Transitions of Care: Optimizing the Handoff from Hospital-Based Teams to Primary Care Physicians

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Am Fam Physician. 2014 May 1;89(9):706-707.

In a recent study of Medicare beneficiaries who had been hospitalized, nearly one in five was readmitted within 30 days of discharge, and those with conditions such as congestive heart failure or chronic obstructive pulmonary disease had even higher rates of readmission.1 This results in an estimated cost of more than $17 billion to the federal government.1 A systematic review of interventions to improve the handover of patient care from hospital-based teams to primary care physicians found that multicomponent interventions that include medication reconciliation, use of electronic tools to facilitate communication, and shared involvement in coordinating follow-up care reduce rehospitalizations and improve patient satisfaction.2 Because the average length of hospitalization is four days for most general medicine patients, primary care physicians and hospital-based teams must partner from the moment of hospitalization to optimize the transition plan.

The effectiveness of hospital-based care transition programs is unclear. Although some programs reduced 30-day rehospitalization rates,3,4 a systematic review found that no single intervention is reliably helpful, and successful readmission reduction programs generally occur only in single institutions.5 However, it seems that programs that focus on the whole patient rather than a specific diagnosis are more successful in reducing readmissions.6 This concept is in keeping with the focus of primary care physicians. To solve the challenge of

Address correspondence to Christopher S. Kim, MD, at seoungk@med.umich.edu. Reprints are not available from the authors.

Author disclosure: Dr. Kim formerly served on the speaker's bureau for Merck, where he led peer discussion sessions on the topic of optimizing transitions of care. He did not discuss any specific drugs or devices. He terminated his relationship with the speaker's bureau in November 2011. Dr. Coffey reports no relevant financial affiliations.


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8. Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005;143(2):121–128.

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10. Kim CS, Flanders SA. In the clinic. Transitions of care. Ann Intern Med. 2013;158(5 pt 1):ITC3-1.

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