Hospital Medicine and Transitions of Care

By:  AMFS Hospital Medicine Expert

Over the past two decades, there has been a growing trend for the care of the hospitalized patient to be assumed by physicians who care only for patients in the inpatient setting, and who do not have an outpatient medical practice. These physicians have come to be known as “hospitalists”, and their area of practice as “hospital medicine”. Hospitalists are a departure from the old style of practice, in which the primary care physician (PCP) cared for their seriously ill patients in the hospital while still maintaining a busy outpatient practice. Because of the increasing complexity of modern medicine, and due to a variety of economic pressures, the trend now is for physicians in primary care specialties to focus their practice on either outpatient or inpatient care, but not both.

There are many advantages to this trend of dedicated hospitalists, including that the hospitalized patient will be under the care of a physician who remains in the hospital throughout the day and is very experienced in the care of acutely ill hospitalized patients. That said, there are also a few disadvantages, the main one having to do with the changing of providers between the outpatient and inpatient setting. This discontinuity of care is also a significant source of medical-legal risk in hospital medicine.

The hospitalist’s role is primarily one of overseeing the patient’s care during the hospitalization of the patient.  This role includes admitting, diagnosing, and treating the patient, calling in specialists when necessary, and discharging the patient back to their PCP at the end of the stay.  In a sense, they assume the role of the primary care physician while the patient is in the hospital.  Hospitalists typically work as a member of a hospitalist or a multispecialty medical group, and during a hospital stay the patient will sometimes be cared for by more than one of the hospitalists in the group.

When most hospital care was provided or coordinated by a patient’s primary care physician, that physician typically was already acquainted with the patient and would know well the patient’s medical and personal history.  The PCP would also have ready access to the outpatient medical records, since these were kept in that PCP’s office.  Much of the risk of medical errors or negligence for hospitalists has to do with the transitions of care between the hospitalist and the primary care physician, when vital information necessary for effective care can be lost.  Similar risks can also arise in transitions of care to or from another hospitalist or specialist during a hospital stay itself. When a new and unfamiliar hospitalist physician assumes the care of a patient entering the hospital, there is much catching up to do for that physician to become familiar with the patient’s medical history and preferences for care.  Although much of this information can be obtained from the initial history and physical exam and through subsequent discussions with the patient and others during the hospital stay, the hospitalist does not have the prior relationship or knowledge of the patient that the PCP has, and much important information may be difficult for the hospitalist to obtain.  In addition, when the patient is discharged from the hospital, the hospitalist will generally not be the physician seeing that patient in follow up in the office, the nursing facility, or the home, and important information from the hospital stay may be missing in these settings.

The standard of care for a hospitalist requires that the hospitalist make every effort to obtain important past medical information if it is not readily available at the time of admission.  It also requires that information vital to a patient’s care be communicated to other clinicians that will be caring for the patient during the hospitalization and after discharge from the hospital.

Listed below are some of the care transitions facing the hospitalist, and the responsibilities that go along with them:

Admission of the patient to the hospital:

• The hospitalist needs to communicate and exchange important information with the ED physician, and as soon as possible with the primary care physician, or other physicians that have previously cared for the patient and whose care may have a bearing on the current illness and care of the patient.

During the hospital stay:

• The hospitalist must coordinate the overall care of the patient, while engaging specialists as needed. The specialists are typically responsible for care of the patient within their area of expertise, while the hospitalist must keep the “big picture” in mind.

• There is sometimes a transfer of the care of a patient during a hospital stay, especially a prolonged one, from one hospitalist to another hospitalist within the same group. Important information regarding care of the patient must be communicated in this transition.

Discharge from the hospital:

• Insure appropriate follow up, including appointments with the primary care or other clinicians, and treatments or tests that are necessary after discharge.

• Follow up on any pending results of tests done during the hospital stay.

Some hospitalist groups create policies outlining the expectations of its members regarding communication with primary care and other physicians during the stay, to help insure the safest and smoothest transitions of care into and out of the hospital.  But even if such a policy does not exist, it is generally accepted within the hospital medicine community that excellent communication with other physicians involved in the care of the patient, especially the primary care physician, is an essential part of their role as a hospitalist.

Medical-Legal Considerations

Transitions to different doctors providing care in the inpatient and outpatient settings are now becoming the norm, and if not managed well these transitions can lead to inadequate care or follow up for the patient.  Failure to exchange vital clinical information with other physicians involved in the ongoing care of the hospitalized patient places that patient at risk of harm, and opens the hospitalist to accusations of negligence.