If hospitals want to improve care coordination, they will need a heavy dose of primary care in their leadership ranks, argue two physicians in a recent article.
Noemi Doohan, M.D., Ph.D., and Jennifer DeVoe, M.D., D.Phil., note in their article(www.annfammed.org) in the July/August issue of Annals of Family Medicine that hospitalists make up the fastest-growing internal medicine subspecialty, and continuity of care remains the Achilles' heel of the hospitalist model.
That situation could be reversed if hospitals were to employ an executive-level physician whose responsibilities included developing and managing primary care connections across the hospital system and with community partners. The authors propose creating the position of chief primary care medical officer (CPCMO), who would split daily responsibilities between clinical care and care coordination across the health spectrum. They said funding for the position could come from "savings that arise from improved value" and that family physicians are the best choice to fill the new role.
"Primary care's core tenets of comprehensiveness and continuity are critical contributors to patient and population health, yet the connection between patient and primary care physician is increasingly severed at the hospital door," the authors wrote.
Ideally, the CPCMO would be a primary care physician who works 25 percent of the time in an outpatient clinic setting, another 25 percent as a hospital clinician, and the remaining 50 percent in administration at the hospital leadership level.
As a strategist, the CPCMO would build and maintain continuity of care between the hospital and chronic care settings through tactics that include keeping inpatient and outpatient care teams connected and increasing primary care's role in acute-care settings. The officer's effectiveness could be measured in part by lower readmission rates and shorter hospital stays.
Creating the role of CPCMO would help reduce costs and improve care by addressing the breaks in continuity that often lead to readmissions. Under the current system, for example, details about a hospital visit might not be sent to a patient's primary care physician, or a patient might not even have a primary care physician.
"Patients are discharged and told to follow up with their primary care physician by hospital systems that often have little knowledge of the primary care physician's practice," the authors wrote.
Even a gradual implementation of the CPCMO model that focused initially on high-need, high-cost patients could make a major difference, the authors wrote, because the top 1 percent of these patients account for 20 percent of all health care spending.
The authors included several hypothetical examples of gaps in care that could be addressed by their proposal. In one scenario, a patient reports to the hospital with terminal cancer and wants to be discharged to hospice care at home, but he has no primary care physician who can supervise the transition. In this case, a CPCMO would ensure that the patient is assigned to a primary care physician and make the first appointment within hospice care.
Another hypothetical case involves a patient with a hip fracture whose discharge to a skilled nursing facility is prolonged because her primary care physician recently retired. A CPCMO would connect the patient with a primary care physician, supervise the referral to the skilled nursing facility and confirm that the patient schedules an initial primary care appointment.
The authors closed by explaining why family physicians are best suited to take on the role of CPCMO.
"Family physicians' hospitalist knowledge, coupled with continued expertise and leadership in the outpatient setting, uniquely positions our profession to bridge the divide between the inpatient and outpatient worlds," the authors wrote. "Family physicians can fill the expert-generalist role that is increasingly needed in our evolving health care system."
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