Tuesday, April 06, 2010

The hospitalist model and the fragmentation of health care

Over at Med Rants DB cited an article in Annals of Internal Medicine lamenting the discontinuity of care associated with the hospitalist movement. Earlier today I pointed out that hospitalists, rather than being the integrators of health care some purport them to be, have in many ways become the enablers of fragmented care.

So now that we have built discontinuity into the system how can we mitigate the effects? This is a good opportunity to point out, again, that there are now guidelines for communication between hospitalists and primary physicians. These guidelines do not put the onus for communication on the hospitalist. It's a two way street, a push-pull function. According to the guidelines emergency room physicians should call the PCP and discuss the case before handing the patient off to the hospitalist for admission. The PCP is expected to contact the hospitalist and provide input, as well as visit the patient in the hospital. These guidelines are not well publicized. They were not promulgated or promoted by the Society of Hospital Medicine. They could go a long way toward closing the communication gap, but I suspect adherence is very low.


Anonymous said...

I'm not sure whose blog to comment on so I'll comment on both.

I agree the hospitalist is a contributor to fragmentation of care, but I also see its benefits.

I'm a pharmacist, who does both inpatient & outpatient work. As an inpatient pharmacist, I get prompt responses to my queries or concerns. As an outpatient pharmacist, I get nada - the hospitalist won't give me the time of day & refers me to the PCP.

However, the PCP has no knowledge of the recent admission & the change in medication doses.

As an inpatient pharmacist, I know all about the med rec sheets, but it is a nurse who goes over that sheet & they do a sh*tty job of it - I've seen it happen & they give downright awful or wrong information! Also - the EDs med rec sheet is wrong in the first place! Pts often don't know what they take, so get it right from the PCP!

Now, I'm also a child of someone who was recently hospitalized. My mother was admitted by ambulance thru the ER @ 3AM completely competent, but had back & chest pain. She requested her PCP be called twice in the ER. After she was admitted to the floor, she requested he be called again - 3 times. She was concerned because she had an appt with him that very day.

Her PCP called my sister concerned about my mom. My sister filled him in & asked if he'd been callled & he never was. She was seen by him the day after discharge & she had to sign a release for him to get the medical records.

Now - that is fragmentation at its finest. This all occurred at a major teaching hospital in southern California, so we're not talking about problems with getting info to rural areas.

Hospitalists & ER docs should be required to phone the PCP within 24 hours of admission. This should be the same as the criteria as evaluations on time to cath labs, time for antibiotics to be given, all other parameters that benefit pts health!

Anonymous said...

I tried to leave a post earlier, but your site didn't take it.

I left the same post over at DBs rants.

I hope you read it & the responses - intesting!