AMA Outlines Physician Responsibilities for Discharged Patients

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How to practice patient safety following their release from the hospital is an ongoing concern for physicians. In seeking to further clarify the issue, the American Medical Association Center for Patient Safety issued a report containing five areas of responsibility that it believes physicians should incorporate into their patient care.

John Commins at HealthLeaders Media writes, “The recommendations listed in the report were developed to improve safety and reduce hospital readmissions for patients returning home.” In issuing this report, the AMA Center for Patient Safety “is attempting to build a bridge between inpatient and outpatient settings.” Also, “it hopes to break a historic trend that left the responsibility for transition plans almost solely in the hands of the inpatient clinical teams.”

The authors of the study said, “There has been relatively little attention paid to exploring specific roles and responsibilities for outpatient clinics and other ambulatory practices during care transitions. But one thing we know is that patients leaving the hospital too often return to ambulatory-care settings that are not well-connected to the hospital team and this can result in inefficient, confusing, and sometimes unsafe conditions.”

Therefore, the five physician responsibilities are: 1.) Assessment of the patient’s health; 2.) Goal-setting to determine desired outcomes; 3.) Supporting self-management to ensure access to resources the patient may need; 4.) Medication management to oversee needed prescriptions; and 5.) Care coordination to bring together all members of the healthcare team.

According to the report, “Inpatient teams face important limitations in ensuring safe transitions to ambulatory settings. Given the great variability of inpatient and ambulatory-care team resources and capabilities, there can be no ‘one-size fits all’ model for safe-care transitions; but certain tasks during care transitions are probably best carried out by members of the ambulatory rather than the inpatient care team, since the ambulatory practice will be responsible for providing ongoing care to the patient in the ambulatory setting.”

The AMA is also trying to anticipate the “new models of care delivery, improved methods of communication, and changes in payment systems” that await physicians in the near future. It “built the codes to catalog care-management services, including time spent talking about a care plan, connecting patients to community services, transitioning them from inpatient settings, and preventing readmissions.”

Jeremy Lazarus, MD, AMA president, said, “When a patient leaves the hospital to go home, they are transitioning back into the care of their outpatient primary care and specialty physicians. Physicians in ambulatory-care settings must first have access to information about their patients’ hospital stays to ensure continuous, high-quality care. The lists of actions recommended in this report can then serve as a guide as physicians care for recovering patients.”

The entire report can be accessed here.

What are your thoughts on the outpatient-care process? Does the AMA report effectively address these matters? What would you add to coordination planning?

-by Pete Fernbaugh

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