Primary care-hospital integration has the potential to improve the quality of care for patients in Community Health Centers (CHCs).
Hospitals can better manage acute episodes when they can build on the medical and social history that the primary care provider knows well. Better management of conditions may lead to shorter lengths of stay and better patient experiences. In recent years, much attention has been paid to reducing preventable readmissions because preventable readmission to hospitals exacts a significant financial and human cost in the United States. About three-quarters of readmissions for Medicare patients are potentially preventable, representing an estimated $12 billion in potential cost savings each year. Readmission rates are highest for Medicare and Medicaid beneficiaries, with one in five Medicare patients re-hospitalized within 30 days. Unnecessary readmissions can be considered a surrogate measure for poor care coordination between hospital and primary care.
Although the majority of people admitted to a hospital report having a usual source of care, one in three adults discharged from the hospital do not see a clinician outside of the hospital within a 30-day time period. There is growing evidence that primary care follow-up after hospitalization reduces the rate of readmissions. Nearly half of patients discharged from the hospital experience at least one medical error in the post-discharge period, and many of these errors are preventable through improved communication between the hospital and primary care providers. Despite these findings, there is a lack of standardization in hospital discharge procedures for the transfer of patient data to primary care providers for proper follow up care. The hospital discharge summary (physician-dictated, transcribed reports) is the most common method for documenting the details of a patient’s hospital stay and arrangements for post-discharge follow-up, yet primary care providers do not consistently receive this information, even when they do follow-up with patients after a hospitalization. A review of literature found that only 12-13% of primary care providers had received a discharge summary at the time of their first post-discharge visit with the patient; moreover, key information such as test results and discharge medications was often not included.
Hospitals around the country are employing a number of strategies to reduce readmission rates and better integrate care. Recommendations for content, format, and timeliness of hospital communication to primary care medical homes can be found in published guidelines from the Joint Commission, the Society of General Internal Medicine, and the Society of Hospital Medicine, among other organizations. However, both the hospital and the primary care medical home have a role and responsibility in the coordination of patient care and in the effort to provide high quality care while reducing cost and preventable re-hospitalizations.
Strategies to promote coordination between primary care and hospital care fall on a spectrum of care integration. The most integrated model involves a primary care provider delivering inpatient care, though with the advent of hospitalists. A more common practice is the use of a hospital-based nurse to coordinate care at the time of discharge to home, primary care, or both. In the models described in our report, the nurse provides tailored care and education for patients, ensures that post-discharge follow-up appointments are made at primary care sites, and sometimes facilitates the transfer of patient information from the hospital to primary care providers. The most common care coordination practice is limited to the transfer of information through the hospital discharge form, through a shared electronic medical record system or via fax, mail, or hand-delivery. Finally, care coordination can involve primary care practices guaranteeing prompt access to post-discharge patients. These strategies are not specific to CHCs, but all are applicable to diverse primary care settings. Many of the models for coordination fit into a combination of the three coordination approaches, and, as in earlier sections, represent hybrids.