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Since our General Internal Medicine division was formed several years ago by combining the Hospitalist Medicine and Outpatient Adult Internal Medicine divisions, we've grown significantly, each section expanding clinically, forging new partnerships and building many fruitful research relationships.

But one important point has been recognizing that, despite the fact that we're all taking care of adult patients and managing many of the same conditions, our unique perspectives on the clinical situations in which we find ourselves are so different that it often highlights the differences between us, and makes working together as one group quite a challenge.

A patient may be cared for in our practice, and then become sick at home and seek care in the emergency department, where they are admitted to the inpatient service, followed by a hospitalist, and then sent home when ready for discharge, to be followed up with us.

Or, we may see someone in the office, and decide that they are too sick to go home and that they need further evaluation and treatment in a monitored setting, and thus send them directly across the street to be stabilized and possibly admitted. At that point, we turn over care to our hospitalist colleagues, who will manage them while they're hospitalized.

The Olden Days

Years ago, before our hospital moved over to a primarily hospitalist model, we outpatient physicians covered our own inpatients, as well as those of our interns and residents, when they needed to be admitted to the hospital.

But over the years, we were asked to divest ourselves of this responsibility, and turn over the care to hospitalists who are there all the time, every day, and therefore many of us have essentially given up the inpatient portion of our lives, relinquishing that skill set as it fades farther and farther away into the past. Conversely, for many of the hospitalists, the last time they saw a patient in the outpatient world was when they themselves were in clinic as residents.

So, when we all get together, hospitalists and outpatient physicians, we often look at each other like we are from different planets, masters of different scopes of care, with strikingly different perspectives on each patient.

The hospitalist's patients have a higher level of acuity, more instability, more potential for short-term bad things to occur, and they're all lying in bed in hospital gowns. On the other hand, our patients in the outpatient world come to us in their street clothes, change briefly into that thin cotton gown, at which point we deal with the length and breadth of their health conditions, and then they get dressed again and go back home.

Three Phases of Care

Figuring out how we can all work better to take care of our patients at the intersections of inpatient and outpatient medicine is an interesting challenge, and worth spending some time to think about how to do it better, both for the patient's and for the doctor's sake.

I think of this as potentially occurring during three phases:

• First, right before admission, when a clinical situation has presented itself and it looks like we are deciding that a patient should be admitted.
• Second, throughout the hospitalization, when all the parties are kept informed of what's going on, as well as communicating any useful information and insights from the outpatient world to those taking care of the inpatient -- insights that might help move the clinical course along.
• And third, that time right before going home and immediately after that, in that delicate transition period when they're getting ready to go and then just settling in back at home, and a lot of things need to happen just right to make sure everything continues to improve.

All three need some interventions and improvement, but best to break the problem down and address them one by one. Our division has been focusing on developing research projects around these transition points, and our division chief has been making a focused effort to bring together hospitalists, outpatient doctors, and other members of our research team to focus everyone's different areas of expertise, and the wisdom we each may bring to the table to help our patients.

As we think about building a patient-centered transitions of care program for that third phase, what we all need to know is what everyone else is thinking.

I, as an outpatient doctor, want to hear the hospitalist's perspective about how things went, what worked and what didn't work, and what we all need to do for this patient once they leave the hospital to ensure that things are continuing to mend. The hospitalists need to hear from us about what we're ready to take on, what we are willing to be responsible for, and what we have the resources to do. And surrounding us all, there needs to be a team, including social workers, visiting nurses, home health aides, pharmacists, family members, and most importantly, the patients themselves.

An Important Meeting

We're trying to create the model of a "transitions of care" meeting that would take place, most likely electronically/telephonically or on video, where everyone gets to talk about what's been going on and what the plan is moving forward.

In that meeting, the hospitalist will hopefully briefly outline for us the course of the admission, the status of the patient, and anything that's pending at the time of discharge that needs follow-up. We want them to delineate a series of goals that they have for this patient: to complete the antibiotic, start physical therapy, resume or stop certain medications, schedule and keep appointments with their primary care physician (PCP) and subspecialists A, B, and C, and so on.

We want to arrange, when appropriate, for a follow-up visit to be either in our practice, or via telemedicine, with specially trained paramedics or visiting nurses, to check in with the patient at home, and hopefully engage both the hospitalist who was their inpatient caregiver and their PCP or another physician who is helping handle this transition, to make sure it goes smoothly.

We hope that this will make for a better discharge, a better transition for patients back to their homes, and maybe even prevent readmissions, or at least prevent that situation in which patients arrive at their PCP's office with no idea what happened to them in the hospital, no idea what they were supposed to have been doing all this time, and maybe even needing an enormous amount of work to get them to where they should have already been.

And we hope that by building this type of model, a more patient-centered transition of care, we will improve collaboration and communication between inpatient hospitalists and outpatient primary care providers, all for the betterment of our patients.

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