Virtual Patient-PCP-Hospitalist Care Transition Meeting Before Hospital Discharge.

Area of Science:

• Health Services Research
• Digital Health Interventions
• Patient-Provider Communication

Background:

• Fragmented healthcare systems pose challenges to patient trust and effective communication during hospitalization.
• Seamless transitions of care require robust communication among patients, hospitalists, and primary care practitioners (PCPs).

Purpose of the Study:

• To evaluate the feasibility and perceptions of a video-mediated digital tool for communication between hospitalized patients, their hospitalists, and PCPs.
• To assess the impact of this tool on patient-provider relationships and care coordination during the discharge process.

Main Methods:

• A quality improvement pilot study involving 106 adult inpatients, their hospitalists, and PCPs across 3 hospitals.
• Utilized structured, video-mediated interactions before discharge.
• Assessed patient perceptions via the Consultation and Relational Empathy (CARE) measure and clinician perceptions using AIM, IAM, and FIM surveys.

Main Results:

• Significant improvement in patient CARE scores (P < .001).
• PCPs reported higher acceptability (P = .006) and appropriateness (P = .03) than hospitalists.
• Qualitative feedback indicated enhanced information sharing, communication, and collaborative discharge planning, increasing patient confidence.

Conclusions:

• Patient-hospitalist-PCP virtual meetings are feasible and valuable for improving information exchange, patient confidence, and clinician perceptions of care coordination.
• Supports the integration of such digital interventions into routine discharge procedures.
• Suggests potential for Centers for Medicare & Medicaid Services (CMS) to consider these interactions for Transitional Care Management (TCM) billing.