Family Medicine Matters Blog

The OCFP Blog discusses current topics and invites members to share their perspectives and ideas, and engage in a dialogue.

Family Doctors and Transitions in Care

June 24, 2016

This past winter a long-time patient presented to our rural hospital having a myocardial infarction (STEMI).  She was treated here and transferred to our regional centre’s ICU for ongoing acute management.

I saw her a few days after discharge and her recall of events and information was patchy and unclear, as is often the case post-ICU.  She also did not have her medications list, and I had not received a discharge summary.  She saw the cardiologist six weeks following discharge, and the information in his consultation note for that visit did not include any of the recent hospital history or the medication summary, and no real plan.  Clearly, he did not have the discharge summary either.

My ability to manage her care after her hospital stay was made easier only because I have access to the tertiary hospital EMR through our regional hospital network, and I could see details of her care and a list of her discharge medications.

It should not be this difficult. Transferring information to support a patient’s transition in care from the hospital to their family physician should be a systemized process. This is not a “nice to have” – it is a “must have.”  Excellence in informational continuity supports excellence in physician-patient relational continuity, which is a key value of family medicine and primary care.

Why focus on transitions in care?

We know that all transitions in care – all handovers from one provider to another – carry risk. Transitions from one sector to another are even more complicated than simple handovers from one provider to another, and this is perhaps particularly true for transitions in care from hospital back to primary care or home-care in the community.  We know that in Ontario we face some particular challenges in coordinating care for our patients and some of these challenges are highlighted in a recent report from Health Quality Ontario.

With many family physicians less involved now than in the past in the care of their own patients when in hospital, the need to be attentive to how we receive patients back into our practices deserves much greater attention.  This applies, not only to complex seniors discharged from an acute hospital stay, but to all patients experiencing a transition in care from the hospital sector – newborns leaving hospital, children recovering from acute illness, and patients discharged after an admission for mental illness or addiction treatment program.

When transitions in care are not managed successfully from the hospital back to the family physician in primary care, there is risk of readmission to hospital and risk of repeat visit to the ER for the same condition. Importantly, without adequate support in the transitions of care, patient confidence in managing their own care can be badly shaken.

This matters greatly in the lives of patients and their families, and it matters from a system sustainability standpoint.

The role of the family doctor:

As family doctors one of our most important roles is to provide continuity of care to our patients. At a care transition point, it is important that we re-connect to patients who have been discharged from hospital.  This is particularly true for those patients at risk of readmission, who should ideally be seen within seven days of discharge. This allows us to re-establish the caring relationship and ensure that gaps are closed in care and care coordination.

During that first post-discharge visit, we need to ensure attention is paid to areas that create difficulty for patients post-discharge and ensure that home-care is involved if needed. Follow-up lab work, imaging and appointments with specialists all need to be arranged and coordinated, either by us as family physicians or by  practice nurses who also know our patients well; and it is critical that discharge medications are reconciled with the patient’s current medication list.

How can family doctors be better supported to manage transitions?

Upon hospital discharge, a few key pieces need to be in place for family physicians and other health-care providers who care for patients:
  • A discharge notification needs to be sent from the hospital in a timely way and a discharge summary also needs to be sent within 48 hours of the patient being discharged.
  • A confirmation that a patient received a discharge plan and understands it.
  • A discharge medication list that states which medications were stopped, which medications were newly added and why.
  • Better access to home-care coordinators so there is easier communication between family physicians and home-care to optimize patient care at home.

All of these steps will help decrease the risk of readmission and improve patient care.

What can a family doctor do now?

  • Ensure we have access to Hospital Report Manager (or its equivalent) to ensure we are receiving notification about admission and discharge of our patients.
  • Ensure access within seven days for discharged patients by creating practice systems to support access to those visits. This could include ensuring that booking staff is aware of the importance of accommodating discharged patients, and making appointments available each week.
  • Explore ways technology can support transitions in care – through simple things like email and phone calls, and using telemedicine to “visit” patients at home.
  • Begin to build relationships with local home-care coordinators and the local hospital – it is through those relationships that system problems can be most effectively addressed.
  • With colleagues and LHIN primary care councils or networks, encourage our local hospitals to adopt the Re-engineered discharge toolkit to improve discharge planning.

Successful transitions in care require that all health-care providers across sectors come together to function as a system – connected through communication and coordination and ensuring that patient needs are met.  We can do better in Ontario, and family physicians play an important and valuable role in the solution. 

The OCFP is working with the Ontario Hospital Association and other partners to look at how we can better support family physicians to provide better and more timely care to patients through supporting more effective transitions from hospital to home. Let us know what is working in your own communities.

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