Studies show decrease in senior care continuity
End-of-life discussions should be reimbursed
If the discharge planning community's ideal is to begin the discharge process at the door, when patients are admitted to the hospital, then community provider input is necessary for a smooth care transition.
But care continuity has been low, and it's decreasing for older adults, recent studies show.1,2
A study that examined the proportion of patients who are seen by their primary care physician during their hospitalization found a significant decline in this continuity of care, says Gulshan Sharma, MD, MPH, an associate professor at the University of Texas Medical Branch in Galveston.
"The proportion declined from 50.5% to 44.3% between 1996 and 2006," Sharma says.2
The study showed an even greater decrease in continuity in cases where patients were admitted to the hospital on weekends and for those living in large metropolitan areas.2
The results were not too surprising, given the changes that have taken place in the delivery of health care over the past two decades, Sharma notes.
"To improve efficiency of care, you have primary care physicians managing patients in very busy practices, and it's hard for them to go see patients who are hospitalized," he explains. "So there's been a large growth in hospitalists' positions, and these are the people who provide care for patients when they're hospitalized."
The older model of having one physician follow patients through the trajectory of their illness and care no longer is followed.
"The health care system is getting more efficient, with physicians spending more time at their part of this system, but the price you pay is fragmented care," Sharma notes.
"There's a lot of disruption in care, and there's no major effort to have a physician make sure the transition is smooth in either direction," he says.
Similarly, there are no practice or economic incentives for hospitalists to follow up with patients once they've returned to the community, Sharma adds.
"That's where a major discussion is going on: How do you make this transition smooth?" Sharma says. "One way would be through an electronic health record."
Hospital systems and community providers who can connect electronically can provide follow-up care and a smoother transition through electronic communication, he says.
But research suggests that having a primary care provider attend a patient in the hospital can improve health care outcomes. In one study, investigators found that patients with terminal lung cancer who were visited by community physicians while in the hospital were less likely to spend time in the intensive care unit (ICU) before death.1
"So it might be good for discharge planners to have a primary care physician visit patients," Sharma notes, "and discharge planning should include communication with a patient's primary care physician, so they'll know what's going on."
One reason those primary care physician visits to hospitalized patients are decreasing is that there is no reimbursement for them, he says.
"Medicare won't reimburse for two physicians for the same specialty," he explains. "So, if you have an internal medicine doctor providing care and a primary care physician who also sees the patient, then whoever sends in the claim first gets paid."
Health care reform discussion has included a discussion of paying primary care providers for visiting at least terminally ill patients when they are hospitalized, but this possibility may be eliminated from any final Congressional bill because of the summer's emotional debates about insurers covering end-of-life care discussions.
Still, there has to be some discussion between hospital staff and community physicians about the patient's end-of-life care plans, whether this is via the telephone or e-mail, he suggests.
"It's possible there already is some communication occurring over the phone, and our research hasn't captured that in the billing information we used from Medicare," Sharma says. "But we need a better way of reimbursing the primary care physician for helping the hospital doctor in better decision making."
Primary care physicians should be reimbursed for having these discussions with patients, Sharma adds.
"We need to improve care transition communication and building patient-physician trust," Sharma says. "Once patients trust their physicians, they can make more appropriate decisions."
References
- Sharma G, Freeman J, Zhang D, et al. Continuity of care and intensive care unit use at the end of life. Arch Intern Med 2009; 169:81-86.
- Sharma G, Fletcher KE, Zhang D, et al. Continuity of outpatient and inpatient care by primary care physicians for hospitalized older adults. JAMA 2009; 301(16):1671-1680.
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