Originally published June 2012
Many of today's physicians are providing care in community settings such as their offices, health centres, ambulatory sites, and urgent care and walk-in clinics. Physicians practising in these settings are confronted with medico-legal risks which include the coordination of care between providers, information transfer at patient transitions, early discharge from hospitals, effective referrals, and patient follow-up in the community. This article informs members of the medico-legal risks of community-based care, and provides effective strategies to mitigate risk and enhance the safety of care.
As community-based care is growing, so too are studies about adverse events outside of hospitals. For example, one study found that nearly 25% of patients had an adverse event after hospital discharge, and half of these events were preventable or ameliorable1. Another Canadian study found that nearly 20% of patients experienced an adverse event after discharge, with the most common type being adverse drug events2.
Coordination of care
Physicians practising in community-based locations are one of the first points of contact in the healthcare system.
Within this context, the family physician is often viewed as the central hub and is called upon to coordinate access to healthcare delivery. This can involve a number of services including specialized care, rehabilitation, and mental health.
In supporting patients who must navigate the healthcare delivery system, family physicians work with other doctors and healthcare providers. This role will likely continue and expand as care increasingly shifts from institutions to the community. From a patient safety point of view, the effective coordination of care can help to achieve superior delivery of care. To help manage medico-legal risks, physicians involved in collaborative care should ensure the roles and responsibilities of each team member are clearly defined. Team members should also know who is responsible for coordinating patient care, and who is responsible and accountable for healthcare decisions. This information should also be communicated to patients, allowing them to participate in their care. Depending on the community setting, a policy and procedural framework defining and describing the collaborative team function may be valuable.
Another area of community-based care which warrants careful coordination is the monitoring of medication. A pharmacist, nurse practitioner, and physician may all be involved with managing a patient's medications. Effective communication between providers is essential to prevent adverse outcomes for patients. Physicians should obtain a complete history of medication before new prescriptions are considered. This history should form part of the patient health record.
Regardless of which healthcare professional is providing care, patients' medications should be managed effectively. Once physicians assume care, it is their responsibility to review treatment, and that includes monitoring medications. This may involve reviewing orders before signing them; considering whether medications need to be continued for patients who are being transferred; and, when in doubt, contacting the previous treating physician or obtaining all relevant care and medication documentation. If the patient was discharged from hospital, the physician should be aware of the discharge medication orders, as well as care and follow-up instructions.
Test result management
As most diseases are first discovered in primary healthcare settings, the effective management of test results is important.
The CMPA has written about the effective management of test results and how this can improve patient safety in a previous article, "How effective management of test results improves patient safety." As more physicians work with other healthcare providers across the continuum of care, and more patients obtain care periodically in walk-in clinics and emergency departments, there may be some confusion about physicians' responsibility for follow-up in these circumstances. It is also common for physicians to receive investigative results ordered by others. Physicians receiving an abnormal report — whether they ordered it or not — have an obligation to respond, even if the patient is no longer, or never was, in their care.
Physicians should be satisfied there is a system in place in their clinic or practice to follow up on test results. Physicians ordering investigations have a duty to communicate the results to the patient and to make reasonable efforts for appropriate follow-up. In a community-based practice, physicians may consider fostering a culture of safety and encouraging staff members to identify and report any issues with the system for following up on test results. Consideration should be given to standardizing test result processes and using a coding system to prioritize the follow-up of test results. Patients should also be engaged in their own care whenever possible. Discussing why an investigative test was ordered allows patients to recognize its importance to their clinical situation.
Another potential risk area for community-based care pertains to referrals.
Physicians working in community settings should recall the core elements of a good referral and provide: information about the problem; the question to be answered; relevant patient details; relevant investigations and treatment; and medications. Consulting physicians should provide answers to specific questions. Ultimately, a management plan should be developed designating the most responsible physician for follow-up with the patient.
Members are invited to read the CMPA's article entitled, "Improving communication between physicians." The focus of the article is that poor communication between referring physicians and consultants can lead to disruptions in continuity of care, delayed diagnoses, unnecessary testing, iatrogenic complications, and frustrated physicians and patients.
Transfer of care
The transfer of patient care from one physician to another can be challenging in today's busy and complex environment.
In the community setting this may involve emergency transfers, provision of care when a physician is unavailable to work, and transitioning to another physician in a different care location. When warranted, physicians should confirm there is a clear order in the medical record noting the name of the physician to whom care has been transferred. The medical record should also include updated progress notes or other medical history accurately reflecting the patient's current medical condition and significant past history. Results of relevant investigations should also be made known during the transfer of care to another physician. In addition, information should also be provided about new medications, or those to be continued, or both.
A lack of ownership at transition points of care makes patients especially vulnerable to safety risks, and can lead to consequences such as hospital readmission, adverse medical events, and even death. Strategies to make transitions more successful include effective communication among care providers, educating patients and caregivers about what to expect at the next site or stage of care, and patient monitoring of warning signs or symptoms that require medical attention. Medication reconciliation and follow-up plans for outstanding tests and appointments with physicians may also enhance patient transitions3.
Transfer between hospital-based and family physicians
A specific area of concern pertains to the transfer of responsibility for patient care between hospital-based physicians and family physicians. The timely transfer of accurate, relevant data about diagnostic findings, treatment, complications, consultations, tests pending at discharge, and arrangements for post-discharge follow-up may improve the continuity of the handoff4. Given that there may not be direct communication between hospital physicians and family doctors during the discharge process, transfer forms or discharge summaries are often relied upon to ensure adequate follow-up care. These summaries usually include pertinent physical findings, results of procedures and tests, discharge medications, details of follow-up arrangements, information given to the patient and family, test results pending at discharge, and specific follow-up needs5. The hospital physician should provide all the relevant information about the patient's ongoing care needs to the family physician. Regardless of the care setting, all physicians should pay close attention to effective patient handoffs and information transfer.
Transfer between long-term care facilities and emergency or urgent care
Long-term care facilities may rely on emergency departments or walk-in clinics to address the urgent or emergent health condition of residents. It is important for physicians in walk-in clinics or emergency departments to know the patient's reason for seeking care, baseline cognitive function and communication ability, vital signs, advance directives, medication, activities of daily living, and mobility6. Physicians whose practice includes patients in nursing homes or long-term care facilities are also encouraged to provide the necessary information to hospitals when transferring patients. Standardized transfer forms may help to reduce information gaps.
When patients return to their long-term care facility, discharge diagnoses, treatment plans, medications, and test results are among the key pieces of information that should be communicated to the physicians responsible for care in that facility. Physicians working in hospitals should not make assumptions about the resources available in long-term care settings. There may be differences in the medications, medical devices, and human resource expertise in another organization.
In today's resource constrained environment, patients may be discharged from hospital earlier than in the past and this may heighten risk of complications and adverse events.
Courts have an increasing expectation that physicians educate patients to recognize the symptoms and signs that should alert them to seek further medical attention, the urgency of the response required, and where best to seek medical attention. This information should be tailored to each patient and each clinical situation. Similar instructions and even practical demonstrations7 may also be important for patients discharged from an emergency department or a walk-in clinic.
Discharge summaries provide a means for physicians to share key pieces of information and important messages with patients. These summaries may help patients to understand their diagnosis at discharge, as well as the steps they should take to care for themselves at home. Patients should also be encouraged to ask questions about discharge instructions. Documenting these instructions may also help other healthcare professionals to know the reason why a patient may be seeking further care, and will also demonstrate the physician's attention to detail should medico-legal difficulties arise.
Opportunities for patient and family involvement
Regardless of the community setting, patients should be provided the opportunity to be involved in their care and follow-up plans, when appropriate. This includes providing information to patients about their medical condition, care plans, and medications in a way that is understandable to them. Patients should know about the next steps in their care, so they can communicate this to other care providers, or even to a caregiver at home. At all times, patients should know who is responsible for their care, and who to contact if they have a concern about the safety or quality of care8.
Many physicians have likely provided care for orphaned patients — those without a regular family physician. If a treating physician is about to discharge a patient who needs follow-up care but does not have a family physician, the doctor may be obliged to take reasonable steps to ensure the patient has access to follow-up care. This may include talking to the patient about options available for alternative primary care. In any event, the physician should remind the patient to return to the emergency department or walk-in clinic for emergent care. For additional information on orphaned patients see the CMPA website article "Follow-up for orphaned patients."
A final word
Healthcare delivery in a community setting may be challenging, however physicians can take steps to manage the associated medico-legal risks.
- Physicians involved in collaborative care should ensure the roles and responsibilities of each team member are clearly defined.
- Monitoring of medications warrants careful attention. Effective communication between healthcare providers is essential. Once a physician assumes care, the responsibility to review treatment includes monitoring of medications.
- Effectively managing test results is important. Patients should also be engaged in their own care and encouraged to discuss and understand why particular tests are important to their clinical situation.
- Referrals and transfers of patients from one physician to another require clear orders in the medical record, updated progress notes, and suitable medical history, as well as results of relevant medical tests.
- Patients being discharged from hospital may benefit from physicians providing additional information on signs and symptoms that could alert them to seek further medical attention. Discharge summaries can provide a means for physicians to share important messages with patients.
The CMPA's medical officers are experienced physicians who can help to answer your questions and provide guidance. Doctors seeking advice about any issues associated with healthcare delivery in community settings should not hesitate to contact the Association.
"Omissions of content are a major cause of failed communication during handoffs. A checklist of necessary information can help teach others new to the handoff about the process and serve as a monitoring tool in evaluating the content transferred."9
- Foster, A., Clark, H., Menard, A., Dupuis, N., Chernish, R., Chandok, N., Khan, A., van Walraven, C., "Adverse events among medical patients after discharge from hospital," Canadian Medical Association Journal (2004) Vol. 170, no.3 abstract.
- Forster, A., Murff, H., Peterson, J., Gandhi, T., Bates, D., "The incidence and severity of adverse events affecting patients after discharge from the hospital," Annals of Internal Medicine (2003) Vol. 138, no. 3 abstract.
- Canadian Healthcare Manager, "Owning transitions in care," June 2011. Retrieved on June 2011 from: http://www.canadianhealthcarenetwork.ca/healthcaremanagers/management/patient-safety/owning-transitions-in-care-9605. Work attributed to Dr. Ross Baker, University of Toronto.
- Kripalani, S., LeFevre, F., Phillips, C., Williams, M., Basaviah, P., Baker, D., "Deficits in communication and information transfer between hospital-based and primary care physicians: Implications for patient safety and continuity of care," Journal of the American Medical Association (2007) Vol. 297, no.8 p.831.
- Ibid., 833.
- Cwinn, M., Forster, A., Cwinn, A., Hebert, G., Calder, L., Stiell, I., "Prevalence of information gaps for seniors transferred from nursing homes to the emergency department," Canadian Journal of Emergency Medicine (2009) Vol. 11, no.5 p.462.
- Samuels-Kalow, M., Stack, A., Porter, S., "Effective discharge communication in the emergency department," Annuals of Emergency Medicine (2012). Retrieved on February 15, 2012 from: http://www.annemergmed.com/article/S0196-0644(11)01762-8/abstract.
- World Health Organization, "Communicating During Patient Hand-Overs," Patient Safety Solutions (2007) Vol. 1, solution 3, p.3.
- Arora, V., Johnson, J., "A model for building a standardized hand-off protocol," Joint Commission Journal on Quality and Patient Safety (2006) Vol. 32, no.11 p.649-650.