The increasing fragmentation of health care has resulted in more care transitions. This fragmentation includes by site (emergency rooms, ambulatory clinics, nursing facilities, rehabilitation) or physician specialty, which can be either organ-based (eg, cardiologists, nephrologists) or site-specific specialties (eg, emergency medicine physicians, critical care physicians). Hospitalists, of course, are the newest site-specific specialty to arrive on the health care scene. Increasingly, hospital care has become a field that focuses on the elderly, with over 50% of patients admitted to hospitals being older and often with several comorbidities.
This fragmentation has resulted in a greater need for care coordination and a focus on transitions, particularly for elderly patients. For example, the average primary care physician who sees 100 Medicare patients coordinates with 99 other doctors in 53 different practices. Moreover, 40% of hospitalized Medicare patients do not have a simple “hospital to home” transition, instead having brief stays at either a rehabilitation facility or a skilled nursing facility. Unfortunately, prior literature has illustrated that communication between hospital-based physicians and outpatient physicians is poor. While two-thirds of primary care physicians believe the use of hospitalists is a good idea, roughly half were satisfied with their experience communicating with hospitalists, and few received discharge summaries in a timely fashion to facilitate safe and effective management of their patient in the ambulatory setting.
In addition to care transitions in and out of the hospital, hospital care itself has become increasingly fragmented due to increased numbers of handoffs with the implementation of resident duty hour restrictions and the adoption of the familiar shift-work systems utilized by hospitalists. For example, for a typical patient, a member of the patient's primary team is present in the hospital only 50% of the time. Hospitalized patients are passed between doctors an average of 15 times during a single 5-day hospitalization.
Despite the ubiquitous nature of handoffs and care transitions, numerous studies suggest that care transitions and handoffs are plagued by communication errors, which ultimately can lead to patient harm. As a result of these concerns, prevention of handoff errors has been the subject of numerous policy and patient safety initiatives. Namely, The Joint Commission made implementing a “standardized approach to handoffs” a national patient safety goal for acute care hospitals in 2006. That same year, the World Health Organization labeled prevention of “handover errors” as one of the top five patient safety solutions, giving it equal footing with such high-priority solutions as hand hygiene. Physician groups have also taken notice. In 2009, six medical societies representing four different specialties (emergency medicine, geriatrics, general internal medicine, Hospital Medicine) came together for an unprecedented collaboration to acknowledge the importance of care transitions through creation and approval of a Transitions of Care Consensus Policy Statement for care transitions. The general tenets of effective handoffs include such principles as accountability, communication, timely inter-change of information, and involvement of the patient and family members, among others.
Hospitalists have also ...