Closing the Loop: How Transitional Care Services Can Benefit Primary Care Physicians
The role of a primary care physician (PCP) has always been based upon relationships. Many of these physicians are often not only the trusted source for care, but in many cases have built long standing relationships with those whom they care for.
The changing landscape of healthcare has created a labyrinth of the processes, interactions, and information often leaving the PCP out of the loop when their patients are discharged from hospitals.
In a perfect world, a PCP would be informed of discharge instructions and changes as part of a collaborative effort to communicate with each member of the care team. Unfortunately, that is not the typical reality in today’s fast-paced, resource-strapped hospitals.
One way that these outcomes are improving is by a new telehealth initiative called Transitional Care Management (TCM). TCM bridges the gap between patient discharge and the scheduled visit with a primary care physician, providing the PCP with crucial patient information prior to the in-office visit.
TCM enables the exchange of medical information from one site to another through electronic communication to improve a patient’s health following discharge from an inpatient hospital setting and return to home. The goal is to decrease the high percentage of avoidable patient readmissions after discharge through more effective care at the transition.
New companies like ONclick Healthcare are using TCM to improve communication with PCPs. ONclick follows each patient for the required period, making additional phone calls and/or tele-visits to provide the patient with the best opportunity to adhere to their recovery regimen and avoid relapse or unnecessary readmissions to the hospital. The service confirms the patient’s general well-being, understanding of their discharge plan, medication awareness, and appointment schedule. All of this information is made available to support the patient’s PCP. ONclick does not redirect patients nor participate in reassigning patients to alternate PCPs.
Closing the loop for primary care physicians may simply be a task of ensuring stakeholder communication through accountable post-discharge transitional care. TCM services like ONclick Healthcare help PCPs to create better outcomes for their patients.
