Home Working With Other Specialties Bridging the divide between the hospital and primary care

Bridging the divide between the hospital and primary care

How to keep the primary care perspective in inpatient decisions

November 2018

Published in the November 2018 issue of Today’s Hospitalist

THIS SUMMER, hospitalist Louis O’Boyle, DO, CLHM, regional medical director for Adfinitas Health in northeastern Pennsylvania, began visiting local primary care doctors who still follow their patients into the hospital. His mission: to try to convince those physicians to either go “all in” with their inpatients and give up the night and weekend coverage the hospitalists have extended to them for years, or go “all out” and hand their inpatients over to the hospitalists full time.

Otherwise, his group would face one of two unacceptable situations. Either the primary care practices will want to turn over all their inpatients to the hospitalists abruptly, or one of the four hospitals his group covers will buy those practices and expect the hospitalists to take those inpatients on, typically within 90 days. Instead, says Dr. O’Boyle, “we want a controlled expansion under our own terms, or we’ll be overrun.”

When he visits those primary care doctors, they have two overriding concerns about turning their inpatients over. One, they worry about how they’ll make up the money they’ll lose if they stop coming to the hospital. Usually, he notes, “they can schedule more office visits and come out ahead,” so finances aren’t really an issue.

“The key is maintaining free-flowing, two-way conversation between the hospital and primary care.”

~ Louis O’Boyle, DO, CLHM
Adfinitas Health

But their second concern—continuity—is real indeed. “Primary care doctors wonder, ‘How is somebody going to know these patients better than me?’ And that’s a fair question, because I’m not,” says Dr. O’Boyle, who himself worked in primary care for five years before switching to hospital medicine. “The key is maintaining free-flowing, two-way conversation between the hospital and primary care.”

Many hospitalists no longer have to convince primary care doctors to hand over their hospitalized patients. But they still face the same challenge as Dr. O’Boyle: how to effectively bridge the divide between the hospital and the outpatient setting so that each communicates the essential information the other needs.

Primary care in the hospital
It may surprise some hospitalists that there are primary care doctors who still visit hospitalized patients on top of putting in a full day of office visits. In some hospitals, their ranks are so small—and their collegial relationships with hospitalists and executives so longstanding—that even administrators frustrated with outpatient physicians’ outsized lengths of stay don’t press the issue.

But in one hospital where Dr. O’Boyle’s group works, primary care doctors still follow 35% of all the inpatients.

That number is closer to 45% in two other facilities. Having so many primary care physicians follow their own patients raises concerns. While some of the outpatient doctors are excellent clinicians, others are inefficient, and “our hospitalist data generally are way more favorable,” Dr. O’Boyle says. That includes data on documentation, case mix index, cost per case and length of stay. That should come as no surprise, he adds, “because hospitalists are in the hospital all day to drive those metrics.”

Sandeep Pulimi, MD, is TeamHealth’s facility medical director for the five-FTE hospitalist program at Mercy Hospital & Medical Center in suburban Chicago, which is part of the Trinity Health system. Because he doubles as the hospital’s physician advisor, he has an inside view on how the hospitalists compare with the primary care physicians who treat fewer than 10% of the hospital’s patients. “It’s a night and day difference,” Dr. Pulimi says.

While his hospital administration is aware of the difference between hospitalist and primary physician performance on metrics, they continue to welcome community doctors. “The primary care physicians are grandfathered into that role,” Dr. Pulimi explains, “and they bring in a stable referral base.”

The primary care perspective
But while primary care physicians may not be able to match hospitalists’ performance in the hospital, they bring a lot to patient care. Dr. Pulimi says his appreciation for primary care’s role in patient care continues to grow the longer he practices hospital medicine.

“If we don’t dedicate a resource to medication reconciliation, we have a high chance of error.”

~ Ryan Brown, MD
Atrium Health

“We’re great at getting length of stay down to three or four days,” he says of his fellow hospitalists. “What we are not great at is the social component. What is this patient doing outside the hospital that we don’t know about or we’re not doing right? That’s the piece the primary care physician brings to the table.”

Further, Dr. Pulimi adds, he now realizes that a hospitalization “is just a snapshot and that the bigger picture is the readmission. The readmissions we can truly prevent are for patients with good PCPs—and the ones where we have good communication with the PCPs.”

Adfinitas’ Dr. O’Boyle agrees. He and his hospitalist colleagues can access some outpatient EHRs of primary care doctors who have turned over their hospitalized patients. That allows the hospitalists to log in and see a patient’s last outpatient note and medication list.

Plus, he has long made it a habit to attend outpatient group and board meetings where primary care doctors share their cell phone numbers and backline office numbers. Dr. O’Boyle says his group consistently texts or emails back and forth with their patients’ primary doctors, letting those doctors know in advance, for instance, a patient’s discharge plan.

“A doc will text or call back and say, ‘Look at this nursing home instead because the patient’s wife is also there,’ which I have no way of knowing,” he says. “They appreciate us keeping them in the loop, and we appreciate them sharing what they know.” Using secure texting, he adds, “minimizes office interruptions and is generally the preferred method of communication.”

Communication problems out of network
In Chicago, Dr. Pulimi says that he and his hospitalist colleagues share the same EMR with primary care physicians within the Mercy-Trinity network. Those outpatient doctors are automatically notified when patients are admitted, and they automatically receive patients’ hospital records

“What we are not great at is the social component. That’s the piece the primary care physician brings to the table.”

~ Sandeep Pulimi, MD
Mercy Hospital & Medical Center

His group also admits patients for Oak Street Health, a primary care network for Medicare patients that has more than two dozen locations throughout the Midwest. When Oak Street Health’s patients are admitted, network nurses visit those patients in the hospital and fax the outpatient records from their last two office visits.

But with other primary care doctors, particularly those not in his own network, it’s much more difficult. “We have their fax numbers entered into our system,” Dr. Pulimi says. Further, for any discharged patient who needs a follow-up test—another potassium or a Coumadin check—a discharge coordinator from the hospital will call that outpatient practice and speak either to a physician or nurse practitioner. “We tell them to expect the summary and give them a heads-up about the follow-up that’s needed.”

That system “is working,” he says, “but I have one meeting every month on how to communicate better with those private practices.”

The benefits of an integrated system
Ryan Brown, MD, specialty medical director, hospital medicine for Atrium Health (formerly Carolinas HealthCare System), in Charlotte, N.C., heads up more than 230 hospitalists and advanced practice clinicians across 13 hospitals. According to Dr. Brown, fewer than 5% of admitted patients in his system are still followed by primary care physicians.

Further, the primary care doctors of as many as 80% of the hospitalists’ patients are in the Atrium network, part of the same medical group as the hospitalists. They all share an EHR.

“We don’t have daily communication with those physicians,” Dr. Brown says. “As busy as those primary care doctors are, they’d cringe if we did.” The EHR is hardwired to notify those primary care offices at certain key points: when a patient is seen in the emergency room, at admission and at discharge, and at time of death, if that applies.

In addition, Dr. Brown points out that a lot of time goes into standardizing the information that hospitalists communicate to—and gather from—outpatient physicians. Two years ago, for instance, the hospitalists adopted a standardized discharge summary they need to send within 24 hours, with the hospital monitoring the time those summaries are created.

And Atrium dedicates a pharmacy tech to do medication reconciliation at admission, sitting down not only with the patient but getting in touch with the patient’s outpatient pharmacy and primary care office.

“It takes a village to make sure the EHR is accurate and up-to-date,” Dr. Brown points out. “We found that if we don’t dedicate a resource to medication reconciliation, we have a high chance of error.”

A seamless transition
Dr. Brown is now working on standardizing a new section of Atrium’s EHR, one devoted to communicating about discharge needs. The goal is to make sure primary care physicians know and understand what hospitalists think those needs are, with items like end-of-life discussions, indigent medication and Medicaid applications, home health needs, and important follow-up studies.

For patients seen in the hospital who don’t have primary care physicians in the Atrium network, “it’s more difficult,” Dr. Brown says. But Atrium is connected through a health information exchange (HIE) with other hospitals in the area.

“We release our data into this HIE that includes the admission, all the labs and X-rays, and the discharge summary,” he says. Outpatient physicians affiliated with those other hospitals can then access that information.

A lot more needs to be done, particularly to pull information out of primary care offices that aren’t in the Atrium network. Still, from the viewpoint of patients, says Dr. Brown, “even if their primary care and their hospital doctor aren’t in the same medical practice, that fact should almost be invisible to them.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

Who gets to choose your consultants?
WHILE PRIMARY CARE PHYSICIANS may no longer treat patients on the wards, this challenge often pops up: Who gets to decide— the hospitalists or the primary care doctors—which consultants to use in the hospital if patients don’t already have pre-existing relationships with specialists?

Many primary care physicians let their consultant preferences be known and expect them to be followed. Louis O’Boyle, DO, CLHM, regional medical director for Adfinitas Health in northeastern Pennsylvania, tried to accommodate those preferences when he and his hospitalist colleagues first started out, going so far as attempting to develop an app that the hospitalists could use.

“Hospitalists feel they’ve lost some autonomy.”

~ Thea Dalfino, MD
St. Peter’s Health Partners

But “we were growing and adding dozens of new private physicians,” says Dr. O’Boyle. “We had to let outpatient doctors know that we had to choose those specialists who respond the fastest and provide the highest-quality care. You can’t decide what’s best for a patient based on ongoing relationships between two providers.”

That’s likewise been the case at Chicago’s Mercy Hospital & Medical Center, says Sandeep Pulimi, MD, TeamHealth’s facility medical director for the hospitalist program there. Some primary care doctors take offense when hospitalists ignore their consultant preferences by bringing other specialists into a case without communicating their intention to do so.

Dr. Pulimi, however, has had success picking up the phone and telling primary care physicians that he’s going with other specialists who respond more quickly. “They end up being happier,” he notes, “with the quicker turnaround.”

But a primary-care preference initiative put in place six months ago across the three St. Peter’s Health Partners hospitals in Albany, N.Y., is alive and well. Moreover, “it has a lot of organizational support,” says Thea Dalfino, MD, the system’s chief of hospital medicine who oversees 150 hospitalists.

The initiative was the brainchild of the same employed multispecialty group that the hospitalists belong to. All the primary care physicians in that group—also around 150—were surveyed about their preferred consultants, with results posted on a Web site the hospitalists and ED doctors are expected to use. Their compliance with those preferences is now being audited.

The rationale behind the initiative was “to keep patients within our system,” Dr. Dalfino explains. “It would also allow our primary care providers to work with specialists with whom they’re familiar.”

How do the hospitalists feel about it, particularly since they used to have free rein to choose consultants? They’re using the preference list, says Dr. Dalfino, but it’s been an adjustment.

“Hospitalists feel they’ve lost some autonomy, and the Web site that was created is a different login from everything else we use all day, so it’s not integrated into the system. That makes it another step.”

Since the initiative was launched, those primary care doctors who refer patients to St. Peter’s but are not employed have also come up with their own list of preferred consultants. The fix, says Dr. Dalfino, has been to create pocket cards that the hospitalists carry and that contain all the primary care preferences.

She calls the initiative a “major satisfier” for the primary care doctors. It’s a game-changer in terms of consultant dynamics.

Previously, the consultants wanted to provide the best care— and befriend the hospitalists and the ED doctors so they would score more consults. “Now, they’re going out to the primary care providers so they’ll be preferred,” Dr. Dalfino says. “They’re marketing themselves more now to the primary, and less to the ED and hospitalists.”

The case for a chief medical officer of primary care
HOSPITALS HAVE STARTED establishing brand new chief officer positions, chief experience officer and chief wellness officer being two examples.

Why not a chief medical officer of primary care? “It’s such an important part of health care, but that voice tends to not be represented in hospitals,” says Noemi Doohan, MD, PhD. “Instead, it’s quite peripheral.”

Dr. Doohan coauthored a proposal in the July/August 2017 issue of Annals of Family Medicine that advocated for hospitals creating a new full-time position: chief primary care medical officer. According to the proposal, that chief officer would ideally devote 25% of his or her time to both the inpatient and outpatient setting, then 50% administrative in hospital leadership, with membership and voting rights on key committees including the medical executive committee.

“Primary care shouldn’t end at the hospital door, but in most places it now does.”

~ Noemi Doohan, MD, PhD
Adventist Health Ukiah Valley Hospital

Such a medical officer would ensure strong relationships with the primary care community and put systems in place to improve care coordination and communication between both settings. That would be “a step toward fixing the discontinuity in our health care systems,” Dr. Doohan and her coauthor Jennifer DeVoe, MD, DPhil, wrote. Dr. DeVoe, who is chair of the family medicine department at Oregon Health & Science University in Portland, notes that her institution has just created a full-time chief primary care and population health officer position.

Dr. Doohan is clear that she is not advocating for primary care doctors to return to the hospital and follow their own patients.

“I’m definitely in favor of having hospitalists, and I’m employed as one,” she says. (While Dr. Doohan works part time as both a hospitalist and a primary care physician, she spends most of her professional time directing a new rural family medicine residency program sponsored by Adventist Health Ukiah Valley Hospital in Ukiah, Calif. The residency program is affiliated with the University of California, Davis.) “But even though primary care doctors don’t usually follow their own patients into the hospital any more, they bring a very important perspective from the outpatient world. Primary care shouldn’t end at the hospital door, but in most places it now does.”

She cites case management rounds as an example. Primary care doctors have essential information that should help shape discharges and disposition, including who can (or can’t) live independently and which social determinants may derail a discharge.

But typically, hospital case management and primary care don’t directly interact. Outpatient primary care teams, who don’t even know when inpatient case management rounds or huddles take place, have no opportunity to contribute. And most hospital systems don’t launch systems fixes—like moving those huddles to 12 noon, allowing primary care doctors to phone in during a lunch break—to be able to bring their perspective into discharge decisions.

According to Dr. Doohan, a chief primary care medical officer could coordinate continuity including the flow of essential information, and putting communication systems in place that would support more timely, safe discharges as well as lower lengths of stay, fewer readmissions and appropriate follow-up with primary care. Such a medical officer would be particularly valuable in value-based payment models.

“I think the current payment model would fund this,” Dr. Doohan says, “and focusing on the most complex patients initially is the way to test it. I think it can be very readily studied and proven to be effective.”

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