‘My GP knows all about me’: what are the important features of community follow up after acute hospital admission? A scoping review and model of care needs by patient group.

Problem

Relational continuity in primary care is valued by patients and practitioners alike. There is substantial evidence that this reduces unplanned hospital admissions. Less is known, however, about the important features of community follow up for patients after acute admission to hospital. This review aims first to collate the existing literature by exploring who received follow up and how and by whom this was delivered. These questions are designed to characterise follow up care in the community, and secondly enable synthesis into suggested broad models of care for patient groups with differing follow up needs.

Approach

This scoping review was conducted in keeping with the framework set out by Arksey & O’Malley. Relevant studies were identified through extensive searches of MEDLINE and EMBASE. Given the exploratory nature of this work there were no predetermined exclusion criteria, provided that articles were in English or had translations available. A total of 46 articles from 2003-2023 were included, from a variety of healthcare systems globally.

Findings

Hospital discharge is a complex process, and initiation of community follow up largely depends on information flow from secondary care.In the UK this occurs via the discharge summary, although several articles suggest under half of these crucial documents are received by primary care within 48 hours of discharge. Patients identified for follow up received mainly in-person or telephone appointments within the first 28 days post discharge, typically to action medication changes or test requests within the discharge summary. Most follow up was carried out by a doctor, however general practitioners appreciated a multi-disciplinary approach to community follow up. A pilot nurse-led follow up of cardiovascular admissions suggested this resulted in similar clinical outcomes. The research focus is primarily patients over the age of 65, and those with chronic conditions, who valued follow up by their known primary care physician and viewed it as an opportunity to build on their longitudinal therapeutic relationship.

Consequences

It is possible to model the important features of community follow up as a hierarchy. Informational continuity is at the apex of follow up for all patient groups.Relational continuity, particularly with a GP, is next for those with chronic conditions and the elderly. However, further research into the role of the multidisciplinary team is needed.Further work regarding patients of working age and those with a novel diagnosis may suggest access to timely appointments is more important than relational continuity, particularly if contact with primary care was previously sporadic. Applying and extending this model via further research has potential to improve the community follow up available to patients, by offering timely appointments with a range of practitioners appropriate to their needs, as well as highlighting the importance of robust transitional arrangements from hospital to primary care.