Managing the Transition from Hospital to Home

For the elderly and especially the elderly with diabetes in the United States, this is a real problem. Today, most primary care doctors do not make rounds in a hospital and often are not aware that a patient of theirs is in the hospital. Fact is, most hospitals do not contact the patient's doctor to let them know they are in the hospital even when requested by the patient.

This is the reason that transitions from the hospital to home are so difficult for many of the elderly. If they don't have someone available to be a caregiver for them and see to it that they get to their primary care doctor, often that does not happen and the person ends back up in the hospital.

The divide between outpatient and inpatient medicine seems to be growing, highlighting the importance of managing care transitions as an outpatient-only physician, according to this article published in Medical Economics.

According to the article, primary care doctors can play a major role in preventing transition gaps for their hospitalized patients. Lines of communication should remain open between hospital-based clinicians and primary care doctors, via electronic medical records and other modes of communication. Yet, many hospitals are not doing this.

Primary care doctors can have the greatest influence on continuity after patient discharge. Follow-up visits should include assessment of patient recovery and review of the post-discharge care plan and medication regimen. How can the primary care doctor do this when hospitals will not communicate.

The shift to a hospitalist model of care can be unnerving for elderly patients, and it is important to notify patients of this change. Courtesy visits to the hospital allow primary care physicians to stay involved in patient care without being the caregiver in the hospital, and are important for patients. Many primary care doctors will not visit the hospital because they are not reimbursed for doing this. So it is a two way disconnect because most primary care doctors expect their patients to present themselves at their office.

Yet, when a few hospitals have contacted doctors that do make house calls or reach agreements with nurses to see discharged patients from the hospital, primary care doctors become upset and raise all sorts of issues that they are the ones their patient should see. Yeh, right doctors, the patient may not be capable of travel or does not have transportation available to come to your office. This is a catch-22 for some elderly patients.