Physician Office (Home)

Context: Delayed or inaccurate communication between hospital-based and primary care physicians at hospital discharge may negatively affect continuity of care and contribute to adverse events. Objectives: To characterize the prevalence of deficits in communication and information transfer at hospital discharge and to identify interventions to improve this process. Data Sources: MEDLINE (through November 2006), Cochrane Database of Systematic Reviews, and hand search of article bibliographies. Study Selection: Observational studies investigating communication and information transfer at hospital discharge (n = 55) and controlled studies evaluating the efficacy of interventions to improve information transfer (n = 18). Data Extraction: Data from observational studies were extracted on the availability, timeliness, content, and format of discharge communications, as well as primary care physician satisfaction. Results of interventions were summarized by their effect on timeliness, accuracy, completeness, and overall quality of the information transfer. Data Synthesis: Direct communication between hospital physicians and primary care physicians occurred infrequently (3%-20%). The availability of a discharge summary at the first postdischarge visit was low (12%-34%) and remained poor at 4 weeks (51%-77%), affecting the quality of care in approximately 25% of follow-up visits and contributing to primary care physician dissatisfaction. Discharge summaries often lacked important information such as diagnostic test results (missing from 33%-63%), treatment or hospital course (7%-22%), discharge medications (2%-40%), test results pending at discharge (65%), patient or family counseling (90%-92%), and follow-up plans (2%-43%). Several interventions, including computer-generated discharge summaries and using patients as couriers, shortened the delivery time of discharge communications. Use of standardized formats to highlight the most pertinent information improved the perceived quality of documents. Conclusions: Deficits in communication and information transfer at hospital discharge are common and may adversely affect patient care. Interventions such as computer-generated summaries and standardized formats may facilitate more timely transfer of pertinent patient information to primary care physicians and make discharge summaries more consistently available during follow-up care.

August 7, 2019

Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians: Implications for Patient Safety and Continuity of Care JAMA February 28, 2007 297:831-841

Context: Delayed or inaccurate communication between hospital-based and primary care physicians at hospital discharge may negatively affect continuity of care and contribute to adverse events. Objectives: To characterize the prevalence of deficits in communication and information transfer at hospital discharge and to identify interventions to improve this process. Data Sources: […]
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Context: Delayed or inaccurate communication between hospital-based and primary care physicians at hospital discharge may negatively affect continuity of care and contribute to adverse events. Objectives: To characterize the prevalence of deficits in communication and information transfer at hospital discharge and to identify interventions to improve this process. Data Sources: MEDLINE (through November 2006), Cochrane Database of Systematic Reviews, and hand search of article bibliographies. Study Selection: Observational studies investigating communication and information transfer at hospital discharge (n = 55) and controlled studies evaluating the efficacy of interventions to improve information transfer (n = 18). Data Extraction: Data from observational studies were extracted on the availability, timeliness, content, and format of discharge communications, as well as primary care physician satisfaction. Results of interventions were summarized by their effect on timeliness, accuracy, completeness, and overall quality of the information transfer. Data Synthesis: Direct communication between hospital physicians and primary care physicians occurred infrequently (3%-20%). The availability of a discharge summary at the first postdischarge visit was low (12%-34%) and remained poor at 4 weeks (51%-77%), affecting the quality of care in approximately 25% of follow-up visits and contributing to primary care physician dissatisfaction. Discharge summaries often lacked important information such as diagnostic test results (missing from 33%-63%), treatment or hospital course (7%-22%), discharge medications (2%-40%), test results pending at discharge (65%), patient or family counseling (90%-92%), and follow-up plans (2%-43%). Several interventions, including computer-generated discharge summaries and using patients as couriers, shortened the delivery time of discharge communications. Use of standardized formats to highlight the most pertinent information improved the perceived quality of documents. Conclusions: Deficits in communication and information transfer at hospital discharge are common and may adversely affect patient care. Interventions such as computer-generated summaries and standardized formats may facilitate more timely transfer of pertinent patient information to primary care physicians and make discharge summaries more consistently available during follow-up care.
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http://jama.ama-assn.org/cgi/content/abstract/297/8/831

August 7, 2019

Geriatric Resources for Assessment and Care of Elders (GRACE): A New Model of Primary Care for Low-Income Seniors. J Am Geriatr Soc. 2006;54(7):1136-1141.

The majority of older adults receive health care in primary care settings, yet many fail to receive the recommended standard of care for preventive services, chronic disease management, and geriatric syndromes. The Geriatric Resources for Assessment and Care of Elders (GRACE) model of primary care for low-income seniors and their […]
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The majority of older adults receive health care in primary care settings, yet many fail to receive the recommended standard of care for preventive services, chronic disease management, and geriatric syndromes. The Geriatric Resources for Assessment and Care of Elders (GRACE) model of primary care for low-income seniors and their primary care physicians (PCPs) was developed to improve the quality of geriatric care so as to optimize health and functional status, decrease excess healthcare use, and prevent long-term nursing home placement. The catalyst for the GRACE intervention is the GRACE support team, consisting of a nurse practitioner and a social worker. Upon enrollment, the GRACE support team meets with the patient in the home to conduct an initial comprehensive geriatric assessment. The support team then meets with the larger GRACE interdisciplinary team (including a geriatrician, pharmacist, physical therapist, mental health social worker, and community-based services liaison) to develop an individualized care plan including activation of GRACE protocols for evaluating and managing common geriatric conditions. The GRACE support team then meets with the patient's PCP to discuss and modify the plan. Collaborating with the PCP, and consistent with the patient's goals, the support team then implements the plan. With the support of an electronic medical record and longitudinal tracking system, the GRACE support team provides ongoing care management and coordination of care across multiple geriatric syndromes, providers, and sites of care. The effectiveness of the GRACE intervention is being evaluated in a randomized, controlled trial.
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http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2006.00791.x/abstract

August 7, 2019

Team-Developed Care Plan and Ongoing Care Management by Social Workers and Nurse Practitioners Result in Better Outcomes and Fewer Emergency Department Visits for Low-Income Seniors

Social worker/nurse practitioner teams collaborate with a larger interdisciplinary team and primary care physicians to develop and implement individualized care plans for low-income seniors. The social worker/nurse team also proactively manages and coordinates the patient’s care on an ongoing basis through regular telephone and in-person contact with both patients and […]
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Social worker/nurse practitioner teams collaborate with a larger interdisciplinary team and primary care physicians to develop and implement individualized care plans for low-income seniors. The social worker/nurse team also proactively manages and coordinates the patient's care on an ongoing basis through regular telephone and in-person contact with both patients and providers. The program, known as Geriatric Resources for Assessment and Care of Elders (GRACE), improved the provision of evidence-based care; led to significant improvements in measures of general health, vitality, social functioning, and mental health; reduced emergency department visits and hospital admissions; and generated high levels of physician and patient satisfaction. A recent analysis found that the program was cost neutral for high-risk patients in the first 2 years, and yielded savings by year three. Strong: The evidence consists of a randomized controlled trial (RCT) of 951 patients that compared results for program participants with patients receiving usual care on a variety of metrics (including functional status, activity of daily living status, ED and hospital use, and patient and physician satisfaction).
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http://www.innovations.ahrq.gov/content.aspx?id=2066

August 7, 2019

AARP: Advance Directives: Planning for the Future

AARP: Advance Directives: Planning for the Future. [Web site]. http://assets.aarp.org/external_sites/caregiving/multimedia/EG_AdvanceDirectives.html . Accessed July 31, 2015. Do you know what your loved one’s health care wishes are at the end of life? Find out how advance directives can help.
AARP: Advance Directives: Planning for the Future. [Web site]. http://assets.aarp.org/external_sites/caregiving/multimedia/EG_AdvanceDirectives.html . Accessed July 31, 2015. Do you know what your loved one's health care wishes are at the end of life? Find out how advance directives can help.
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http://assets.aarp.org/external_sites/caregiving/multimedia/EG_AdvanceDirectives.html

August 7, 2019

AARP: Talking About Your Final Wishes

AARP: Talking About Your Final Wishes. [Web site]. Published October 1, 2003. Accessed July 31, 2014. Making decisions about how you want to spend your final days is not simple. There are many factors and options available today that may influence your care at the end of life. Where do […]
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AARP: Talking About Your Final Wishes. [Web site]. Published October 1, 2003. Accessed July 31, 2014. Making decisions about how you want to spend your final days is not simple. There are many factors and options available today that may influence your care at the end of life. Where do I want to die? Who will take care of me? What do I have to do to achieve a "good death?" These questions raise just a few of the issues to be considered in deciding your care at the end of life.
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http://www.aarp.org/relationships/grief-loss/info-2003/endoflife-finalwishes.html

August 7, 2019

What is the Patient-Centered Medical Home?

A Patient-Centered Medical Home is a team-based model of care led by a personal physician who provides continuous and coordinated care throughout a patient’s lifetime to maximize health outcomes. The PCMH practice is responsible for providing for all of a patient’s health care needs or appropriately arranging care with other […]
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A Patient-Centered Medical Home is a team-based model of care led by a personal physician who provides continuous and coordinated care throughout a patient's lifetime to maximize health outcomes. The PCMH practice is responsible for providing for all of a patient’s health care needs or appropriately arranging care with other qualified professionals. This includes the provision of preventive services, treatment of acute and chronic illness, and assistance with end-of-life issues. It is a model of practice in which a team of health professionals, coordinated by a personal physician, works collaboratively to provide high levels of care, access and communication, care coordination and integration, and care quality and safety.
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http://www.acponline.org/running_practice/pcmh/understanding/what.htm

August 7, 2019

Reducing Emergency Visits in Older Adults With Chronic Illness

Coleman E, Eilertsen T, Kramer A. Reducing Emergency Visits in Older Adults With Chronic Illness. Eff Clin Pract. 2001;(4) 49-57. http://www.caretransitions.org/documents/Reducing%20ER%20-%20ECP.pdf Accessed August 1, 2014. On average, patients in the intervention group attended 10.6 group visits during the 2-year study period. These patients averaged fewer emergency department visits (0.65 vs. […]
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Coleman E, Eilertsen T, Kramer A. Reducing Emergency Visits in Older Adults With Chronic Illness. Eff Clin Pract. 2001;(4) 49-57. http://www.caretransitions.org/documents/Reducing%20ER%20-%20ECP.pdf Accessed August 1, 2014. On average, patients in the intervention group attended 10.6 group visits during the 2-year study period. These patients averaged fewer emergency department visits (0.65 vs. 1.08 visits; P=0.005) and were less likely to have any emergency department visits (34.9% vs. 52.4%; P =0.003) than controls. These differences remained statistically significant after controlling for demographic factors, comorbid conditions, functional status, and prior utilization. Adjusted mean difference in visits was –0.42 visits (95% CI, –0.13 to –0.72), and adjusted RR for any emergency department visit was 0.64 (CI, 0.44 to 0.86).
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http://www.caretransitions.org/documents/Reducing%20ER%20-%20ECP.pdf

August 7, 2019

The Advanced Medical Home: A Patient-Centered, Physician-Guided Model of Health Care

A policy paper providing proposals for resolving some of the major problems with the health care system in America was released today by The American College of Physicians (ACP) at its annual report on “The State of the Nation’s Health Care.” “The Advanced Medical Home: A Patient-Centered, Physician-Guided Model of […]
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A policy paper providing proposals for resolving some of the major problems with the health care system in America was released today by The American College of Physicians (ACP) at its annual report on "The State of the Nation's Health Care." "The Advanced Medical Home: A Patient-Centered, Physician-Guided Model of Health Care," proposes a fundamental change in the way that principal - or primary care - is delivered and financed. "ACP proposals would provide patients with access to care that is coordinated by their own personal physician," explained C. Anderson Hedberg, ACP president. "The physicians will be working in a practice environment organized around patients' needs." The paper recommends voluntary certification and recognition of primary care and specialty medical practices that use health information technology, quality measurement and reporting, patient-friendly scheduling systems and other "best practices" to deliver better value and improve care coordination for patients, especially those with multiple chronic illnesses.
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http://www.acponline.org/pressroom/admed_home.htm

August 7, 2019

The Medicare Physician Group Practice Demonstration: Lessons Learned on Improving Quality and Efficiency in Health Care

ABSTRACT: In April 2005, the Centers for Medicare and Medicaid Services (CMS) initiated the Physician Group Practice demonstration, which offers 10 large practices the opportunity to earn performance payments for improving the quality and cost-efficiency of health care delivered to Medicare fee-for-service beneficiaries. This report is based on the proceedings […]
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ABSTRACT: In April 2005, the Centers for Medicare and Medicaid Services (CMS) initiated the Physician Group Practice demonstration, which offers 10 large practices the opportunity to earn performance payments for improving the quality and cost-efficiency of health care delivered to Medicare fee-for-service beneficiaries. This report is based on the proceedings of a 2006 site conference held in Baltimore and cosponsored by The Commonwealth Fund, CMS, and the Agency for Healthcare Research and Quality. The meeting provided a forum for PGPs to: 1) explore specific care management models, including methods for implementation and assessment of effectiveness; 2) accelerate learning across PGPs through information sharing; and 3) harvest knowledge and develop a plan for case studies and descriptive reports on successful care management models. A number of promising practice changes were discussed, such as increasing patient engagement, expanding care management, improving care transitions, and expanding non-physician roles.
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http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2008/Feb/The-Medicare-Physician-Group-Practice-Demonstration--Lessons-Learned-on-Improving-Quality-and-Effici.aspx

August 7, 2019

Are Electronic Medical Records Helpful for Care Coordination? Experiences of Physician Practices

BACKGROUND Policies promoting widespread adoption of electronic medical records (EMRs) are premised on the hope that they can improve the coordination of care. Yet little is known about whether and how physician practices use current EMRs to facilitate coordination. OBJECTIVES We examine whether and how practices use commercial EMRs to […]
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BACKGROUND Policies promoting widespread adoption of electronic medical records (EMRs) are premised on the hope that they can improve the coordination of care. Yet little is known about whether and how physician practices use current EMRs to facilitate coordination. OBJECTIVES We examine whether and how practices use commercial EMRs to support coordination tasks and identify work-arounds practices have created to address new coordination challenges. DESIGN, SETTING Semi-structured telephone interviews in 12 randomly selected communities. PARTICIPANTS Sixty respondents, including 52 physicians or staff from 26 practices with commercial ambulatory care EMRs in place for at least 2 years, chief medical officers at four EMR vendors, and four national thought leaders. RESULTS Six major themes emerged: (1) EMRs facilitate within-office care coordination, chiefly by providing access to data during patient encounters and through electronic messaging; (2) EMRs are less able to support coordination between clinicians and settings, in part due to their design and a lack of standardization of key data elements required for information exchange; (3) managing information overflow from EMRs is a challenge for clinicians; (4) clinicians believe current EMRs cannot adequately capture the medical decision-making process and future care plans to support coordination; (5) realizing EMRs’ potential for facilitating coordination requires evolution of practice operational processes; (6) current fee-for-service reimbursement encourages EMR use for documentation of billable events (office visits, procedures) and not of care coordination (which is not a billable activity). CONCLUSIONS There is a gap between policy-makers’ expectation of, and clinical practitioners’ experience with, current electronic medical records’ ability to support coordination of care. Policymakers could expand current health information technology policies to support assessment of how well the technology facilitates tasks necessary for coordination. By reforming payment policy to include care coordination, policymakers could encourage the evolution of EMR technology to include capabilities that support coordination, for example, allowing for inter-practice data exchange and multi-provider clinical decision support.
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http://www.springerlink.com/content/j02w23143245j24r/