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.