Published in the March 2009 issue of Today’s Hospitalist
JONATHAN STALLKAMP, MD, is well aware of the safety problems that can crop up when information goes missing at discharge. Several years ago, when his group’s communication strategy with primary care physicians consisted of just faxing a discharge summary, important information “about pending test results or a necessary consult “sometimes fell through the cracks.
But as part of a hospitalist group in suburban Philadelphia, Dr. Stallkamp is also keenly aware that he works in a very competitive market and that his group needs to stand out for superb customer service. After all, local physicians can refer to any of a half-dozen other suburban and Philadelphia-based facilities within minutes of Lankenau Hospital in Wynnewood, Pa., where Dr. Stallkamp’s group practices.
Despite that heavy competition, Dr. Stallkamp and his colleagues are seeing their referral business grow between 15% and 20% a year “growth he attributes in part to having hospitalists telephone primary care physicians after virtually every discharge.
“Some of our recent growth is attributable to word of mouth, but much of it is definitely performance,” Dr. Stallkamp says. “Physicians want to see that our outcomes are better than those of other providers.”
Targeting more referrals
When Dr. Stallkamp’s group first began mandating physician calls at discharge several years ago, its main objective was to ensure better continuity of care.
But enhancing primary care communications was also designed to grow the group’s business. Many patients treated by the 19-physician program are underserved, so the group is always looking for patients with better insurance coverage and preventive care.
“We wanted to include more patients with longstanding relationships with primary care physicians,” Dr. Stallkamp explains. “These relationships have allowed us to expand the number of primary physicians we partner with.”
The calls the hospitalists make at discharge typically take less than five minutes per patient. To streamline the work, hospitalists tend to bunch the calls at the end of the day. “It’s a quick, down and dirty conversation,” Dr. Stallkamp points out. “We tell them why the patient came in, what happened during their stay and what needs to happen in follow-up.”
While the group also faxes the patient’s discharge medication list and summary, Dr. Stallkamp says that primary doctors take advantage of the phone calls to solicit details that may be omitted in the summary dictation, such as the name of a subspecialist consulted in the hospital. (Residents dictate the discharge summaries.)
The phone calls are now so engrained that the group’s “heavy-hitter referrers,” those two dozen or so primary care physicians who have worked with the Lankenau group for several years, call and ask why they haven’t heard from the attending hospitalist if a call goes missing.
“If you provide a certain level of service,” says Dr. Stallkamp, “people come to expect it.”
Follow-up for unassigned patients
Hospitalists also use the calls to make sure primary care physicians have received other faxed patient information. That includes an admission notice with details of the history and physical, and the attending hospitalist’s name and contact information.
During the course of a hospitalization, the group will also fax interim reports. Some primary care physicians like progress reports on all patients, says Dr. Stallkamp, while others just want to be appraised of any major change in status, such as a trip to the ICU.
While about 40% of the group’s patients are unassigned or under- or uninsured, the hospitalists try to find a physician to call for all those patients as well. “Some of those primaries are not that easy to get a hold of,” he says, referring to high-volume Medicaid practices, “and some flat out just don’t want any type of contact.”
For unassigned patients, either the residents or the group’s nurse coordinator will try to make follow-up appointments at public health clinics. But “sometimes there is no good way to do that in a reasonable timeframe,” Dr. Stallkamp points out. “In those cases, we tell the patient just to walk into the clinic. Otherwise the wait is about two months.”
The role of nurse coordinator
The group’s robust lines of communication also reap information that helps the hospitalists. Primary care physicians often respond to an admission notice by letting the group’s nurse coordinator know about a patient’s previous hospitalizations or recent tests that don’t need to be repeated. They also provide up-to-date medication lists and important aspects of social and family history.
All that communication highlights the importance of the group’s nurse coordinator, Pam Dolan, RN. Ms. Dolan interviews every patient and fills out and faxes all of the notices, summaries and reports to make sure all the information is safely transferred.
She also “tees up” for the hospitalists all the contact information about the primary care physician. “I would say,” Dr. Stallkamp notes, “that communication is close to 80% of her job.”
“The personal touch”
According to Dr. Stallkamp, the group is working toward being wired with an inpatient electronic medical record (EMR). (The 351-bed Lankenau, which is part of Main Line Health, is affiliated with Jefferson Medical College in Philadelphia.)
But an EMR “will give us access to only a small percentage of our patients,” he says. “Most are referrals from independent providers who do not have an EMR in their practices.”
Even if the entire primary care network could be electronically connected, he adds, group physicians would continue to provide “the personal touch” of calling at discharge, which they now successfully complete for 90% of their patients. Dr. Stallkamp says he’s also working on an incentive plan that will tie bonus payments for physicians in part to their rate of discharge phone calls.
He now monitors that rate with quarterly phone calls to high-referring physicians. He also makes it a point to meet with primary care physicians in their offices at least once a year to maintain personal contact.
“As in many markets, patients and physicians here have many referral choices,” says Dr. Stallkamp. “Health care is about people, not about marketing campaigns or billboards.”
Bonnie Darves is a freelance health care writer based in Lake Oswego, Ore.
Check out the communication forms used by the hospitalists at Lankenau Hospital in Wynnewood, Pa. The forms are online in the Clinical Protocol section of the Today’s Hospitalist Web site.