Care coordination when patients go to ED or hospital

My patient, who lives in assisted-living, went to the Emergency Dept and then was hospitalized last night. (We’ll call him Ken.)

So once again I get to see what works well and what works less well, when it comes to care coordination. As usual, I’m not impressed, although things could be worse.

In part, they are not so bad because I’m the one who urged Ken to go the ER. Whereas my patients are often sent to ER without anyone even calling me first, in this case, I knew he was going, and was even able to take action to smooth the process.

An added bonus: Ken has a  long-time care manager who I connect with regularly, and she arranged for the transportation there and stayed with him for the first few hours.

Furthermore, to help Ken get the right care from the ER and to facilitate coordination of care, yesterday I wrote a note for the ER doctors. Ken’s care manager brought this with them to the ER, along with a medication list from the facility.

In my note, I summarized:

  • The most important aspects of Ken’s past medical history
  • Recent changes to his health — including recent lab and radiology results — and why we were sending him to the ER
  • Information on Ken’s background, including the fact that he’d been living at the facility for a few years, that he’d had the same care manager for years, and that he’d been homebound due to a psychiatric condition, which caused him to refuse to leave the facility to see his assigned PCP
  • Information regarding Ken’s preferences for medical care, including the fact that he’d consistently refused medical care meant to extend his life, and had repeatedly emphasized a desire to have pain and comfort addressed
  • Information regarding Ken’s usual mental capacities and decision-making capabilities
  • My contact information (phone and fax)

In short, Ken arrived at the ER better equipped than most to facilitate care coordination.

Now here is what has happened so far:

  • I have heard nothing from the ED, by phone or fax. It was Ken’s care manager who sent me an update last night, and then this morning informing me he’d been admitted.
  • I called the hospital this morning and left a message saying I wanted the nurse or doctor to call me. That was over 4 hours ago and nothing yet.

I’m not surprised by this, but it’s still disappointing. If I send a patient to the ER, with a note that includes my fax number, is it crazy to expect the clinicians to fax me something about what they found and did??

How I did get an update on my patient’s ER course and hospitalization

I did get a copy of the ER note, and also the admission H&P, shortly after I called the hospital. But it’s not the way you’d expect me to get it, and it’s really not how it should work.

Here’s what happened: yesterday morning, before we realized Ken was going to have to go to the ER, I decided to make a referral to home health care. Ken was homebound and we needed skilled RN services. So I made a referral to a large agency that is affiliated with the hospital system near Ken’s residential facility.

The home health RN was supposed to see Ken today. This morning, I sent the agency a fax saying he’d been hospitalized and that we’d have to put off the referral.

An hour later, I got a phone call from one of the home health RNs. She was at the hospital, and wanted to let me know that the patient I referred had been hospitalized.

This I did not need to hear from her. (Although I did find myself wondering what would’ve happened if my patient had been hospitalized and had had no care manager and no pending home health referral to inform me that the ED visit resulted in admission. How is a PCP supposed to know their patient went to the ED? Are we only going to expect basic prompt communication if patients agree to have their PCP and ER and home health referrals on the same EMR system?)

But I was glad to have the home health RN on the phone. Since her agency is part of the hospital system, she was in a position to access the ER/hospital notes. I told her I wanted copies of the ER note and admission note faxed to me asap. So she faxed me the notes, and I was able to learn more about what had happened in the ED and hospital.

What I learned by reviewing the ER & hospital notes

Here’s what I found in the ER notes:

  • The ER doctor liberally quoted from my note, but never mentioned me by name, and never acknowledged the existence of a clinician who’d been recently following the patient in the outpatient setting. Instead, the note says “most history obtained from [name of residential facility].”
  • The ER note lists a PCP that Ken has not seen for over three years
  • The note includes factually incorrect information, such as that the patient currently smokes, and that the DPOAH is his conservator. (In fact, he has no conservator.) Instead of listing Ken’s current facility, the note says he lives in the residential facility that he left over 3 years ago.
  • The BP is documented as 134/87; the ER doc notes that vitals are normal other than “hypertension”

The note ends with the plan to hospitalize for further evaluation, but makes no mention of communicating with the outpatient providers.

The hospital admission note, to my great relief, show much more evidence of thought. This note does list me as the PCP, and notes that the patient has not seen his system-listed PCP in several years. The note acknowledges that I’d been evaluating the patient for his recent decline in physical health. The note also quotes Ken’s POLST (which I helped him complete in the past year) and documents he currently wants the same preferences to be respected.

At the end of the note, it is cc’ed to the author of the note. (This hospital system is on Epic.)

I appreciate that the hospital doctor has understood and documented the care Ken had prior to coming to the hospital. But still.

I wonder why the note isn’t cc’ed to me; the hospital doctor has quoted from my note, which included my fax number. I wonder how this big hospital system is planning to keep me in the loop.

I wonder why it’s such a pain to find out what has happened to someone when they are hospitalized.

I wonder what would have happened to Ken, if I hadn’t had the time and inclination to write a useful note to accompany him to the ED and convey the most important issues to his other clinicians. (Needless to say, what I wrote was much more useful than the information EMRs create using “structured data,” and was much better for the ER/hospital docs than my faxing over my last 5 clinical notes.)

I wonder how much longer we’ll have to tolerate a system of fragmented medical information and poor care coordination.



  1. David Utzschneider MD PhD says:

    As a hospitalist for too long this all rings true and the problems may seem insurmountable unless the big vendors make things better (which they should but will take eons) but there are little things we can all do now on both sides of the inpatient/outpatient divide to make things less miserable.

    -share cell numbers (everyone)
    -get access to the EHR (outpatient doc)
    -minimize in hospital physician turnover/handoffs (hospitalist)
    -keep family/care managers central to the conversation (everyone)
    -take a minute and google info of PCP (hospitalist:which clinic? which part of town ? etc)
    -spend time on DC note to get an accurate cc: list PCP and consultants (hospitalist)

    • Leslie Kernisan, MD MPH says:

      All excellent ideas.

      Still, if they can’t even send me an update when I bother to send the patient in with my contact info, it will be a stretch to get them to Google the PCP…or even check to see if the PCP as named by the system is actually the right person to coordinate with.

      As you might recall, last fall I had an elderly patient get hospitalized and the hospital EMR inserted all her old medications from a few years prior, which the hospitalist then discharged her on. Epic Medication Reconciliation Fail: A True Story

  2. I’m working with a team on a research project related to the transition home after being hospitalized for a stroke. We knew the process was chaotic and overwhelming – that’s the point of the project (we’re testing an intervention to help address some of the issues that arise once patients are home). I think, however, we have all been amazed at the level of chaos and disorganization and the absolute lack of “usual” in “usual care. Thanks for sharing your experience and contributing this conversation.

    • Leslie Kernisan, MD MPH says:

      Thanks for commenting. Yes, usual care is riddled with holes.

      I am repeatedly sobered by how hard it is to get things coordinated, DESPITE my making extra efforts beyond what many clinicians attempt. (I can do this in part because my clinical work is part-time.)

      If you are interested in transitions then you should also see the post Epic Medication Reconciliation Fail: A True Story.

  3. Mary Sive says:

    This only confirms my decision to have my Living Will say “Do not hospitalize ” (in addition to DNR and “Do not intubate”).

    • Leslie Kernisan, MD MPH says:

      Great that you have a living will, and for some people it’s very reasonable to say “do not hospitalize.”

      That said, Ken’s POLST says “do not hospitalize,” but we still went ahead and sent him to the ER because it had become impossible to manage pain and another difficult symptom in his assisted-living facility.

      Most “do not hospitalize” orders include some caveats.

      Last but not least, sometimes people’s advance directives are not found at the time of emergency or are simply ignored.

      Hopefully none of this will ever be an issue for you, but it’s important to be aware of these issues that often mean things don’t happen as people originally hoped they would.

  4. Hugh Byers says:

    Good on you for taking the time and effort to overcome all the obstacles. Or at least try to do so. I wonder how many providers have the will and the patience, much less the time, to stay involved.

    • Leslie Kernisan, MD MPH says:

      Not many providers do this because usual clinician working conditions leave doctors with little time and patience. I left conventional practice because I was too stressed by trying to do the right thing under usual working conditions.

      To make healthcare better, it needs to be easier for the average clinician to do the right thing under average working conditions. Technology can help but so far the EHR technology has often hindered things because it’s not well-designed to optimize clinical care and has created more cognitive load on clinicians.

  5. I have had similar-worse experience as both my parents transited through dementia in their 80’s and 90’s. I’m now accustomed to an Apple Watch always on my body. And an iPhone nearby.

    If there were suitable Watch apps, is there any way we could incent the hospital, ED services to check to see if we have offered up all our relevant patient history?

    • Leslie Kernisan, MD MPH says:

      Thanks for commenting. It is always possible to create incentives, but historically when we’ve done so, we have not gotten quite the result we wanted, and we’ve also experienced some unintended consequences.

      The trouble with bringing in an app or device that presents patient history is that often the information presented is not what is most useful to the clinician, to facilitate the right care, and takes a lot of effort to receive and make sense of. Devices and tech processes generally cannot create anything close to what I created for my patient.

      Otherwise, Meaningful Use created all these incentives in an attempt to get clinicians to “meaningfully use” the EHR to improve clinical care…this may have improved some aspects of healthcare, but the outcomes overall have been mixed, to say the least.

      For now, to get clinicians to review past information and make sure the information they document is correct, patients and families have to bring in useful information, make sure clinicians make note of it, and ideally check on the documentation and be offered an opportunity to correct it. This is a heavy responsibility to place on patients and families though.

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