Three Crucial Factors Link After-Hours Care to Primary Care

Emma Hitt, PhD

June 06, 2012

June 6, 2012 — Primary care practices (PCPs) can better integrate after-hours care if they have adequate payer support and incorporate features such as shared electronic health records and systematic notification procedures to maintain continuity of care, according to a new analysis.

Ann S. O'Malley, MD, MPH, from the Center for Studying Health System Change in Washington, DC, and colleagues describe their findings in a qualitative analysis published online June 1 in the Journal of General Internal Medicine.

The study also found that efforts to provide after-hours care often work best when adopted as part of a broader PCP strategy to improve access and continuity of patient care.

According to the researchers, after-hours care refers to "care for medical problems arising between 5 p.m. and 8 a.m., and on weekends and holidays, that could be appropriately managed by the patient's primary care physician/team."

Nearly two thirds of all US emergency department visits occurred between 5 p.m. and 8 a.m. or on weekends, the authors note, and a substantial portion of those visits likely could be managed in less-costly settings if appropriate after-hours care were available. However, they add, minimal information is available to providers on developing sustainable models of after-hours care.

The qualitative analysis included in-depth interviews with 44 primary care physicians from 28 organizations involved with providing after-hours care. Of the 44 respondents, 33 were from PCPs, 9 worked at health plans or as patient-centered medical home program managers, and 2 worked at free-standing urgent care centers.

The study identified 5 models of after-hours care that coordinated with primary care: same PCP all the time; PCP plus practice partners, usually with limited extended hours and 24-7 telephone coverage; PCP plus small, local cross-coverage network, usually 24-7 telephone coverage, and sometimes extended hours; PCP plus large cross-coverage network that may have multiple sites with extended hours and may own an urgent care center or after-hours clinic; and PCP contracting with an urgent care center or after-hours clinic.

Their analysis uncovered 3 key themes common to current models that coordinate after-hours care with a patient's usual PCP. The first was that after-hours care systems must incorporate feasible and sustainable designs that meet local population needs.

"Several factors affect the design and feasibility of after-hours models, including gaining primary care clinician buy-in, assessing patient needs and preferences to ensure scheduling and staffing meet demand, consideration of location and practice size and financial sustainability," Dr. O'Malley and colleagues note.

The second theme that emerged was that shared electronic health records and systematic notification procedures between the after-hours providers and daytime PCPs are extremely helpful in maintaining continuity of care. One interviewee noted that the "most critical piece of setting up after-hours care is information exchange in real time."

The third theme was that 24-7 access is best implemented as part of a larger practice approach to access and continuity. "Many respondents noted that for after-hours care to be coordinated with a patient's usual PCP, it needs to be part of a larger practice focus to improve access and continuity," the authors note.

Study limitations include the fact that the sample size was small and did not represent all after-hours care arrangements. In addition, patients' opinions within these models were not assessed.

"Ultimately, identifying sustainable models to accommodate both provider quality of life and patient access and continuity to after-hours care may require a larger and better distributed primary care workforce, and payment reforms to reward providers for after-hours care," the authors conclude.

The study was not commercially funded. The authors have disclosed no relevant financial relationships.

J Gen Intern Med. Published online June 1, 2012. Abstract


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