Inpatient vs Outpatient

By: Chi Zheng, M.D., Patrick Ryan, M.D. and Marisa Echaniz, M.D.

How Providers Are Working Together to Bridge the Divide

As hospitalists, we build bridges quickly. We build bridges with our patients when they are admitted, with the myriad of nurses they encounter in different departments throughout the hospital, with the emergency department and with our consultants. However, the important relationship bridging hospitalist and primary care providers (PCP’s) can be easily overlooked.

Hospitalists care for patients during several days of acute illness, yet we can forget that they have a PCP who has developed a relationship with them over the course of years. The PCP has struggled to help the patient understand their disease, improve their adherence, and see the value in preventing future disease. The patient’s relationship with their PCP can be as therapeutic as it is diagnostic, therefore the PCP’s perspective of their patient’s course can provide invaluable information during a patient’s hospitalization.

Denver Health’s integrated health care system includes 10 geographically dispersed primary care clinics that feed into our safety-net hospital. While hospitalists are familiar with PCPs by name, many are unfamiliar with the faces of the providers and the communities where their clinics are located. Recognizing this gap, Dr. Chi Zheng, a hospitalist, and Dr. Patrick Ryan, a PCP, established a Community Health Services (CHS)-hospitalist workgroup to identify and improve the culture around transitions of care. Through the CHS-hospitalist work group, we created the Community Health – Hospitalist Ambassador Program (CHHAPs). This initiative brings hospitalists into the family health centers with the goal to meet PCP’s face-to-face, see the community their patients live in with their own eyes and work collaboratively with primary care colleagues to improve transitions of care. Hospitalists assigned themselves to our CHS clinics to serve as a point of contact for the clinics. The Transitions of Care workgroup reviewed findings of the CHHAPs program in monthly meetings, and produced system-based improvements to identified issues using input from both inpatient and outpatient perspectives. Through CHHAPs, we have spearheaded efforts in the following quality improvement projects:

1. Creation of the medication transitions team: an emergency department-based pharmacy team to assist in the medication reconciliation process around admission and discharge
2. Streamlining home oxygen ordering upon discharge by creating new electronic medical record based order sets
3. Implementing home health ordering into the electronic health record
4. An improved discharge summary with a transitions of care focus
5. Overhauling and streamlining the direct admission process by improved communication and response time with the transfer center

We proposed that the CHHAPs program would improve communication between hospitalists and PCPs, identify solutions to address system-wide gaps in transitional care, and increase hospitalists’ engagement in the community. Ultimately, we hoped to improve cooperation and satisfaction among both hospitalists and PCPs.

We surveyed PCP and hospitalist leaders on the effects of the CHHAPs program. Eleven leaders responded to our survey. Sixty-four percent of respondents identified a lack of time as a barrier to communication between PCPs and hospitalists. Eighty-two percent found that the use of CHHAPs provides a means to address barriers in communication. Sixty-four percent found that CHHAPs improve sense of community between departments, identifying themes of feeling connected, improving teamwork in patient care and developing collaborative partnerships. Eighty two percent identified CHHAPs as a means of improving provider satisfaction. As one Denver Health family medicine physician said: “[CHHAPs] humanize the hospitalist and the PCP. It’s not us vs them – it’s all of us [working] together.”

The sustainability and spread of this model will be dependent on its ability to overcome the challenges of coordinating busy hospitalists’ and PCPs’ schedules. We’ve secured institutional support to provide refreshments for meetings at outlying clinics, which has been helpful with hospitalist turn-out. While this program has been sustainable in a vertically integrated system, it may also be beneficial in community-based settings that do not have shared electronic health records, and especially in a system with competing hospitalist groups working with a few large primary care practices.

Through the CHHAPs program, both hospitalists and PCPs have found that many of their struggles with transitions of care issues were shared, systemic issues and not just individual struggles unique to their area of clinical practice. By jointly solving these problems with inpatient and outpatient perspectives, this program offers sustainable solutions to transitional care issues – transforming individual islands of frustration into functional bridges of communication between PCPs and hospitalists.