The Marin Hospitalist Medical Group makes every effort to ensure communications with receiving facilities are timely and thorough. According to Dr. Cumming, the group has surveyed—and will continue to survey—its referring primary care physicians, whether office or facility-based, for feedback on their performance. Hospital case managers also relay feedback to the hospitalist group, she notes. “We’ve tried to use the customer service model across all the groups of physicians who transfer patients to us and to whom we transfer patients, to keep that level of communication where it needs to be,” she says. Some of the questions they ask of their facilities:
- Are we sending the information you need?
- Do you want to receive all documents with the patient when he or she is transferred, or just a small subset of documents?
- How do you want information delivered? Do you want forms, discharge summaries and other documents faxed to you? Would you prefer a phone call?
- What can we do better?
Dr. Haimowitz’s advice to hospitalists might parallel the advice he recently gave to local a hospital administrators who were considering starting an intensivist program. “If you’re going to do this right, you must have physicians who are sensitive to older patients and what they want,” he says. Quality of life, DNR orders, and goals of care take on subtle gradations when applied to the elderly, he emphasizes.
Absent the time to visit the area nursing homes, hospitalists can always at least call, Dr. Crecelius notes.
Just as a hospitalist or emergency department physician would contact the family to corroborate patient history, they should also call the nursing home. “Speaking with the nurse at the skilled nursing facility, you can access a wealth of information—and save time and effort,” he says.
Improve Transfers
Dr. Haimowitz believes communication—on a form or by phone—is essential. He sees even more opportunity for miscommunication between hospitals and nursing homes because of different recordkeeping systems.
Hospitals are moving increasingly to electronic health records, while nursing homes still rely on paper documentation. “How do you foster communication?” Dr. Haimowitz asks. “How do you get the right people on the same bus? The best transfer sheet in the world is no good if one, it’s not filled out, and two, if it’s not read.”
Disparate systems can be a barrier, but it does not mean you should not try to optimize communication within whatever system you have, says Dr. Cumming.
The Marin Hospitalist Medical Group is setting up a communication system to alert all primary care physicians of pending lab results so such tests do not fall through the cracks after patients are discharged.
In another initiative, the hospital will set up a system to note that any pneumonia or influenza vaccinations performed while the patient was hospitalized are communicated either to PCP or outside facility. The group is also working to urge all local nursing facilities to include records of patients’ recent vaccinations when they are transferred to the hospital.
It’s clear that effective transfers of elderly patients require a concerted effort by all involved. “If you perform a root cause analysis of [transfer] errors, most occur not because of any negligence, but because communication—written or verbal—was not handled as best as it could have been,” Dr. Gartland notes. “Oftentimes, we are just as frustrated as they [nursing facilities] are when patients return to the emergency room unable to communicate their medical conditions, wishes, and the like,” he says. As medical director of care coordination at Emory, he has worked to improve relationships with administrators and physicians in nursing facilities used most often by the hospital. “If people have a vested interest in a relationship, they are more likely to be diligent about the transfer of patients,” he asserts.