Care Coordination and Children’s Hospitals

Until the mid-1990s, clinical care was typically managed by a single provider who followed patients throughout the continuum of care. That model has been deliberately separated into hospital-based inpatient care and practice-based outpatient care, enabling greater specialization and more effective treatment in each setting. However, an unintended consequence of the change was the emergence of information gaps between providers, resulting in disjointed care as patients crossed boundaries. Children’s hospitals have typically tackled this problem by having hospital staff manually call or fax the outpatient providers, such as pediatricians, for a handful of the most high-risk patients — a laborious process that is inconsistent, prone to error, and ignores the bulk of the patients who walk through the hospital or ED.

From the outpatient provider’s perspective, not only is it an embarrassment to be caught off-guard when a parent and child arrives from the hospital, but it is also frustrating to scramble for the information needed — whether it be the laborious process of calling the hospital, or logging into slow legacy hospital systems to retrieve an unwieldy 20-page EMR. Given, for example, that the average PCP has only 5–15 minutes to treat a patient, more often than not he/she will simply complete the patient visit without the benefit of that data. As a result, patient care compromised, and the hospital reputation suffers.

This results in lost referrals for the hospital, which is a major concern for hospitals that receive significant referral revenues. Outpatient providers typically refer patients to the hospitals that provide a strong level of base service and are easy to work with. As a result, in the eyes of this provider, the perceived disjointedness of the post-discharge transition can be a major factor in deciding whether or not to refer patients to the hospital.

​State of the State

  1. Direct communication between hospital physicians and primary care physicians occurs in only 3 to 20 percent of cases. -Journal of the American Medical Association, 2007
  2. Only 12-34% of doctors received discharge summaries by the time patients make their first post-discharge visits. The range rises to only 51-77% after four weeks, affecting the quality of care in about a quarter of follow-up visits. - Journal of the American Medical Association, 2007
  3. 78% of patients discharged from the ER do not understand their diagnosis, their ER treatment, home care instructions, or warning signs of when to return to the hospital. – Annals of Emergency Medicine, June 2000
  4. At discharge, only 42% of patients are able to state their diagnosis, and 37% are able to state the purpose of all of their medications. – Mayo Clinic Proceedings, 2005
  5. A 20% reduction in the national readmission rate would prevent approximately 7,000 readmissions per year for AMI, 22,000 for heart failure, and 14,000 for pneumonia. –The Centers for Medicare and Medicaid
  6. 41% of inpatients are discharged with a pending test result. 2/3 of physicians are unaware of the results of the pending tests. –Annals of Internal Medicine, 2005
  7. 75% of discharge summaries do not mention any pending test results. Only 13% of discharge summaries document all pending tests.  –The Journal of General Internal Medicine, September 2009

Bottom Line

Poor care coordination not only impacts health outcomes, but also degrades the experience of both patients and community pediatricians. The solution is to engage patients during each hospital and ER encounter and proactively communicate patient status to community pediatrians. Sounds easy, right? The reality is that it is difficult for large organizations to make needed changes to the way they communicate with their stakeholders -- in this case patients and community physicians. Axial has a proven method for making these changes as painless as possible for hospitals and as beneficial as possible for health outcomes and the satisfaction of patients and providers. Want to learn more? Check out our white papers. And then let's talk.