By  |  June 15, 2011 | 

Transitions, schmanzitions, potato, tomato, ACO, PHO, let’s call the whole thing……really complicated.  Is anyone getting it right? Well, Jim Henson did….(check out this clip).

For the past 3 months I have been working on a project that aspires to understand the link between the hospitalist/inpatient team and the PCP/ patient centered medical home. In particular, we want to understand the barriers to effective, closed-loop, timely communication between these two entities at the point of transition from inpatient to post-acute-care setting.  We have held a think tank, consulted with leading experts in the field, and have started to amass some data in order to understand how we hospitalists can be more integrated with the primary care team especially in settings where that relationship does not otherwise exist.

We have asked hospitalists to take this brief survey about their perspectives: (please click here to answer 10 simple questions and then return to my post).

What do you think?  Well, click here to see where you fall in the distribution.

By and large, I believe hospitalists want to own the discharge and many would agree that this may be the most important part of  complex inpatient care. Let’s face it, for those of us who have done this for a while, we understand the importance of the nicely packaged discharge. I am a 42 year old hospitalist and actually completed a PRIMARY CARE residency. I practiced outpatient medicine. Like many of my contemporaries, we understand the concept of the medical home.  But what about the new generation of hospitalists? How do they establish rapport and empathy with their colleagues in the medical neighborhood without having experienced the slings and arrows of Primary Care for themselves? Take a peek at this AHRQ white paper to learn more about PCMH.

The work our specialty has done in the quality and safety domain, especially around transitions, has been important and transformative.  Yet, I would like to suggest, perhaps challenge, to us that the heavy lifting for care transitions  lies in establishing a strong and meaningful relationship  with the patient centered medical home (whatever that may look like in your neighborhood, please tell us).

I am fearful that if we do not take the lead in establishing a robust partnership with the medical home, we may lose an opportunity to truly innovate during this critical moment in our history.

If you are currently working with a liaison in the medical home, kudos to you. If you are not, it may be prime time to reach out to the medical directors of your referring practices. Creating that meaningful relationship with your patients’ medical neighborhood will serve you and your patients well.

Is anyone out there willing to share some stories about how they have either
successfully or unsuccessfully partnered with the PCMH in their neighborhood?




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One Comment

  1. Joe Miller June 17, 2011 at 6:37 pm - Reply

    I am working with Mike on this project and it has been an enlightenment. Somebody has to own responsibility for the patient after they leave the hospital. This responsibility may need to be negotiated with PCPs, especially for the “complex medically ill”, the patients who keep coming back again and again. Some hospitalists (see CAREMORE in California) have taken on an extended role, seeing these sick patients in a post discharge clinic.

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