Letter to Hospitals

In the old days when a patient’s office-based physician believed the patient needed a more intensive level of care she admitted the patient to the hospital where that same physician managed the patient’s care. When she judged the patient ready she discharged the patient back to the office practice. One can easily see how the physician’s failure to continue the patient’s care after discharge might have been considered abandonment.

Today, however, hospitalists usually assume care of the patient on admission and discharge the patient back to the office-based practice when ready. This works well provided the hospital makes contact with the outpatient physician at admission and in planning for discharge, if only to make sure the office-based physician feels she remains the best option for the patient.

Increasingly in my experience hospitals and addiction rehabilitation facilities fail to contact me at the time of admission and fail to confer with me about the best plan for aftercare. Perhaps the most critical and, unfortunately, frequent such situation arises when a suicide attempt has led to admission. Such a situation strongly suggests failure of the outpatient physician’s treatment plan and argues strongly for referral to a different physician for aftercare.

In response I have decided to change my patient policy and treatment agreement to the effect that neither the facility nor the patient can assume that I will continue to provide care after discharge unless one or the other has informed me of the admission, and the hospital has coordinated discharge planning with me during the hospital stay. I propose putting each inpatient facility in my community on notice by writing a letter as follows. I believe such notice should prevent accusations of abandonment, especially considering that by definition I can no longer provide for the patient’s care adequately. I hope it will also force inpatient facilities to involve the office-based physician in discharge planning.

Dear Hospital (Medical Director, Chief of Staff, Chief Executive Officer):

When a patient presents to an emergency room or for admission to an inpatient facility it is standard of care to attempt to contact the treating physician in order to obtain or confirm history and to coordinate subsequent care, and as a courtesy, to inform the physician of the admission.

Due to the consistent failure of inpatient psychiatric facilities, drug rehabilitation facilities and emergency departments to contact me at the time of admitting patients under my care I am giving you notice that, effective immediately, I deem all such admissions to represent indefinite transfer of care to your physicians. This means that admission to your facility will trigger automatic discharge of the patient from my practice based on the apparent need of the patient for a more intensive level of care than I can provide. Your staff must contact me prior to discharge from your facility if they wish to assist the patient in applying for return to my office practice.

I will base my decision whether to accept the patient back into my practice on my assessment of my ability to best serve the patient’s clinical needs, including medication or other somatic treatments. I deem a suicide attempt by a patient under my care sufficient evidence of failure of that care such that for me to resume care would be neither reasonable nor prudent, would not meet standard of care, and would not be in the patient’s best interest.

I will appreciate your input and comments and encourage others to follow my example.

Hospital Transitions

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