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

The fragmented health care system presents significant challenges to promoting trust with hospitalized patients.

To test the feasibility and perceptions of a digital connection tool for communication among patients, hospitalists, and primary care practitioners (PCPs).

This quality improvement study was conducted as a feasibility pilot study from September 2022 to June 2023 on medical floors across 3 hospitals. Participants included adult inpatients, the hospitalists who managed their care, and the patients' PCPs. Data were analyzed from September 2023 to April 2025.

Structured, video-mediated interaction among the patient, family caregiver (if available), hospitalist, and PCP, conducted before discharge.

Outcomes of interest were patient perceptions, assessed using the Consultation and Relational Empathy (CARE) measure. Open-ended question sought patients' feedback. Hospitalists' and PCPs' perceptions were evaluated using Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM), and Feasibility of Intervention Measure (FIM) surveys.

The study sample included 106 participants (mean [SD] age, 63.2 [14.9] years; 55 [51.9%] male). Bedside video meetings were a mean (SD) of 8 (2.8) minutes. Overall score for CARE questions showed a significant improvement, increasing from 40.9 (95% CI, 39.5-42.2) to 47.5 (95% CI, 46.5-48.5) (P < .001). Of clinicians, 50 of 95 PCPs (52.6%) and 42 of 56 hospitalists (75.0%) completed surveys. PCPs reported more positive perceptions than hospitalists regarding acceptability (4.1 [95% CI, 3.90-4.38] vs 3.6 [95% CI, 3.34-3.84]; P = .006) and appropriateness (4.1 [95% CI, 3.86-4.35] vs 3.7 [95% CI, 3.41-3.94]; P = .03). Qualitative feedback highlighted improved information sharing, communication, and collaborative discharge planning. Patients felt more cared for and were more confident about follow-up steps.

Findings of this quality improvement study highlighted the value of patient-hospitalist-PCP virtual meetings in addressing gaps in information exchange, increasing patient confidence, and improving clinician perceptions of care coordination. These results supported the feasibility and potential of incorporating such interventions as part of routine discharge procedures. The Centers for Medicare & Medicaid Services could consider incorporating a direct interaction component with hospitalists, patients, and PCPs before hospital discharge into the requirements for Transitional Care Management billing or allow current billing codes to be applied in the hospital setting.