Transitions of care: should hospitalists reach outside the walls of the hospital or should PCPs reach in?

An editorial in American Family Physician, citing evidence that hospital initiated efforts to reduce readmissions have had limited success, recommends involvement by PCPs when patients are hospitalized, even though their care is delivered by hospitalists:

.. the primary care physician should have a prominent role at three times: at admission, immediately after discharge, and at the postdischarge follow-up visit...

At the time of hospitalization, the primary care physician should contact and maintain communication with hospital-based clinicians…The primary care physician should discuss any concerns about the care plan, medications, medical history, and any social or family dynamics that may affect care, and should obtain an estimated date and destination of discharge…

To bridge the gap between discharge and follow-up, the primary care physician or a staff member with clinical knowledge can contact the patient 24 to 72 hours after discharge…

If that seems like a radical idea, it’s not. In fact, it’s in keeping with guidelines published several years ago that even take it further, recommending that ED physicians should contact the patient’s PCP first, before calling the hospitalist to arrange admission.