Dr. Crecelius’ prescription for avoiding the above scenario: “If you think the medicine is an odd choice, ask the prescriber why the patient is on it. We need to respect each other and get the information when there is a question.”
Cornerstones of Continuity
Medical directors have addressed continuity of care issues in their own ways. Whenever possible, Dr. Crecelius sees his patients in the hospital. He has also been working as a representative of the Missouri Association of Long-Term Care Physicians with a statewide transition planning committee. The committee is drafting new transfer forms for hospitals and post-acute care facilities.
The Asheville Hospitalist Group, PA has “gone to extraordinary lengths to address the issue of inter-facility transfers,” says Marc Westle, DO, FACP, president and managing partner for the large private group in N.C. His group has coordinated efforts with another group of hospitalists who specialize in managing patients in the Asheville area’s 20-plus nursing homes.
To facilitate transfers to a hospital, the nursing homes send paperwork (including history, physical, and medication records) with patients to the emergency department. When patients are ready for discharge, discharge summaries are dictated stat and faxed to the nursing home. Hospitalists discharging patients pre-order diagnostic tests that will be necessary when the patient returns to the nursing home by noting those tests on discharge orders. In addition, “The nursing home group has a list of all our beeper numbers for direct contact should a question arise,” says Dr. Westle.
Every patient transferred to another facility from Emory University Hospital in Atlanta is accompanied by a three-page transfer form, says Dr. Gartland. Included is a one-page summary of detailed nursing care; a second page listing hospitalization events, including pertinent consults, procedures, diagnoses, pending lab tests, and recommended follow-up; and a detailed medication sheet with discontinuation dates for such medication as antibiotics.
During his time as medical director at the Jewish Home for the Aging, Dr. Osterweil created what he calls his own “pseudo-hospitalist arrangement” to ensure continuity of care. He identified multiphysician groups comprising internists and nephrologists who, between them, could offer 24 hours on-call coverage.
When patients were transported to a local community hospital, Dr. Osterweil or his staff would call one of these physicians, who would take care of the patients when they were admitted to the floor. That arrangement is still in place.
“Any major decisions that are made, we are kept in the loop,” says Dr. Osterweil. “Twenty-four hours before readmission back to the skilled nursing facility, we receive a call letting us know the patient is coming back and his or her issues. The physician group executes a ‘stat’ dictated discharge summary, and the patient leaves the hospital with those orders. This ensures the continuity of care when the patient goes back to the nursing home or the board and care facility.”
Beef Up Communication
Dr. Crecelius concedes that certified medical directors (CMDs) are also often guilty of dropping the ball when it comes to communicating with inpatient provider colleagues.
Care of nursing home patients can be improved if hospitalists and medical directors of nursing homes talk directly on the phone, he says. “I met one wonderful hospitalist who actually showed up at the nursing home to see how the patients that he’d been sending out of the hospital were doing,’’ he recalls. “It was so nice to see the face behind the voice. You can’t get mad at a face!”
However, again demonstrating the range of practice techniques, another hospitalist group in Dr. Crecelius’ area does not do anything beyond faxing him the patient’s diagnosis. “Well, I knew the diagnosis, so that fax is not telling me anything,’’ he says. “And unfortunately, that is their idea of communication.”