enhancing Communication Between Inpatient
Hospital Teams and Outpatient Primary Care
Physicians

• A QUALITY IMPROVEMENT PROJECT
• Seunggu Han, Michelle Jonelis,
• Jasmine Lai, Ryan OMalley

Project Advisors Drs. Arpana Vidyarthi and Karen
Hauer
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The Problem
Delayed or inaccurate communication between
inpatient hospital teams and outpatient PCPs at
discharge disrupts continuity-of-care.
The Stakeholders

• Patients
• Providers (inpatient and outpatient)
• Hospital administration
• Insurance companies

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The Problem
Delayed or inaccurate communication between
inpatient hospital teams and outpatient PCPs at
discharge disrupts continuity-of-care.
The Stakeholders

• Patients
• Providers (inpatient and outpatient)
• Hospital administration
• Insurance companies

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Background

• Survey of California Academy of Family Physicians
  8
• 33 receive discharge summaries on time
• 56 satisfied with communication with
  hospitalists
• Discharge summary content
• Discharge medications 94 deemed very
  important
• Discharge diagnosis 90 deemed very important
• Efforts of UCSF Personnel

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Purpose

• To describe the current guidelines for
  communication at hospital discharge
• To evaluate how well UCSF communicates discharge
  information
• To characterize elements of a clinically
  informative discharge summary
• To guide the development of more effective
  discharge summaries

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Methods

• Interviews with UCSF hospitalists
• Survey of outpatient PCPs at UCSFs Lakeshore,
  Mt. Zion, and Parnassus campuses

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Interview Results Current Guidelines

• Complete dictated discharge summaries should
  include
• a.       Dates of admission and
  dischargeb.       Reason for Admissionc.      
  Description of Hospital Course including
                  i.      care, treatment and
  services provided                ii.     signific
  ant lab, radiologic or path findings             
     iii.    description of hospital course
                  iv.    procedures performed and
  treatment d.       Discharge Diagnoses
  (Principal and Secondary)e.       Discharge
  Medicationsf.        Dispositiong.      
  Condition on dischargeh.       Follow up
  Plansi.        Information provided to patient
  j.        Discharge Instructions (diet,
  activity, wound care)
• Should be dictated within 14 days of discharge

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Interview Results The Reality

• Discharge summaries are designed for billing
  purposes, not for clinical communication
• No measure of compliance to required elements of
  dictated summaries
• No formal guidelines in contacting PCPs
• Estimated 50
• Barriers in process of communication
• Identifying PCP and contact info
• Method of communication

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Interview Results Steps in Communication at
Discharge
Patient discharged
Pt presents to PCP
Inpatient Team Calls PCP
Hospital Stay lt48 hrs
Hospital stay gt48 hrs
1-14 days
No patient discharge summary
Discharge Summary DS dictated
Physician accesses DS on UCARE
Physician receives DS through fax/mail/email
PCP not aware pt was in hospital
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Survey Results

• 3 Domains Assessed
• Timeliness
• Content
• Confidence

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Survey Results Timeliness
When one of your pts is hospitalized at
PARNASSUS, when are you notified of their
hospitalization?
78 would like a discharge summary immediately
after patient discharge!
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Survey Results Content

• Essential elements of discharge summaries
• Major tx/procedures performed 98
• Updated medication list 98
• Discharge diagnoses 88
• Hospital course 88
• Pending data/tests 88
• Follow-up plan 88
• Future appointments and procedures 88

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Survey Results ConfidenceHow confident are
you
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Comments from Providers
The system and procedures for transition of
patient care from hospital back to the outpatient
office is deeply flawed rules and expectations
for providing essential information to the
outpatient docs need to be established and
enforced. This needs to be elevated to the same
priority level as making certain all patients
have a pain assessment and all verbal orders are
signed.
discharge meds and f/u recommendations can
usually be found on UCare or STOR, but in
different locations and may not be consistent
(e.g., pharmacist med d/c note vs d/c summary).
Would be great to have single source for d/c recs
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Conclusions

• There is a need for better discharge
  communication!
• Discharge summaries are currently designed for
  billing, not clinical communication
• There are no structures in place to evaluate or
  enforce compliance with current discharge summary
  guidelines
• PCPs are not confident in the information they
  are receiving
• PCPs are not receiving information in a timely
  manner
• PCPs agree on what to include in an ideal
  discharge summary

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Recommendations

• Discharge Summary optimization should be a
  priority for UCSF
• More research needed to analyze process of
  discharge communication
• Possible strategies for optimizing DS include
• - implementing an additional summary note
• that can be written in a timely manner
• - revising the current guidelines for a
  dictated
• note more consistent with what PCPs need
• Reassess quality gap/ outcome after intervention

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Quality Improvement
OUTCOME
PROCESS
- Timely arrival - Adequate Information - High
confidence to continue care
Inpt team sends information
Pt discharge
Documentation
Quality GAP
Salient information gathered
Proper PCP identified
PCP receives information
- Not timely - Low PCP confidence - Inadequate
information
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Recommendations

• Discharge Summary optimization should be a
  priority for UCSF
• More research needed to analyze process of
  discharge communication
• Possible strategies for optimizing DS include
• - implementing an additional summary note
• that can be written in a timely manner
• - revising the current process to support
  patients follow up care
• Reassess quality gap/ outcome after intervention

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Lessons Learned

• Awareness of Quality of Healthcare
• Importance of Assessing Quality in Healthcare
  Delivery
• Development of Quality Improvement Project
• Process of Change

Focus
Analyze
Develop
Execute
Evaluate
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References

• 1. Kripalani, Sunil, et al. Deficits in
  Communication and Information Transfer Between
  Hospital-Based and Primary Care Physicians. 2007.
  JAMA 2978.
• 2. Schllinger, Dean, et al. Effects of Primary
  Care Coordination on Public Hospital Patients.
  2000. Journal of General Internal Medicine
  12329-336.
• 3. Hurby M, Pantilat SZ, Lo B. How do Patients
  View the Role of Primary Care Physician in
  Inpatient Care. 2001. Am J Med. 111(9B)21S-25S.
• 4. Dvorak SR, McCoy RA, Voss GD. Continuity of
  care from acute to ambulatory care setting. 1998.
  Am J Health-Syst Pharm55250004
• 5. www.caretransitions.org
• 6. Coleman, EA et al. Development and testing of
  a measure designed to assess the quality of care
  transitions. 2002. International Journal of
  Integrated Care
• 7. Coleman, EA et al. Assessing the Quality of
  Preparation for Post-hospital Care from the
  Patient's Perspective The Care Transitions
  Measure. 2005. Medical Care. 43(3)246-255, 8.
  Coleman, EA. Post-Hospital Care Transitions
  Patterns, Complications, and Risk Identification.
  2004. Health Services Research. 37(5)1423-1440.
• 9. Pantilat SZ et al. Primary Care Physician
  Attitudes Regarding Communication with
  Hospitalists. 2002. Dis Mon 48218-229.
• 10. Bodenheimer T. Coordinating Care A
  Perilous Journey through the Health Care System.
  2008. NEJM vol 35810.

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Acknowledgements

• UCSF Department of Hospitalist Medicine
• Dr. Adrienne Green
• Dr. Niraj Sehgal
• Dr. Lisa Ward
• UCSF Department of General Internal Medicine
• UCSF Department of Family and Community Medicine
• PISCES Colleagues
• Brook Calton
• Kate Gregg
• Daniel Orjuela
• Derek Ward
• QI Project Advisors
• Dr. Karen Hauer
• Dr. Arpana Vidyarthi