COMMENTARY
Coordinating the Medical Home With Hospitalist Care
THE MEDICAL HOME The Patient Centered Medical Home (PCMH) is an approach to providing comprehensive primary care for children, youth, and adults.1 PCMH facilitates partnerships with individual patients, their personal physicians, and family. In pediatrics, PCMH is usually referred to as the Patient and Family Centered Medical Home, or just the Medical Home (MH). The MH was named over 40 years ago as a way to maintain centralized medical records of children and has evolved over the years to the current concept. The MH should be accessible, continuous, comprehensive, patient- and family-centered, coordinated, compassionate, community-based and culturally effective.2–4 The principles of the MH are: 1. Each patient has an ongoing relationship with a personal physician; 2. The personal physician participates in a team of individuals who take responsibility for the ongoing care of that patient; 3. The personal physician is responsible for providing all of the patient’s health care needs or appropriately arranging care with other qualified professionals; 4. The patients’ health care is coordinated across all elements of the health care system (including hospitals) as well as with community-based organizations (schools, mental health centers, etc).
AUTHORS Jerrold Eichner, MD, FAAP1,2 and W. Carl Cooley, MD, FAAP 3,4,5 1
Great Falls Clinic, Great Falls, Montana Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington 3 Crotched Mountain Foundation, Greenfield, New Hampshire 4 Center for Medical Home Improvement, Concord, New Hampshire 5 Department of Pediatrics, Dartmouth Medical School, Hanover, New Hampshire 2
www.hospitalpediatrics.org doi:10.1542/hpeds.2011-0033 HOSPITAL PEDIATRICS (ISSN Numbers: Print, 0031 - 4005; Online, 1098 - 4275). Copyright © 2012 by the American Academy of Pediatrics
Care coordination is one of the key principles of the MH.5 Care coordination tracks ancillary studies, referrals, and transitions in care to ensure completion and document outcomes. Consistent, timely, bidirectional communication is at the heart of care coordination. Such communication includes the primary care MH, the other involved health care professionals, and the patient or family. Knowing the patient and family’s preferences and wishes for care and sharing that information with other caregivers is essential.6 When a child requires hospitalization the child may arrive self-referred, by ambulance, or by referral from the MH. Hospitalization is a significant and stressful event in the life of a child and family. Some MHs are part of a larger health care organization, including the hospital, making care coordination and hospital admission an integrated process. However, most of the time the transfer of care requires contact by the MH physician with a hospitalist when admission is necessary.
PEDIATRIC HOSPITALISTS The hospitalist movement began over 20 years ago with adult programs7 and spread to pediatrics at least 15 years ago. The American Academy of Pediatrics instituted the Provisional Section on Hospital Medicine in 1999 which matured into the Section on Hospital Medicine in 2003. Benefits of care by pediatric hospitalists
Downloaded from http://hosppeds.aappublications.org/ at Nyu Medical Center on April 28, 2015
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may include a decrease in cost of hospital care and length of stay.8,9 There is possible improvement and at least no decrease in quality of care, patient and family satisfaction, and teaching in residency programs.10,11
HOSPITALIZATION A major problem with sharing care between the MH and hospitalists seems to lie with the transitions between caregivers.12–14 On admission, information shared between the hospitalist and the MH physician should include the rationale for admission, the working diagnosis and chronic conditions (problem list), key components of the history, especially recent changes, pertinent laboratory results, radiologic tests, and the patient’s and family’s status and reaction to the hospitalization.15 During hospitalization, routine communication regarding progress in the hospital, significant events, surgeries, and other procedures during the hospital stay should trigger communication with the MH physician. Without such communication, the MH physician who knows that child and family best may be left out of important evaluation and management decisions. Poor communication between the MH and the hospitalist at the time of admission and between the hospitalist and MH at the time of discharge may have detrimental effects on the patient.16–20 Readmission and adverse events due to medical errors especially those involving medications, failures in diagnostic test follow-up, and poor follow-through with the treatment plan are common and may be prevented or ameliorated by effective communication at hospital discharge.18,21–23 Children with medical complexity, in particular, those who are medically fragile or technology dependent, account 106 |
VOLUME 2 • ISSUE 2
for increasing numbers of pediatric hospitalizations.24,25 Care coordination and effective communication between the hospitalist and the primary care MH are critical for this population. In such instances, a “continuity visit” by the MH physician may be useful to endorse the hospitalist and the care being given, propose revisions in care, fill gaps in the patient’s history, clarify patient or family preferences for care, and gain familiarity with the patient’s condition in the hospital that will benefit care as an outpatient.12,26
DISCHARGE COMMUNICATION Planning for discharge begins at the time of admission. Criteria for discharge should be developed simultaneously with the plan of care resulting in a time line or estimate for the length of hospitalization. Before discharge there should be agreement among the inpatient team, the patient/family, and the MH physician on the conditions and timeliness of discharge. If the family is not ready (issues with home caregivers or equipment, etc) or the MH team cannot arrange a follow-up visit in the time period necessary, the discharge may be delayed. Safety is of paramount importance and The Joint Commission’s patient safety goals require communication at discharge (as well as at admission and at regular intervals during hospitalization).27 Methods of discharge communication should include a telephone call for rapid notification of discharge followed by discharge information by fax, e-mail, regular mail, or electronic transfer. Communication should include the discharge diagnosis, medications (reconciled with the admission medications), laboratory and radiology test results, pending test results, and the timing of follow-up appointments.
www.hospitalpediatrics.org
Naturally, this information needs to reach the MH before the hospitalization follow-up visit. The hospitalist should provide a written plan for the family to follow, including instructions in case the patient’s condition changes and whom to contact with problems or questions before the follow-up appointment. The few controlled studies looking at hospital discharge involved adult patient settings.28–30 The idea of an explicit “care transitions intervention” to improve outcomes after discharge has developed. Four principles form the core of this intervention: (1) assistance with medication self-management; (2) a patient-centered record owned and maintained by the patient (or family) to facilitate cross-site information transfer; (3) timely follow-up with primary and specialty care; and (4) a list of “red flags” indicative of a worsening condition and instructions on how to respond to them. Two mechanisms were used to encourage patients and their caregivers to assert a more active role during transitions and to foster care coordination and continuity: (1) a personal health record and (2) a series of visits and/or telephone calls with a “transition coach.” The transition coach was an advance practice nurse in Coleman’s study, but could be a registered nurse in the MH.21,30
TRANSITIONS OF CARE The “Transitions of Care Consensus Policy Statement” was published in 2009, endorsed by the American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians and Society for Academic Emergency Medicine,31 and identified 9 principles for effective care transitions:
Downloaded from http://hosppeds.aappublications.org/ at Nyu Medical Center on April 28, 2015
HOSPITAL Pediatrics ®
1. Accountability 2. Communication: clear and direct communication of treatment plans and follow-up expectations 3. Timely feedback and feed-forward of information 4. Involvement of the patient and family member, unless inappropriate, in all steps 5. Respect for the hub of coordination of care (the MH). 6. Ability of patients and families to identify their MH or coordinating clinician. 7. Clarity for patients and families at all times during the transition process about who is responsible for care at a given time, whom to contact, and how to do so. 8. Establishment of national standards for transitions in care to be adopted and implemented at the national and community level through public health institutions, national accreditation bodies, medical societies, and medical institutions to improve patient outcomes and patient safety. 9. Standard measures related to these standards to track outcomes and undertake continuous quality improvement and accountability. From these 9 principles the Transitions of Care Consensus Conference attendees identified 7 standards and prioritized them in this order: 1. All transitions include a transition record (care plan) 2. Transition responsibility is explicitly identified 3. Coordinating clinicians (the MH) are identified 4. Patient and family are involved and own the transition record 5. Communication infrastructure exists for the transmission of information
AN OFFICIAL JOURNAL OF THE AMERICAN ACADEMY OF PEDIATRICS
6. Timeliness remains a priority 7. Community standards are adopted and followed
CONCLUSIONS Future challenges include documenting the effectiveness of the standards, obtaining the endorsement of various physician groups, hospitals, and insurance carriers (including Medicare and Medicaid) and then implementing them around the country. Excess costs for the development of MH programs and their implementation are likely to be mitigated by savings from prevention of readmission, duplication of laboratory and radiology testing, and prevention of medical errors.
REFERENCES 1. American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint principles of the patientcentered medical home. 2007. Available at: www.medicalhomeinfo.org/Joint%20 Statement.pdf. Accessed December 5, 2011.
8. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287(4): 487–494. 9. Landrigan CP, Conway PH, Edwards S, Srivastava R. Pediatric hospitalists: a systematic review of the literature. Pediatrics. 2006; 117(5):1736–1744. 10. Landrigan CP, Muret-Wagstaff S, Chiang VW, Nigrin DJ, Goldmann DA, Finkelstein JA. Effect of a pediatric hospitalist system on housestaff education and experience. Arch Pediatr Adolesc Med. 2002;156(9):877–883. 11. Friedman J. The hospitalist movement in general pediatrics. Curr Opin Pediatr. 2010; 22(6):785–790. 12. Harlan G, Srivastava R, Harrison L, McBride G, Maloney C. Pediatric hospitalists and primary care providers: a communication needs assessment. J Hosp Med. 2009;4(3):187–193. 13. Harlan GA, Nkoy FL, Srivastava R, et al. Improving transitions of care at hospital discharge—implications for pediatric hospitalists and primary care providers. J Healthc Qual. 2010;32(5):51–60. 14. Ruth JL, Geskey JM, Shaffer ML, Bramley HP, Paul IM. Evaluating communication between pediatric primary care physicians and hospitalists. Clin Pediatr (Phila). 2011; 50(10):923–928.
2. American Academy of Pediatrics. The medical home. Medical Homes Initiatives for Children With Special Needs Project Advisory Committee. Pediatrics. 2002;110(1):184–186.
15. Seelbach EB, Ottolini MC. Primary care physicians and hospitalists: two branches of the same tree. Pediatr Ann. 2010;39(2): 84–88.
3. American Academy of Pediatrics Council on Children with Disabilities. Care coordination in the medical home: integrating health and related systems of care for children with special health care needs. Pediatrics. 2005; 116(5):1238–1244.
16. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297(8): 831–841.
4. American Academy of Pediatrics. National Center of Medical Home Initiatives for Children With Special Needs. Available at: www.medicalhomeinfo.org. Accessed December 5, 2011. 5. Homer CJ, Cooley WC, Strickland B. Medical home 2009: what it is, where we were, and where we are today. Pediatr Ann. 2009;38(9): 483–490. 6. Lye PS; The Committee on Hospital Care and The Section on Hospital Medicine. Physicians’ role in coordinating care of hospitalized children. Pediatrics. 2010;126(4):829–832. 7. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335(7):514–517.
17. Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007;2(5):314–323. 18. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161–167. 19 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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20. Coleman EA, Smith JD, Raha D, Min SJ. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005;165(16):1842–1847.
24. Burns KH, Casey PH, Lyle RE, Bird TM, Fussell JJ, Robbins JM. Increasing prevalence of medically complex children in US hospitals. Pediatrics. 2010;126(4):638–646.
21. Coleman EA, Smith JD, Frank JC, Min SJ, Parry C, Kramer AM. Preparing patients and caregivers to participate in care delivered across settings: the Care Transitions Intervention. J Am Geriatr Soc. 2004;52(11): 1817–1825.
25. Simon TD, Berry J, Feudtner C, et al. Children with complex chronic conditions in inpatient hospital settings in the United States. Pediatrics. 2010;126(4):647–655.
22. Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18(8): 646–651. 23. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. Adverse drug events occurring following hospital discharge. J Gen Intern Med. 2005;20(4):317–323.
108 |
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26. Wachter RM, Pantilat SZ. The “continuity visit” and the hospitalist model of care. Dis Mon. 2002;48(4):267–272. 27. The Joint Commission. Joint Commission Resources, 2012 Comprehensive Accreditation Manual for Hospitals (CAMH), PC02.02.01 EPS 1-17. Available at: www.jcrinc.com/ ProductDetails4108.aspx. Accessed February 24, 2012. 28. Balaban RB, Weissman JS, Samuel PA, Woolhandler S. Redefining and redesigning
www.hospitalpediatrics.org
hospital discharge to enhance patient care: a randomized controlled study. J Gen Intern Med. 2008;23(8):1228–1233. 29. van Walraven C, Taljaard M, Bell CM, et al. Information exchange among physicians caring for the same patient in the community. CMAJ. 2008;179(10):1013–1018. 30. Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822–1828. 31. Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus policy statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine. J Hosp Med. 2009;4(6):364–370.
Downloaded from http://hosppeds.aappublications.org/ at Nyu Medical Center on April 28, 2015
Coordinating the Medical Home With Hospitalist Care Jerrold Eichner and W.Carl Cooley Hospital Pediatrics 2012;2;105 DOI: 10.1542/hpeds.2011-0033
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Coordinating the Medical Home With Hospitalist Care Jerrold Eichner and W.Carl Cooley Hospital Pediatrics 2012;2;105 DOI: 10.1542/hpeds.2011-0033
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://hosppeds.aappublications.org/content/2/2/105
Hospital Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 2012. Hospital Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2012 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 2154-1663.
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Coordinating the Medical Home With Hospitalist Care
THE MEDICAL HOME The Patient Centered Medical Home (PCMH) is an approach to providing comprehensive primary care for children, youth, and adults.1 PCMH facilitates partnerships with individual patients, their personal physicians, and family. In pediatrics, PCMH is usually referred to as the Patient and Family Centered Medical Home, or just the Medical Home (MH). The MH was named over 40 years ago as a way to maintain centralized medical records of children and has evolved over the years to the current concept. The MH should be accessible, continuous, comprehensive, patient- and family-centered, coordinated, compassionate, community-based and culturally effective.2–4 The principles of the MH are: 1. Each patient has an ongoing relationship with a personal physician; 2. The personal physician participates in a team of individuals who take responsibility for the ongoing care of that patient; 3. The personal physician is responsible for providing all of the patient’s health care needs or appropriately arranging care with other qualified professionals; 4. The patients’ health care is coordinated across all elements of the health care system (including hospitals) as well as with community-based organizations (schools, mental health centers, etc).
AUTHORS Jerrold Eichner, MD, FAAP1,2 and W. Carl Cooley, MD, FAAP 3,4,5 1
Great Falls Clinic, Great Falls, Montana Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington 3 Crotched Mountain Foundation, Greenfield, New Hampshire 4 Center for Medical Home Improvement, Concord, New Hampshire 5 Department of Pediatrics, Dartmouth Medical School, Hanover, New Hampshire 2
www.hospitalpediatrics.org doi:10.1542/hpeds.2011-0033 HOSPITAL PEDIATRICS (ISSN Numbers: Print, 0031 - 4005; Online, 1098 - 4275). Copyright © 2012 by the American Academy of Pediatrics
Care coordination is one of the key principles of the MH.5 Care coordination tracks ancillary studies, referrals, and transitions in care to ensure completion and document outcomes. Consistent, timely, bidirectional communication is at the heart of care coordination. Such communication includes the primary care MH, the other involved health care professionals, and the patient or family. Knowing the patient and family’s preferences and wishes for care and sharing that information with other caregivers is essential.6 When a child requires hospitalization the child may arrive self-referred, by ambulance, or by referral from the MH. Hospitalization is a significant and stressful event in the life of a child and family. Some MHs are part of a larger health care organization, including the hospital, making care coordination and hospital admission an integrated process. However, most of the time the transfer of care requires contact by the MH physician with a hospitalist when admission is necessary.
PEDIATRIC HOSPITALISTS The hospitalist movement began over 20 years ago with adult programs7 and spread to pediatrics at least 15 years ago. The American Academy of Pediatrics instituted the Provisional Section on Hospital Medicine in 1999 which matured into the Section on Hospital Medicine in 2003. Benefits of care by pediatric hospitalists
Downloaded from http://hosppeds.aappublications.org/ at Nyu Medical Center on April 28, 2015
| 105
HOSPITAL Pediatrics ®
AN OFFICIAL JOURNAL OF THE AMERICAN ACADEMY OF PEDIATRICS
may include a decrease in cost of hospital care and length of stay.8,9 There is possible improvement and at least no decrease in quality of care, patient and family satisfaction, and teaching in residency programs.10,11
HOSPITALIZATION A major problem with sharing care between the MH and hospitalists seems to lie with the transitions between caregivers.12–14 On admission, information shared between the hospitalist and the MH physician should include the rationale for admission, the working diagnosis and chronic conditions (problem list), key components of the history, especially recent changes, pertinent laboratory results, radiologic tests, and the patient’s and family’s status and reaction to the hospitalization.15 During hospitalization, routine communication regarding progress in the hospital, significant events, surgeries, and other procedures during the hospital stay should trigger communication with the MH physician. Without such communication, the MH physician who knows that child and family best may be left out of important evaluation and management decisions. Poor communication between the MH and the hospitalist at the time of admission and between the hospitalist and MH at the time of discharge may have detrimental effects on the patient.16–20 Readmission and adverse events due to medical errors especially those involving medications, failures in diagnostic test follow-up, and poor follow-through with the treatment plan are common and may be prevented or ameliorated by effective communication at hospital discharge.18,21–23 Children with medical complexity, in particular, those who are medically fragile or technology dependent, account 106 |
VOLUME 2 • ISSUE 2
for increasing numbers of pediatric hospitalizations.24,25 Care coordination and effective communication between the hospitalist and the primary care MH are critical for this population. In such instances, a “continuity visit” by the MH physician may be useful to endorse the hospitalist and the care being given, propose revisions in care, fill gaps in the patient’s history, clarify patient or family preferences for care, and gain familiarity with the patient’s condition in the hospital that will benefit care as an outpatient.12,26
DISCHARGE COMMUNICATION Planning for discharge begins at the time of admission. Criteria for discharge should be developed simultaneously with the plan of care resulting in a time line or estimate for the length of hospitalization. Before discharge there should be agreement among the inpatient team, the patient/family, and the MH physician on the conditions and timeliness of discharge. If the family is not ready (issues with home caregivers or equipment, etc) or the MH team cannot arrange a follow-up visit in the time period necessary, the discharge may be delayed. Safety is of paramount importance and The Joint Commission’s patient safety goals require communication at discharge (as well as at admission and at regular intervals during hospitalization).27 Methods of discharge communication should include a telephone call for rapid notification of discharge followed by discharge information by fax, e-mail, regular mail, or electronic transfer. Communication should include the discharge diagnosis, medications (reconciled with the admission medications), laboratory and radiology test results, pending test results, and the timing of follow-up appointments.
www.hospitalpediatrics.org
Naturally, this information needs to reach the MH before the hospitalization follow-up visit. The hospitalist should provide a written plan for the family to follow, including instructions in case the patient’s condition changes and whom to contact with problems or questions before the follow-up appointment. The few controlled studies looking at hospital discharge involved adult patient settings.28–30 The idea of an explicit “care transitions intervention” to improve outcomes after discharge has developed. Four principles form the core of this intervention: (1) assistance with medication self-management; (2) a patient-centered record owned and maintained by the patient (or family) to facilitate cross-site information transfer; (3) timely follow-up with primary and specialty care; and (4) a list of “red flags” indicative of a worsening condition and instructions on how to respond to them. Two mechanisms were used to encourage patients and their caregivers to assert a more active role during transitions and to foster care coordination and continuity: (1) a personal health record and (2) a series of visits and/or telephone calls with a “transition coach.” The transition coach was an advance practice nurse in Coleman’s study, but could be a registered nurse in the MH.21,30
TRANSITIONS OF CARE The “Transitions of Care Consensus Policy Statement” was published in 2009, endorsed by the American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians and Society for Academic Emergency Medicine,31 and identified 9 principles for effective care transitions:
Downloaded from http://hosppeds.aappublications.org/ at Nyu Medical Center on April 28, 2015
HOSPITAL Pediatrics ®
1. Accountability 2. Communication: clear and direct communication of treatment plans and follow-up expectations 3. Timely feedback and feed-forward of information 4. Involvement of the patient and family member, unless inappropriate, in all steps 5. Respect for the hub of coordination of care (the MH). 6. Ability of patients and families to identify their MH or coordinating clinician. 7. Clarity for patients and families at all times during the transition process about who is responsible for care at a given time, whom to contact, and how to do so. 8. Establishment of national standards for transitions in care to be adopted and implemented at the national and community level through public health institutions, national accreditation bodies, medical societies, and medical institutions to improve patient outcomes and patient safety. 9. Standard measures related to these standards to track outcomes and undertake continuous quality improvement and accountability. From these 9 principles the Transitions of Care Consensus Conference attendees identified 7 standards and prioritized them in this order: 1. All transitions include a transition record (care plan) 2. Transition responsibility is explicitly identified 3. Coordinating clinicians (the MH) are identified 4. Patient and family are involved and own the transition record 5. Communication infrastructure exists for the transmission of information
AN OFFICIAL JOURNAL OF THE AMERICAN ACADEMY OF PEDIATRICS
6. Timeliness remains a priority 7. Community standards are adopted and followed
CONCLUSIONS Future challenges include documenting the effectiveness of the standards, obtaining the endorsement of various physician groups, hospitals, and insurance carriers (including Medicare and Medicaid) and then implementing them around the country. Excess costs for the development of MH programs and their implementation are likely to be mitigated by savings from prevention of readmission, duplication of laboratory and radiology testing, and prevention of medical errors.
REFERENCES 1. American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint principles of the patientcentered medical home. 2007. Available at: www.medicalhomeinfo.org/Joint%20 Statement.pdf. Accessed December 5, 2011.
8. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287(4): 487–494. 9. Landrigan CP, Conway PH, Edwards S, Srivastava R. Pediatric hospitalists: a systematic review of the literature. Pediatrics. 2006; 117(5):1736–1744. 10. Landrigan CP, Muret-Wagstaff S, Chiang VW, Nigrin DJ, Goldmann DA, Finkelstein JA. Effect of a pediatric hospitalist system on housestaff education and experience. Arch Pediatr Adolesc Med. 2002;156(9):877–883. 11. Friedman J. The hospitalist movement in general pediatrics. Curr Opin Pediatr. 2010; 22(6):785–790. 12. Harlan G, Srivastava R, Harrison L, McBride G, Maloney C. Pediatric hospitalists and primary care providers: a communication needs assessment. J Hosp Med. 2009;4(3):187–193. 13. Harlan GA, Nkoy FL, Srivastava R, et al. Improving transitions of care at hospital discharge—implications for pediatric hospitalists and primary care providers. J Healthc Qual. 2010;32(5):51–60. 14. Ruth JL, Geskey JM, Shaffer ML, Bramley HP, Paul IM. Evaluating communication between pediatric primary care physicians and hospitalists. Clin Pediatr (Phila). 2011; 50(10):923–928.
2. American Academy of Pediatrics. The medical home. Medical Homes Initiatives for Children With Special Needs Project Advisory Committee. Pediatrics. 2002;110(1):184–186.
15. Seelbach EB, Ottolini MC. Primary care physicians and hospitalists: two branches of the same tree. Pediatr Ann. 2010;39(2): 84–88.
3. American Academy of Pediatrics Council on Children with Disabilities. Care coordination in the medical home: integrating health and related systems of care for children with special health care needs. Pediatrics. 2005; 116(5):1238–1244.
16. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297(8): 831–841.
4. American Academy of Pediatrics. National Center of Medical Home Initiatives for Children With Special Needs. Available at: www.medicalhomeinfo.org. Accessed December 5, 2011. 5. Homer CJ, Cooley WC, Strickland B. Medical home 2009: what it is, where we were, and where we are today. Pediatr Ann. 2009;38(9): 483–490. 6. Lye PS; The Committee on Hospital Care and The Section on Hospital Medicine. Physicians’ role in coordinating care of hospitalized children. Pediatrics. 2010;126(4):829–832. 7. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335(7):514–517.
17. Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007;2(5):314–323. 18. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161–167. 19 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.
Downloaded from http://hosppeds.aappublications.org/ at Nyu Medical Center on April 28, 2015
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20. Coleman EA, Smith JD, Raha D, Min SJ. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005;165(16):1842–1847.
24. Burns KH, Casey PH, Lyle RE, Bird TM, Fussell JJ, Robbins JM. Increasing prevalence of medically complex children in US hospitals. Pediatrics. 2010;126(4):638–646.
21. Coleman EA, Smith JD, Frank JC, Min SJ, Parry C, Kramer AM. Preparing patients and caregivers to participate in care delivered across settings: the Care Transitions Intervention. J Am Geriatr Soc. 2004;52(11): 1817–1825.
25. Simon TD, Berry J, Feudtner C, et al. Children with complex chronic conditions in inpatient hospital settings in the United States. Pediatrics. 2010;126(4):647–655.
22. Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18(8): 646–651. 23. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. Adverse drug events occurring following hospital discharge. J Gen Intern Med. 2005;20(4):317–323.
108 |
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26. Wachter RM, Pantilat SZ. The “continuity visit” and the hospitalist model of care. Dis Mon. 2002;48(4):267–272. 27. The Joint Commission. Joint Commission Resources, 2012 Comprehensive Accreditation Manual for Hospitals (CAMH), PC02.02.01 EPS 1-17. Available at: www.jcrinc.com/ ProductDetails4108.aspx. Accessed February 24, 2012. 28. Balaban RB, Weissman JS, Samuel PA, Woolhandler S. Redefining and redesigning
www.hospitalpediatrics.org
hospital discharge to enhance patient care: a randomized controlled study. J Gen Intern Med. 2008;23(8):1228–1233. 29. van Walraven C, Taljaard M, Bell CM, et al. Information exchange among physicians caring for the same patient in the community. CMAJ. 2008;179(10):1013–1018. 30. Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822–1828. 31. Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus policy statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine. J Hosp Med. 2009;4(6):364–370.
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Coordinating the Medical Home With Hospitalist Care Jerrold Eichner and W.Carl Cooley Hospital Pediatrics 2012;2;105 DOI: 10.1542/hpeds.2011-0033
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Coordinating the Medical Home With Hospitalist Care Jerrold Eichner and W.Carl Cooley Hospital Pediatrics 2012;2;105 DOI: 10.1542/hpeds.2011-0033
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://hosppeds.aappublications.org/content/2/2/105
Hospital Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 2012. Hospital Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2012 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 2154-1663.
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