Table 3.

Summary of Results by Theme and Perspective

Theme	Shared	Hospitalist Only	PCP Only
Care coordination challenges	Lack of time	Difficulty obtaining PCP appointments	Unaware patients were hospitalized
	Difficulty reaching other clinicians		No hospital records for appointment
	Lack of personal relationships		Difficult to navigate hospital records
	Lack of information feedback loops		Feeling undervalued
	Medication list discrepancies
Accountability challenges
Pending tests	Unclear accountability for pending tests and home health	PCPs accountable for tests recommended after discharge	Hospitalists accountable for tests until results shared with PCP
	Concern about missed test results		PCPs uncertain about responsibility for follow-up on tests
	Specialists accountable for tests they order	Accountability for test results varies by test	PCPs often do not receive information about pending tests
	Hospitalists accountable for sharing information with PCPs
Home health care (HHC)	Hospitalists responsible for initial HHC orders	PCPs responsible for HHC once patient discharged	PCPs have difficulty addressing HHC issues prior to follow-up appointment
		Unwelcome receipt of HHC documents beyond initial contact
Care coordination solutions and ideals	Greater efforts for “high-risk” patients	Centralized scheduling system for PCP appointments	Short, structured, timely summaries
	Direct phone access to other clinicians	Hospitalist-run follow-up clinics	Follow-up appointments made prior to discharge
	Shared EMRs		Outpatient-based transitional care innovations
	Enhancing interpersonal relationships
Accountability solutions and ideals	Defined accountability for pending tests and home health