There's one thing, at least, that the primary care physicians and hospitalists could agree on during Thursday afternoon's panel discussion on "Transitions to Outpatient Care"--it's hard to get patients safely across the gap between care settings.
They also agreed on the importance of a follow-up visit shortly after discharge, but no one had a perfect solution for making it happen. One attendee noted that he's gone so far as to get the police involved to get patients to show up (no details provided on how exactly that worked out). The Medicare code for transition of care doesn't help much, others noted, since it requires a lot of documentation and a bundled payment for 30 days of care (which can work out badly payment-wise for the primary care practice if the patient makes a lot of office visits).
Then there were also some complaints that were directed more at each other than the system. Hospitalists get frustrated when they try to call primary care physicians about a patient and never hear back, while primary care physicians don't like being told to log in to a portal to collect a discharge summary.
Interoperable electronic health records would solve a lot of these issues, the physicians agreed. But until that happens, they brainstormed some smaller solutions. For example, one attendee described how his health plan is using a HIPAA-secure app to allow physicians from different groups and facilities to share information, including PDFs of discharge summaries. It's a workaround, for sure, but maybe one that works?