Communication provides continuity of care
Communication provides continuity of care
The hospitalist as quarterback
Concerns about continuity of care are not germane to the question of whether to employ hospitalists, says one health care executive.
The most important issue is communication, not whether the primary care physician knows his patient’s favorite color, says Dan Dworsky, MD, an inpatient internist at La Jolla, CA-based Scripps Clinic, which uses hospitalists.
"The continuity-of-care argument doesn’t hold water in today’s health care arena," he explains.
In today’s world, only the very sick are admitted to the hospital. This means the needs of hospitalized patients are different from those who present at the office.
"You can look at this two ways," Dworsky says. "First, continuity of care has very little to do with patients being in the hospital today. People typically are there for less than two or three days. The brief acute intervention doesn’t impact the continuity of care anymore. If a patient has had a stroke, for example, I treat that condition. I don’t have to know details about the patient’s family life. Years ago, when patients were in the hospital longer and for less clear indications and had lower levels of acuity, that argument held. But not today."
Scripps launched its hospitalist configuration in August 1992, a program that involves a rotating schedule of primary care physicians, each of whom is the "dedicated admitting physician" for week-long tours of duty.
The program began in response to what doctors there perceived as inefficiencies in their practices. When a doctor had only one or two patients hospitalized and the distance between office and hospital was sizeable, they spent too much time traveling. They sought to correct this by having an on-site doctor do all the hospital work.
"That person could read laboratory tests in real time, make real-time decisions, and get the patient along to the next spectrum of care," Dworsky says.
Today there are 12 to 15 hospitalists at Scripps.
"Initially, outpatient doctors were definitely skeptical, both primary care physicians and specialists," Dworsky says. "But we’ve been doing this now for a while, and the system’s become accepted."
Care coordinators work with Scripps’ hospitalists, and the focus of those professionals is to clinch the diagnosis that’s keeping the patient in the hospital and start therapy.
"Patients are not kept there while we look at lots of other diagnostic tests that are possibly unrelated to their hospitalization," Dworsky says. "Those are in the purview of the outpatient doctor."
Include patients in communication loop
So how does Scripps reconcile the continuity issue, particularly for complex problems that require longer hospitalizations?
"The important thing is good communication," Dworsky explains. "But the communication has to be three-way, and include the patient. We make sure we update the outpatient physicians on their patients’ progress daily." Scripps does this by phone, fax, and informal hallway consultation.
"In addition, you have to assure the patient that his doctors are communicating daily," Dworsky says."If you don’t do that, you’re in trouble from two standpoints: You may not be facilitating adequate communication, and you have an unhappy patient."
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