Smoothing the transition of care for general internal medicine patients

An 80 year old woman is awaiting a knee replacement surgery. During her wait, she is admitted to the hospital with symptoms of congestive heart failure (CHF), however her tests come back negative and CHF is ruled out.

Weeks go by and her primary care provider does not receive a discharge summary until three days before her knee replacement surgery – and the discharge summary received is inaccurate. The inaccuracy and lateness causes issues at the time of surgery and causes uncertainly with the primary care provider.

Scenarios like this one are all too familiar – but this does not have to be the case. In an effort to improve the discharge process and make scenarios like this one a thing of the past, a team of clinical directors and physicians at (MSH) embarked on a journey with the Improving and Driving Excellence Across Sectors (IDEAS) program in late 2014. The outcome was Post-Hospital : From Hospital to Family Practice, a project aimed at improving the discharge process and creating a smooth transition of care for general (GIM) patients.

The aim of this project was clear: by April 2015, 75 per cent of patients discharged by a GIM physician would have a comprehensive discharge summary sent to their primary care physician within 48 hours.

“The goal was to have a comprehensive, legible discharge summary on the family physicians desk (virtual or otherwise) within two days of discharge, thus achieving the broader goal of primary care engagement with the hospital as well as a more seamless transfer of care to the community for patients,” says Paul Cappuccio, Director, Mental Health Services and Family Medicine, South East York Region Health Link and Interim Director of Emergency Services at Markham Stouffville Hospital.

The broader goal was to develop a better working relationship with primary care partners to improve the quality of care for patients in the hospital’s catchment area.  In this context, a survey of primary care providers showed that over 95 per cent of surveyed physicians valued timely, electronic discharge summaries from the hospital.

By enabling an electronic transfer of discharge summaries and implementing a 48 hour turnaround goal, patients receive better care. Primary care providers can schedule follow-up appointments in a timely manner, medication reconciliation is built into the electronic medical record (EMR) system EMR and the demand for transcription services decreases.

“In order to engage primary care physicians in a timely and meaningful manner, being able to electronically transfer discharge summaries was imperative. The development and application of the IT/Health Record (EMR) system which would help achieve the ability to transmit electronic summaries was paramount to ensure a successful turnaround time,” says Julie Sullivan, Director, Medical Services at Markham Stouffville Hospital.

In order to implement a project of this scope, the team relied on the expertise of a large inter-disciplinary team from across the hospital including senior leaders, physicians, nurses, and staff from information technology, pharmacy and human resources. There were also many enabling factors within the organization that needed to happen to ensure this project would not only work, but last. From figuring out how to ensure commitment to this change from within the organization, to recognizing and engaging the diverse disciplines affected by this change – getting and maintaining support from across the organization was crucial for this project to succeed.

Although the influencers were from a broad group of disciplines within the organization, the most important enablers were the GIM physicians themselves. To ensure success, GIM physicians needed to transition to EMR and their behavioural change was the key to success.

“In order to grow and improve, change is not only possible, but necessary. This notion is what enabled our success,” says Dr. Lola Oyenubi, General Internist/Hospitalist. “Being able to empower the GIM physicians to be the force of change was very rewarding for everyone involved – and ultimately, our patients are benefiting directly from this change and that’s what is really important.”

The IDEAS team worked tirelessly and diligently to ensure this project was not just a change, but a shift in behaviour. By including all the areas impacted by this change into the project, and by implementing this from the ground up, the results that have been observed so far have surpassed the project’s original goals.

Following the implementation of the Post Hospital Transition of Care project, GIM discharge summary turnaround time has dramatically decreased by 94.6 per cent and 86.7 per cent of all discharge summaries are provided to primary care physicians within 48 hours (the original aim was 75 per cent).

“Now that we have a successful model, there is no going back,” says Dr. Karuna Gupta, Family Physician. “By providing a clear goal for the discharge summary turnaround time and improving the quality of the discharge summary, we are one step closer to providing a seamless transfer of care for patients from the hospital to their family doctor.”

For physicians working in busy hospitals, seeing past the walls of their own unit can be difficult and engaging primary care physicians has historically been a time consuming task. The team at MSH noticed these barriers and set out to break them down by using technology and behaviour change. This new process makes discharge summaries easier, more effective and makes getting the info to primary care providers simple and more streamlined.

To ensure long-term success, this project has been accepted into MSH’s Quality Improvement Plan (QIP) and going forward, progress will be monitored quarterly. MSH is now exploring opportunities to spread the success of this initiative to other programs within the organization.

To learn more about this initiative, email