Article Figures & Data
Tables
Starfield Primary Care Function CPCMO Role Measurable Outcomes Specific Examples Accessible PCP contact Ensure strong primary care bridge between acute and chronic care settings Increased involvement of primary care function in acute care setting
Improved communication including better understanding of primary care resourcesDevelop computerized networking systems to help match PCPs with patients needing care. Be a “match maker” based on expert knowledge of PCPs in the community; Promote hospitable environment for PCPs on hospitalist teams to increase PCP input Care coordination Build systems that support improved bidirectional flow of information and effective clinical follow-up Timely and safe hospital discharges; patient-centered transitions to optimal location after hospital discharge; Confirmation of timely connection between inpatient and outpatient care teams for every patient Facilitate collaboration between hospitalists, specialists, and PCP in care planning; Improve support for PCPs that enables them to successfully implement discharge plans Ensure comprehensiveness Facilitate complete care for multiple comorbidities across the spectrum Decreased readmission rates; decreased length of stay in hospital Coordinate with PCP and hospitalists to identify accessible services and referrals that hospitalized patient needs in order to facilitate comprehensive discharge planning Maintain continuity Ensure inpatient and outpatient teams stay connected Safer handoffs; improved patient satisfaction Reinforce central role of PCP and consistency of PCP relationship with patient across shift changes and discharge transitions; Monitor Neighborhood Stress Scores (NSS7)33 in order to optimize systems of primary care CPCMO = chief primary care medical officer; PCP = primary care physician.
Starfield Primary Care Function Patient CPCMO (and CPCMO-Led Team) Response to Specific Patient Scenario Accessible PCP contact
Care coordination
Ensure comprehensiveness
Maintain continuityWoman aged 92 years with hip fracture unable to be discharged to skilled nursing facility because PCP recently retired Leverage relationships with community PCPs and computerized PCP networking resources to identify and refer to a new PCP
Provide PCP functions including admission to SNF until patient established with new PCP and first appointment can take place
Ensure patient has comprehensive pain management plan and that Advanced Directive planning has been done with hospitalists, patient, and family before discharge
Coordinate communication with prior PCP; ensure relevant information from prior PCP is transferred to new PCP and to SNF and that follow-up with orthopedics occurs in timely fashionAccessible PCP contact
Care coordination
Ensure comprehensiveness
Maintain continuityMan aged 54 with meta-static cancer unable to be discharged home with hospice because has no PCP Leverage relationships with community PCPs and computerized PCP networking resources to identify and refer to a new PCP
Provide PCP functions including admission to hospice until first appointment with new PCP can take place
Support hospice function as needed so that patient can be discharged home.
If there is not time to identify new PCP, facilitate communication and care with hospice as PCP would normally do
Stay connected to patient through the end-of-life process until and unless new PCP can be identifiedAccessible PCP contact
Care coordination
Ensure comprehensiveness
Maintain continuityChild with traumatic brain injury whose PCP is not included in care during hospitalization with resultant avoidable readmission Work with hospitalist team so that PCP can be included in family meetings
Ensure that plan for specialist referrals after discharge is realistic for the family and that PCP team has the resources to support complex discharge plan
Assist social workers with accurately and adequately addressing social determinants of health for the family so that social as well as medical needs are being addressed at discharge
Facilitate effective discharge plan to adequately supported PCPAccessible PCP contact
Care coordination
Ensure comprehensiveness
Maintain continuityHomeless geriatric woman with complex social and health needs whose PCP is not contacted Work with hospitalist team so that PCP is identified and contacted
Engage complex care team in hospital who will follow up with intensive case management after discharge
Provide assistance to hospitalists and PCP in order to facilitate systems of care for complex patients
Create hospital systems for complex patients so that inpatient and outpatient care can be connected alongside frequent readmissions to acute care settingsCPCMO = chief primary care medical officer; PCP = primary care physician; SNF = skilled nursing facility.
Additional Files
The Article in Brief
The Chief Primary Care Medical Officer: Restoring Continuity
Noemi Doohan , and colleagues
Background When patients are admitted to the hospital, their connection to their primary care physician is often disrupted, leading to difficult transitions of care, readmissions, higher costs, and worse health outcomes. In this essay, two family physicians propose a solution.
What This Study Found The authors call for the creation of the hospital chief primary care medical officer. This primary care physician would lead hospital efforts to create systems that ensure the primary care continuum is complete, even for complex patients. The position could be funded by savings that arise from improved value, the authors suggest, particularly as health care systems shift away from a focus on volume towards a focus on value.
Implications
- The authors call for a health care system that supports a trusting primary care relationship at critical junctures in individuals' lives.
