Is Redesigned Primary Care the Solution to Readmissions?

Written by on August 31, 2012 in Practice tips - No comments

The Centers for Medicare  & Medicaid Services (CMS) will penalize hospitals for readmissions beginning in the Fall of 2012.  With increased financial pressures to address chronic diseases in hospitalized patients, changes to care delivery are critical to financial viability for practices.

Primary care providers are already besieged with inefficiency and inability to provide truly value-based care within a fee for service model.  Significant care delivery changes must be implemented and resource networks must be created to redesign models of care that offer comprehensive care management to patients with chronic diseases.

Ideally, offering ancillary services such as nutrition and diet counseling, remote monitoring of glucose, and daily weights for diabetes and heart failure patients will improve quality care metrics and improve patient outcomes.  Improvement in outcomes is also inherently an improvement in disease control and utilization of the ER as well as inpatient services.  Unfortunately, many community primary care practices do not have access to such resources.  Improvements in communication, technology and team redesign may be the solution.

Communication in Care Transitions

Ideally, a primary care provider would know:
- when their patient is admitted to the hospital,
- what the inpatient treatments and interventions were,
- what the discharge disposition was and what changes were made so follow up could be done within the critical 72 hour window famous for bounce-back readmissions.

This does not happen universally or efficiently in virtually all communities. As a primary care provider, often I am relying on patients and families to “fill me in” on what was done in the larger medical center hospital that does not communicate efficiently with our individual community office.  Sadly, we are often chasing a paper trail and if that discharge summary is not dictated in a timely fashion, then we are “out” of information within that 72-hour window for bounce backs.  Redesigning care transition teams that work efficiently with the hospitalists and pharmacy will ensure timely outpatient follow up as well as critical medication reconciliation.

Developing Smart Technology

Health Information Exchanges are supposed to be building networks to facilitate such communication, but as hospitals opt out, access to this data on the community level is scarce.  Electronic health records come in many shapes, sizes and capabilities, and the sad reality is that they do not communicate across systems without extensive networks and programming, a cost unable to be borne by smaller and independently owned practice groups.  The creation of data feeds and information exchanges that communicate ER utilization and admissions data to primary care providers will assist those practices joining accountable care organizations ( ACOs) and participating in Medicare Shared Savings Plans (MSSP).

Team Approach

A significant amount of funds in the Affordable Care Act (ACA) went towards programs that train primary care providers, not just doctors but nurse practitioners (NPs), and physician assistants (PAs).  Health policy advocates believe that the well-known shortage in primary care will be alleviated, not just by having more doctors but also by having doctors work in teams with other less highly-trained specialists who can deliver quality primary care. Many studies show that good, quality primary care can be delivered by PAs and NPs on a physician-led team.

Ann Davis, senior director of state advocacy and outreach at the American Academy of Physician Assistants states in a recent National Public Radio (NPR) interview, that when you “…think about a scarce resource, there’s sort of three ways to think about that. You can increase supply of physicians. You can use the scarce resource more wisely, or you can actually reduce demand. And I think the second two are where physician assistants (PAs) are particularly critical.”

PAs and NPs extend the reach of physicians by that team.  And, then, if the PAs are available to do some health promotion, some exquisite coordination of care so that you decrease readmissions, that helps address the physician shortage also.


by Lisa P. Shock, MHS, PA-C

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