Primary Care Consultant Program at 
Cambridge Health Alliance 
 
Evaluation of the pilot program and the feasibility of its expansion 
 
March 29, 2016 
 
 
Report prepared for the Department of Medicine at Cambridge Health Alliance 
 
DaEun Dana Im | Joint MD-MPP Candidate, 2016 
Harvard Kennedy School of Government & Harvard Medical School 
 
HKS Advisor: Joseph Newhouse, PhD 
HMS Advisor: Barbara Ogur, MD 
PAE Seminar Leader: Joshua Goodman, PhD 
 
 
 
This PAE reflects the views of the author(s) and should not be viewed as representing the views of the 
PAE's external client(s), nor those of Harvard University or any of its faculty.  
Table of Contents 
 
Executive Summary 3 
Introduction 5 
     A. Background: Continuity of Care 5 
     B. About the Client: Cambridge Health Alliance (CHA) 6 
     C. PCP Consultant Program: A Pilot Program 6 
     D. Problem Statement 7 
     E. Policy Options 7 
     F. Methodology Overview 7 
Problem Evaluation 8 
     A. Needs Assessment: Patient Perception of PCP Continuity Visit 8 
     B. Process Evaluation: Perception of the Process of Involving PCP Consultants  13 
     C. Outcome Evaluation: Impacts of Care Provided by PCP Consultants  21 
     D. Feasibility Assessment Cost of Care Provided by PCP Consultants 26 
Criteria & Policy Analysis 31 
Recommendations 35 
Appendices 39 
 
 
 2 
Executive Summary 
 
Introduction 
 
On January 1, 2015, Cambridge Health Alliance (CHA) Department of Medicine transitioned 
from the traditional inpatient model practiced by seven PCPs to the hospitalist model of care. A 
pilot program, “PCP Consultant Program,” incorporated these seven PCPs into inpatient care as 
consultants. In this pilot program, PCP consultants visit once or twice during a patient’s 
hospitalization, providing care the PCP considered relevant: a focused exam, insight into prior 
care, discussion of care decisions with the patient and family, and assistance in planning after-
hospital care. PCPs consultants’ services are reimbursed by CHA for this pilot program. A year 
after the implementation of the pilot program, CHA Department of Medicine must decide 
whether the pilot program should be expanded to include all CHA-affiliated PCPs, including 
internists and family medicine physicians.  
 
 
Findings 
 
Need Assessment: Patient Satisfaction  
• 77% of 199 interviewed patients with CHA-affiliated PCPs reported that the PCP 
involvement in inpatient care would be helpful 
• Older patients (50 or older), higher education (more than 12 years of education), and higher 
PCP ratings were associated with patients valuing PCP involvement during their 
hospitalization   
• Factors associated with patients’ valuation of PCP involvement can be used to identify 
patients who would most benefit from PCP consultation 
 
Process Evaluation: Perspectives of PCP Consultants, Hospitalists, and Residents 
• In pre-consultation phase, the program must clarify the process for initiating a consultation 
(who should initiate, whom to contact, and how to initiate)  
• During consultation, the program must define “areas of expertise” of PCP consultants  
• In post-consultation phase, the program need to structure a communication pathway for 
PCP consultants to relay their recommendations to inpatient providers 
 
Outcome Evaluation: Patient Outcomes related to the Pilot Program  
• The non-consultants’ average readmission rate increased over time by 5% more than the 
PCP consultants’ average readmission rate over time (p=0.11) 
• The non-consultants’ average number ED admissions per PCP decreased over time by 7.7 
patients more than the PCP-consultants’ average number of ED admissions per PCP 
decreased over time (p=0.78) 
 
Feasibility Assessment: Cost of Pilot Program and Estimated Cost of Expansion 
• Per year cost of the pilot program with six PCPs is $22836  
• Per year cost of expanding the program to include all 100 CHA-affiliated PCPs is $65,098, 
which may be an overestimation 
 
 
 3 
Recommendations 
 
Based on the four criteria—patient satisfaction, operational feasibility, impact on patient 
outcomes, and financial feasibility— I recommend that CHA does not expand the pilot PCP 
Consultant Program. Instead, I advise CHA to continue its pilot program for another calendar 
year while the recommendations to improve the consultation process are implemented.  
 
To improve the process of the existing pilot program, CHA Department of Medicine must:  
1. Define the role of PCP consultant 
2. Define PCP consultant’s scope of recommendations 
3. Allow team-based agenda setting 
4. Standardize communication  
 
In addition to improving the consultation process, CHA Department of Medicine should take 
the following steps towards making a case for expanding the pilot program: 
1. Emphasize data gathering and improve analysis of patient outcomes  
2. Assess PCP engagement and their willingness to serve as consultants  
3. Secure a sustainable reimbursement model 
 
 4 
I. Introduction 
 
A. Background: Continuity of Care 
 
Primary care is central to effective and efficient healthcare systems as it focuses on preventive 
medicine.1 The core of primary care is “continuity of care,” an ongoing personal patient-doctor 
relationship. Continuity of care has been associated with improved patient satisfaction and 
improved management of chronic diseases like diabetes.2 Studies have shown that certain 
groups of patients place more value on continuity of care in outpatient settings, including: 
seniors, new parents, patients with Medicare and Medicaid, chronically ill patients, females, 
and those with lower levels of education.3 Greater continuity of care and longer length of 
patient-doctor relationship with primary care doctors (PCPs) have been associated with greater 
patient satisfaction in outpatient settings.4 
 
In the past quarter century, the role of PCPs in general medical inpatient care has diminished, 
replaced by hospitalists who specialize in inpatient care. There are many benefits to a hospitalist 
including more efficient care of similar quality, availability throughout the day to care for 
patients, and honed acute care skills.5 However, the resulting discontinuity of care raises 
concerns about fragmented care and patient dissatisfaction.6,7 
 
Attempts to mitigate the loss of continuity of care and longitudinal relationship in inpatient care 
have been focused on integrating primary physicians in form of informal “social visits.” Theses 
“social visits” lack clear guidelines. Primary physicians have reported usually or always visiting 
their hospitalized patients only 34% of the time, ineffectively bridging the value primary care to 
inpatients. 1  
 
Several authors have proposed the model of “continuity visit” to describe a compensated 
encounter where a PCP is able to formally communicate with patients, endorse hospitalists, 
provide clinical insights, facilitate coordination care, and provide continuity of care.2,8 In 
providing continuity visits, primary physicians would work within a health system that makes 
it a standard practice to interact the patient and act as consultants to the inpatient team who 
maintains full attending-physician responsibilities.3  
 
Although the values of continuity visits by PCPs in inpatient setting are largely speculative, 
several studies suggest that patients would desire PCP involvement in certain clinical settings. 
In the palliative care literature, several authors have shown that patients are family members 
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  
1 Fan VS, Burman M, McDonell MB, Fihn SD. Continuity of care and other determinants of patient satisfaction with primary care. 
Journal of General Internal Medicine 2005;20:226-33. 
2 Goroll AH, Hunt DP. Bridging the hospitalist-primary care divide through collaborative care. The New England journal of 
medicine 2015;372:308-9. 
3 Greysen SR, Detsky AS. Solving the puzzle of posthospital recovery: What is the role of the individual physician? Journal of 
hospital medicine 2015;10:697-700. 
4 Kuo YF, Sharma G, Freeman JL, Goodwin JS. Growth in the care of older patients by hospitalists in the United States. The New 
England journal of medicine 2009;360:1102-12. 
5 Pandhi N, Saultz JW. Patients' perceptions of interpersonal continuity of care. Journal of the American Board of Family Medicine : 
JABFM 2006;19:390-7. 
6 White HL, Glazier RH. Do hospitalist physicians improve the quality of inpatient care delivery? A systematic review of process, 
efficiency and outcome measures. BMC medicine 2011;9:58. 
7 Wachter RM, Goldman L. The emerging role of "hospitalists" in the American health care system. The New England journal of 
medicine 1996;335:514-7. 
8 4. Wachter RM, Pantilat SZ. The "continuity visit" and the hospitalist model of care. Disease-a-month : DM 2002;48:267-72. 
 5 
feel abandoned when PCPs are not involved in their end-of-life discussions; moreover, PCPs 
want to and feel largely competent to provide palliative care in inpatient settings.9,10 In a 
qualitative study by Hruby and colleagues, patients were found to be similarly satisfied with 
hospitalists compared to PCPs as their physicians-of-record, but they wanted their PCPs to 
inform them of a serious diagnosis or discuss choices between medical and surgical 
management.  
 
 
B. About the Client: Cambridge Health Alliance (CHA) 
 
Cambridge Health Alliance (CHA) is an academic community health system committed to 
serving over 150,000 patients in Cambridge, Somerville, and Boston’s metro-north region.11 
CHA is well known for its expertise in 
primary care, mental health, and “CHA is currently transforming its system to 
substance abuse as well as caring for ensure excellent patient experiences and control 
diverse populations with complex healthcare costs. This work is important and 
medical and social needs. With its meaningful, and will allow us to serve our 
commitment to providing care to patients today and in the future.”  
vulnerable communities, CHA constantly – About CHA, Serving our Communities 
develops community and public health 
models that enable them to demonstrate effective new ways to integrate care and improve the 
well-being of, not only their patients, but also the communities.  The CHA system also has well-
established personal and population health functions. CHA operates the Public Health 
Department for the City of Cambridge, has a large community outreach team and a medical 
staff that actively collaborates in community projects and advocates around public policy 
issues. These teams work closely with municipalities and community groups to address broad 
health issues like tobacco use, obesity, childhood mental health and depression. 
 
 
C. PCP Consultant Program: A Pilot Program 
 
On January 1, 2015, CHA Department of Medicine transitioned from the traditional inpatient 
model practiced by seven PCPs to the hospitalist model of care. A pilot program, “PCP 
Consultant Program,” incorporated these seven PCPs as consultants. PCP consultants visited 
once or twice during a patient’s hospitalization, providing care the PCP considered relevant:  a 
focused exam, insight into prior care, discussion of care decisions with the patient and family, 
and assistance in planning after-hospital care. PCPs were asked to submit billing information to 
CHA for all consult services for reimbursement. CHA has agreed to reimburse the PCP 
consultants in the pilot program for the first year of the pilot program and to evaluate the 
option of expanding it to include the 100 CHA-affiliated PCPs.  
 
 
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  
9 Back AL, Young JP, McCown E, Engelberg RA, Vig EK, Reinke LF, Wenrich MD, McGrath BB, Curtis JR. 
Arch Intern Med. 2009 Mar 9;169(5):474-9. 
10 Silveira MJ, Forman J. J Gen Intern Med. 2012 Oct;27(10):1287-93. 
11 Cambridge Health Alliance Website, About CHA: http://www.challiance.org/AboutCHA/AboutHome.aspx 
 6 
D. Problem Statement 
 
Should CHA Department of Medicine expand the pilot PCP Consult Program to include all 
CHA-affiliated PCPs? 
 
 
E. Policy Options 
 
After a thorough evaluation process, CHA will consider the following policy options:  
• Option A, “Expansion”: Expand the pilot program to include all CHA-affiliated PCPs, 
thereby allowing them to provide formal consult services for their patients on the 
medicine wards at the CHA hospitals. They will be reimbursed appropriately for their 
services.  
• Option B “Continuation”: Do not expand the pilot program, but continue it while 
incorporating the recommendations to improve the consultation process.  
• Option C “Discontinuation”: Discontinue the pilot program.  
 
 
F. Methodology Overview 
 
Program evaluation was conducted to generate evidence used for assessing three policy 
options. The four steps of the evaluation process include: (1) need assessment, (2) process 
evaluation, (3) feasibility assessment, and (4) outcome evaluation. Program evaluation is a 
major component of value-based health care, 
the goal of which is to lower health care costs 
and to improve quality and outcomes.  
 
• Stage 1: Need assessment consists of 
estimating patients’ desire for 
involving PCPs in their inpatient care, 
which may improve patient 
satisfaction, a component of 
healthcare quality.  
• Stage 2: Process evaluation examines 
the perceived PCP consultation 
process from the active participants of 
the program. 
• Stage 3: Outcome evaluation focuses 
on the clinical outcomes of the 
patients with the PCP consultants 
before and after the program 
implementation.  
• Stage 4: Feasibility assessment conducts cost analysis of the pilot program, which would 
inform the client the financial feasibility of the policy options under consideration.  
 7 
II. Program Evaluation 
 
A. Needs Assessment: Patient Perception of PCP Continuity 
Visit 
 
Background 
 
Continuity of care over time from a primary care physician (PCP) in the ambulatory setting 
results in better outcomes, lower cost of care, and higher patient satisfaction.12  These improved 
outcomes appear to be mediated through increased adherence to prescribed medication, higher 
rates of preventive interventions, and improved coordination of care. The literature suggests 
that, in the ambulatory setting, patients from certain demographics may be more likely to prefer 
receiving care from their own PCP, particularly older patients, patients from the non-majority 
culture, and patients on public insurance, suggesting that trust and concordance of view of the 
medical issues may be important factors.13  Less is known about continuity of care between 
outpatient and inpatient venues.  Moreover, there has been little assessment of patients’ 
attitudes about maintaining PCP involvement during inpatient stays.     
 
Understanding patients’ “CHA is transforming its system to align with the 
perception of PCP involvement in Institute for Healthcare Improvement Triple Aim: 
hospitalist care is crucial to improve the health of populations, enhance the patient 
determining the potential value of experience of care, and reduce or control the costs of 
the PCP Consultant Program. In care. This work is important and meaningful, and will 
hospital value-based purchasing allow us to serve our patients and communities into 
program, quality of care is today’s evolving healthcare landscape.”  
measured with two metrics: – Our Transformation, Cambridge Health Alliance 
patient satisfaction (30%) and 
patient outcomes (70%).14 As a result, patient satisfaction carries the promise of rewards and the 
risk of penalties in reimbursement. The Hospital Consumer Assessment of Healthcare Providers 
and Systems (HCAPHPS), the most commonly used measure of patient satisfaction, determined 
hospitals’ loss or gain up to 1.5% of their Medicare payments in fiscal year 2015. The Centers for 
Medicare & Medicaid Services (CMS) will eventually increase the stakes to 2% of 
reimbursement by fiscal year 2017. The importance of patient satisfaction is also highlighted in 
CHA’s recent announcement of its commitment to transforming its system to align with the 
Institute for Healthcare Improvement Triple Aim: (1) improve health of populations, (2) 
enhance the patient experience of care, and (3) reduce or control the costs of care. Positive 
perception of PCP involvement in inpatient care may imply PCP consultants’ potentials to 
improve patient satisfaction, thereby the quality of health care at CHA. This section aims to 
assess the need (or preference) for PCP involvement in inpatient care, as voiced by patients 
themselves.  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  
12 Starfield B, Shi L, Macinko J. Milbank Q. Contribution of primary care to health systems and health. 
2005;83(3):457-502. 
13 Pandhi N, Saultz JW. Patients' perceptions of interpersonal continuity of care. Journal of the American Board of Family 
Medicine.2006;19:390-7. 
14 “Frequently Asked Questions: Hospital Value-Based Purchasing Program.” Accessed April 6, 2015. 
http://www.cms.gov/Medicare/Quality-Initiatives-Patient- Assessment-Instruments/hospital-value-based-
purchasing/Downloads/FY-2013-Program-Frequently-Asked-Questions-about-Hospital-VBP-3-9-12.pdf 
 8 
Methods 
 
During the eight months of data collection (January – August, 2015), three research assistants 
from Harvard Medical School and Harvard School of Dental Medicine conducted semi-
structured, in-person and telephone interviews with 199 patients with CHA-affiliated PCPs, 
being discharged from the Medicine Service at the CHA Cambridge Hospital. This research 
study received IRB approval from Harvard Medical School and Harvard School of Public 
Health.  
 
Patients were asked questions about their demographics, their relationship with their PCP, any 
PCP continuity visits or telephone encounters that may have occurred during their 
hospitalization, and their perception of how continuity visits impacted or might have impacted 
their inpatient care (Appendix A). Each interview was transcribed verbatim. In the answers to 
the interview question, “We are trying to learn how patients feel about having their PCP 
involved in their inpatient care-- how do you feel about this?” a number of key themes were 
identified through a thematic and comparative analysis approach.15 Patient perspective for PCP 
involvement was conceptualized based on the coding of those examples drawn from the 
patients’ answers. The thematic analysis was used to go beyond the individual experience of 
every participant and to build a rich description of the qualitative data. Themes identified were 
grouped together and checked for consistency. To eliminate bias, the research assistants verified 
the data.  
 
Data were reviewed using descriptive statistics for their preferences for involving PCP in 
inpatient care, age, gender, education level, race/ethnicity, self-reported health rating (scale of 
0-10, 10 being most healthy), length of relationship with PCP, and PCP rating (scale of 0-10, 10 
being most favorable). Data were analyzed using STATA Version 13 (StataCorp, College 
Station, TX). Multivariate variable logistic regression models were used to identify factors 
associated with having favorable views of PCP involvement in inpatient care.  
 
 
Results 
 
The mean age of patients interviewed was 62 years, with 44.2% male and 55.73 female. The 
average length of hospitalization was 3.61 days.  68% of patients self-identified as white and 
18% as black.  The mean length of patient-PCP relationships was 7.1 years.  Patients’ mean self-
reported health was 6.30 out of 10.  
 
150 (77%) of patients reported that PCP involvement was or would be helpful. The main 
reasons noted included that their PCP would provide comfort and would have background 
knowledge relevant for their inpatient care. As shown in Table 1, patients also cited continuity 
of care, better communication, and support with medical decision making as reasons for 
desiring PCP involvement in inpatient care.  
 
 
 
 
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  
15 Boyatzis, R.E. (1998) Transforming qualitative information: Thematic analysis and code development. Thousand Oaks, London, & 
New Delhi: SAGE Publications. 
 9 
Table 1: Key themes describing why patients value PCP involvement in inpatient care   
 
Themes Patient Quotes 
• “The PCP can talk about my medical history more than I can.” 
PCP offers • “He would have had more experience with my health than the other 
background doctor.” 
knowledge • “She would have been able to talk to the other doctors and give more 
background on health history.” 
• “I really like it because I’m a little bashful and when a doctor has to look 
at wounds on my backside the doctor looks like she might be under 18 
years old and it makes me feel really uncomfortable.” 
PCP offers 
 • “My doctor would have ben there to calm me down. She could have comfort
calmed me down. She does things where she sticks the needles in me 
while I’m standing up...I can’t lie down and she understands that. At the 
hospital they were almost hurting me to do so, and they didn’t care.” 
• “The PCP can talk about my medical history more than I can.” 
• “He would have had more experience with my health than the other 
PCP offers doctor.” 
continuity of care • “She would have been able to talk to the other doctors and give more 
background on health history.” 
PCP • “Usually when I’ve been in the hospital before my PCP has been able to 
communicates give me a lot more information and tell me what’s going on.”  
with patients 
PCP is involved • “My PCP can voice his or her opinion. I think it would be good to have 
in decision 
them collaborate with each other.”  
making 
 
 
 
From the univariate logistic regression, age was significantly associated with patient’s 
preference for PCP involvement (Table 2). Patients aged 50 or above were more likely to desire 
PCP involvement compared to patients aged 18-49 (OR=2.61, p=0.04, CI 1.06-6.43). Similarly, 
patients with higher level of education (beyond high school) were also more likely to prefer 
PCP involvement in their inpatient care (OR=3.81, p=0.01, 95% CI=1.41-10.25). Although the 
length patient-PCP relationship was not associated with preference for PCP involvement, 
patients who gave high scores (8 or above) were more likely to desire continuity care by their 
PCP during hospitalization (OR=2.39, p=0.04, 95% CI 1.09-13.03). 
 
 10 
Table 2: Univariate model of likelihood of desiring PCP involvement in inpatient care 
Number Odds Ratio p-value 95% CI 
 
Age less than 50 46 reference group   
Age 50 or higher 137 2.61 0.04 1.06-6.43 
Male 85 reference group   
Female 107 1.23 0.62 0.54-2.77 
12 or fewer years of education 111 reference group   
More than 12 years of education 72 3.81 0.01 1.41-10.25 
White 131 reference group   
Non-white 68 1.87 0.18 0.75-4.67 
Self health rating below 8 123 reference group   
Self health rating at or above 8 76 0.45 0.06 0.19-1.04 
Relationship with PCP for less than 5 years 89 reference group   
Relationship with PCP for more than 5 years 110 0.98 0.97 0.43-2.26 
Score for PCP less than 8 20 reference group   
Score for PCP at or above 8 179 3.78 0.04 1.09-13.03 
 
 
 
Discussion 
 
Understanding patients’ perception of PCP involvement in hospitalist care is crucial to 
determining the potential value of any innovative care models or policy changes to incorporate 
PCPs into inpatient care. In the current analysis, the majority of the patients reported that PCP 
involvement would be helpful, underlying the potential for continuity care to increase patient 
satisfaction. Patients appear to prefer PCP involvement in their inpatient care, likely due to the 
personal nature of their relationship with their provider and to their desire for informational 
continuity of care.  
 
Patients who value continuity in inpatient care tend to be older and more educated. They also 
rate their own health poorly and give higher score to their PCPs. The association between 
patients’ rating of their PCPs and their preference for PCP involvement also highlights how 
patients value having contact with providers whom they like and know well. Older patients 
and those with poorer reported health are likely to have multiple medical conditions, which are 
managed by their PCPs in outpatient settings. Naturally, these patients are likely to desire 
involving their PCPs who can provide background knowledge to the inpatient team.  
 
This study sample lacked sufficient statistical power to detect an association with severity of 
illness or mortality score. Nonetheless, the significant associations with older age and poorer 
reported health suggest a potential importance of level of morbidity and should prompt further 
investigation. These associations are consistent with the factors that are correlated with 
relational continuity between patients and PCPs. Kristjansson and colleagues demonstrated that 
older patients and those with chronic disease reported higher relational continuity with their 
 11 
PCPs, while those with higher education reported lower continuity.16 Other studies also have 
shown that patients with less education place higher value on continuity with their PCPs, 
particularly in outpatient settings.17 In contrast, the current analysis showed that patients with 
higher education level (higher than secondary) was also associated with patients’ desire for 
continuity of care provided by their PCPs. One explanation is that patients with higher 
education feel more entitled to PCP contact while they are hospitalized, what is now optionally 
practiced by PCPs. 
 
Some of the factors associated with patients’ desire for PCP contact may be helpful in 
identifying patients who would be more satisfied with their inpatient care, likely influenced by 
the involvement of their PCPs. This information should inform policy decisions on how to best 
structure a program like the PCP Consultant Program. Further research should explore whether 
particular diagnoses, such as psychiatric or end of life issues, may identify patients who most 
prefer inpatient contact with their PCP. 
 
 
 
 
Key Takeaways 
 
• 77% of 199 interviewed patients with CHA-affiliated PCPs reported that the PCP 
involvement in inpatient care would be helpful 
• Older patients (50 or older), higher education (more than 12 years of education), and 
higher PCP ratings were associated with patients valuing PCP involvement during 
hospitalization   
• Factors associated with patients’ valuation of PCP involvement can be used to identify 
patients who would most benefit from the PCP Consultant Program 
 
 
 
 
 
 
 
 
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  
16 Kristjansson E1, Hogg W, Dahrouge S, Tuna M, Mayo-Bruinsma L, Gebremichael G. Predictors of relational continuity in primary care: 
patient, provider and practice factors. BMC Fam Pract. 2013 May 31;14:72. 
17 Nutting PA, Goodwin MA, Flocke SA, Zyzanski SJ, Stange KC. Continuity of primary care: To whom does it matter and when? Ann Fam 
Med. 2003 Sep; 1(3): 149–155. 
 12 
B. Process Evaluation: Perception of the Process of Involving 
PCP Consultants 
 
Background 
 
Process evaluation examines the implementation and operation of different components of the 
program. Conducting a process evaluation for the PCP Consult Program would help identify 
problems faced in the process and strategies for overcoming these obstacles. The entire process 
is divided into three phases: (1) pre-consultation, (2) consultation (PCP’s visit to the patient), 
and (3) post-consultation. Each phase is comprised of a number of steps expected from either 
the PCP or the members of the inpatient team (Figure 1). 
 
To assess the PCP consultation process thus far since the implementation of the program on 
January 1, 2015, three different perspectives were considered: (1) PCP consultants, (2) 
hospitalists, who are physicians-of-record for all hospitalized patients on the Medicine Service, 
and (3) residents, who are physicians-in-training at CHA, a teaching hospital that houses 190 
residents and students every year.18 
 
Figure 1: Expected consultation process for the PCP Consult Pilot Program 
 
 
 
In the first section, PCPs perception of their new role as “consultants” was explored. In doing 
so, their perceived challenges to being effective informants and the values added to patient care 
were evaluated. The following section focused on understanding how hospitalists value PCPs’ 
participation in inpatient care as consultants. Different ways to improve PCPs’ incorporation 
into the hospitalists’ workflow were also explored. For a collaborative model to succeed, it is 
crucial to get buy-in from the inpatient team, including residents who are on the frontlines of 
providing care to patients at teaching hospitals like CHA.  
 
 
Methods 
 
Focus groups are ideal for exploring individual subjective experiences and attitudes towards 
new concepts. They are more effective than individual interviews in inducing real-world 
responses to questions, surveying an overview of attitudes and experiences, and exploring 
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  
18 About Cambridge Health Alliance, CHA FY14 Fact Sheet: http://www.challiance.org/Resource.ashx?sn=CHA-Fact-Sheet 
 13 
consensus.19,20 Thus, this qualitative approach was selected to understand the attitudes of the 
PCP consultants, the hospitalists, and the residents about the process of the pilot program.  
 
One moderator (author) guided the groups through a semi-structured focus group discussion 
that lasted approximately 30 min. Participant’s anonymity was promised and maintained for 
the purpose of gathering honest feedback on the process of the pilot program. All sessions were 
audiotaped and transcribed. The moderator recorded transcribed responses to conduct data 
analysis. As described in the previous section, all responses from each of the focus groups were 
coded and thematically analyzed. Identified themes were grouped together and checked for 
consistency by the research assistants.  
 
PCPs’ perception of their involvement in inpatient care:  
 
Seven months after the implementation of 
the pilot program, a focus group  
discussion was conducted with five of the Guiding Questions for Hospitalist Group 
seven PCP consultants participating in the Discussion and Resident Focus Group Discussion 
program. In addition to the focus group,  
automatic, on-line surveys of all the PCP 1. Can you share your stories/vignettes of 
consultants were conducted at the working with PCP consultants? How have they 
completion of their consult visits from added (or subtracted) value to patient care? 
January 1st to May 23rd, 2015 (Appendix 2. What are some logistical benefits or challenges 
B), specifically asking about the consult to co-managing patients with PCP consultants? 
process and the value added or subtracted 3. What are your ideals for involving PCP 
to patient care. Descriptive analysis of the consultants in in-patient care? In other words, 
survey results was conducted.  how can we best integrate PCP consultants into 
 in-patient workflow to improve patient care?  
Hospitalists’ perception of PCP 
involvement in inpatient care:  
 
Ten months after the initiation of the PCP Consultant Program, a focus group discussion was 
conducted with eight hospitalists at CHA. The semi-structured focus group interview guide 
was developed to explore the hospitalists’ perception of PCP involvement thus far as 
consultants.  
 
Residents’ perception of PCP involvement in inpatient care:  
 
10 months after the implementation of the pilot program, a focus group discussion was 
conducted with six of the 16 second- and third-year Internal Medicine residents. In addition, an 
on-line survey was conducted (response n=11, may include those who participated in the focus 
group) asking: (1) How does having a PCP consultant help with patient care? (2) What, if 
anything, is challenging about having the PCP give recommendations as a consultant for 
inpatients?  
 
 
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  
19 Kitzinger, J. Qualitative research. Introducing focus groups. BMJ 1995, 311, 299–302. 
20 Twohig, P.L.; Putnam, W. Group interviews in primary care research: Advancing the state of the art or ritualized research? Fam. 
Pract. 2002, 19, 278–284. 
 14 
Results 
 
PCPs’ perception of their involvement in inpatient care:  
 
101 automatic, on-line surveys were completed by the PCP consultants between January 1st and 
May 23rd, 2015. PCP consultants felt that the majority (81%) of the consultations went “okay” to 
“excellent.” The majority of the PCP consultants felt that they provided comfort to their patients 
based on their previous relationships, provided pertinent information to the inpatient team, and 
facilitated discharge planning and coordination of care post discharge.  
 
 
• 81% thought the consultation process went “okay” to “excellent” 
• 74% thought they provided comfort to the patient based on their previous relationship 
• 76% thought they provided information to the house officers about the patient’s 
medical issues that they had not known 
• 53% thought they facilitated discharge planning and coordination of care post 
discharge 
• 25% thought they expedited discharge vs. 8% thought they delayed discharge 
 
 
They reported contributing to the care of their hospitalized patients by: providing medical or 
social information, suggesting medical management, supporting transition of care, facilitating 
end-of-life discussions, and providing comfort to patients and family members (Table 3). 
 
 
 15 
Table 3: Perceived Contributions by PCP Consultants 
 
Themes Examples 
PCP provided • Shared knowledge of her baseline mental status 
medical or social • Gave background on complex social situation 
information  • Described home situation and lack of supports 
PCP supported • Performed a neurological exam which patient had not cooperated in 
patient with hospital team 
management • Medical team had difficulties with patient around communication issues 
PCP made • Suggested importance of brain imaging to better understand his 
suggestions for 
cognitive impairment 
medical 
 • Suggested lab follow-up of leukocytosis  management 
• “Patient asked to speak to PCP to help make decision 
PCP facilitated • Communicated with hospitalist about care goals 
patient’s decision • Discussed need for local surgical therapy 
making process  • Defined end of life plan 
• Called nursing home on discharge to assure smooth transition 
PCP supported • Contacted Complex Care Manager about preventing re-admissions 
transition of care  • Facilitated connection to SNF where PCP will follow the patient 
PCP provided 
comfort to • Provided support and comfort to patient before being intubated 
patient  
PCP interacted • Met with family and reassured them that PCP would see patient at rehab 
with family • Supported family members 
members  • Attended family meeting 
• No one called me. I think it would have been helpful to share my 
knowledge of this patient who has difficulties with med adherence. 
PCP could not be • Brief admission.  
involved  • This was an ED visit, so probably shouldn't be counted 
• I was not involved in this admission due to weather 
 
 
The PCP consultants participating in the focus group also identified the areas of improvement 
in the consult process as outlined in Figure 2. In the pre-consultation process, it was unclear to 
both the PCP consultants and the inpatient providers whose responsibility it was to initiate the 
consultation. The PCP consultants felt that the medical and social need for a consultation is 
often best discerned by PCPs themselves, not the primary team. However, when the PCPs 
initiated the consultation process without a request from the inpatient team, they felt 
“awkward” for it was unclear whether their advice would be appreciated. During the 
consultation process, the “advisory role” became vague especially when PCPs wanted to 
provide clinical recommendations. As PCPs who have built longitudinal relationships with 
 16 
their patients, the consultants would provide clinical recommendations that were relevant more 
to outpatient than inpatient management. For this reason, some of the PCPs felt that the term 
“consultant” did not fit their role.  They felt that due to their ongoing relationship with the 
patient, that the ways that they added value were, therefore, fundamentally different from 
those of a consultant.   
 
Figure 2: Areas of improvement in the consultation process, as identified by the PCP 
consultants 
 
 
 
 
 
Hospitalists’ perception of their involvement in inpatient care: 
 
The hospitalists participating in the focus group expressed their appreciation for PCP 
involvement in inpatient care. When describing the areas of improvement in the current 
consultation process (Figure 3), the 
hospitalists also brought up the lack of clarity  
in regards to initiating the consultation. First “100% of patients at CHA would benefit 
of all, not all PCPs in the CHA network serve from having their PCPs involved. Patients 
as consultants, which requires the inpatient often express dissatisfaction when their 
providers to remember the seven PCPs PCPs don’t come to see them.” 
participating in the pilot program. As  
discussed in the focus group with the PCP - A hospitalist in the focus group 
consultants, the medical and social need for a 
consultation is often best discerned by PCPs themselves, not the primary team. Therefore, not 
all inpatient providers can think of a specific question to initiate a consultation. When there is a 
specific question (i.e. regarding medication reconciliation and social history), the hospitalists felt 
that it would be sufficient to have a quick conversation with the PCPs in the early phase of the 
patient’s hospitalization. The hospitalists also identified the need for a clear communication 
mechanism for PCP consultants to close the loop after inpatient visits. Hospitalists also found it 
difficult to reject PCP consultants’ medical recommendations. 
 
 
 17 
Figure 3: Areas of improvement in the consultation process, as identified by the hospitalists  
 
 
 
 
 
Residents’ perception of their involvement in inpatient care: 
 
The residents have found the PCP consultants mainly helpful, especially when the consults are 
based on long, meaningful relationships with patients. The residents reported that the PCP 
consultants have facilitated family meetings, goals of care discussions, and coordination of post-
discharge care. Unlike the hospitalists, the residents felt that it was helpful to have the PCPs 
involved as consultants even when there is not a specific question for patient care.    
 
When identifying the specific areas of improvement in the consultation process (Figure 4), the 
residents, like the hospitalists, mentioned how it can be difficult to remember which PCPs are 
participating in the pilot program and to remind themselves to reach out the consultants when 
specific questions arise. The residents also did not find the process of communicating with PCP 
consultants problematic, but did note that PCPs occasionally recommended additional, non-
urgent inpatient evaluations or tests. 
 
 
 18 
Figure 4: Areas of improvement in the consultation process, as identified by the residents 
 
 
 
 
Discussion 
 
The “PCP consult” provides a model for PCP involvement that residents view as contributing to 
care and that may allow effective modeling of the value of long-term patient-doctor 
relationships. However, the focus group sessions with the stakeholders involved in the 
consultation process revealed that a number of areas of improvement.  
 
The hospitalists and the residents in the focus group sessions found PCP involvement 
important and useful, particularly in providing emotional support to patients, but found a 
number of obstacles, including difficulty in ensuring communication with the team and some 
concerns about ensuring defined responsibilities in inpatient settings.  
 
Meanwhile, PCP consultants identified some of the obstacles that suggested that they were still 
referring back to their previous role as physicians-of-record, prior to the hospital’s transition to 
the hospitalist model of inpatient care. PCPs, whose responsibility is to provide longitudinal 
care, may feel that they have the expertise to know when to initiate the consultation process and 
to provide recommendations that may not be relevant to the acute issue at hand, which the 
focus of the inpatient team. The discordant perceptions of PCP consultant’s role may result in 
difficult power dynamics, as described by the hospitalists.  
 
If the PCP’s role is to be a “consultant,” which by definition is to provide recommendations that 
are subject to rejection by the primary team, there should be a clear, well-defined “areas of 
expertise” for PCP consultants. These areas of expertise should focus on the specific aspects of 
patient care, such as those identified by the residents, and PCPs must agree to limit the scope of 
their recommendations to their defined areas of expertise.  
 19 
Key Takeaways 
 
• Pre-Consultation: Need to clarify the process for initiating a consultation (who should 
initiate, whom to contact, and how to initiate)  
• Consultation: Need to define “areas of expertise” of PCP consultants to ensure clear lines 
of responsibilities in inpatient settings 
• Post-Consultation: Need to structure a communication pathway for PCP consultants to 
relay their recommendations to the inpatient providers 
	
  
 
 20 
C. Outcome Evaluation: Impacts of Care Provided by PCP 
Consultants  
 
Background 
 
Hospital readmission rates, or the proportion of discharged patients for whom rapid re-
hospitalization occurs (typically within 30 days), has become a leading topic of healthcare 
policy. This is due to the fact that high readmission rates can be a sign of low quality healthcare, 
a metric now used nationally to gauge quality of care. Medicare imposes financial penalties on 
hospitals with a high rate of readmissions. Hospital readmissions remain frequent, expensive, 
and largely preventable.21 Improving readmission rates represents an opportunity to 
simultaneously increase quality of care while decreasing cost.22 
 
Utilization of emergency departments (EDs) for non-emergency care is considered another 
quality measure for healthcare networks like CHA. Although controversial, non-emergent ER 
visits are seen as inefficient use of the healthcare system that drives up the cost of medical care. 
A well-functioning healthcare network is to direct its patients to primary care physicians for 
non-acute care, which would then improve the quality of care and reduce the cost of care.   
 
In this section, impact evaluation was conducted to examine whether the PCP Consultant 
Program had an intended effect on improving patient outcomes, including readmission rates 
and total ED visits. To do so, the analysis compares two groups: seven PCP consultants in the 
pilot program and six PCPs who practice at the same clinics as the consultants. Furthermore, 
patient outcomes from two distinct time periods (years 2014 and 2015) are examined to see the 
impact of the pilot program, which was implemented on January 1, 2015.  
 
 
Methods 
 
CHA’s inpatient admission database and ED admission database from January 1, 2014, through 
December 31, 2015 were used to determine whether the PCP Consultant Program was 
associated with improved patient outcomes (readmission rates and ED admission). Difference-
in-difference analysis was conducted compare changes in readmission rates and ED admissions 
among PCP consultants before and after the implementation of the pilot program (Year 2014 vs. 
2015) to changes among outpatient clinic-matched PCPs not participating in the program. Table 
4 describes in detail how the difference-in-difference analysis was designed. Further analysis 
examined whether effects on readmission rates varied according to patients’ age, gender, and 
preferred language.   
 
 
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  
21 van Walraven C, Bennett C, Jennings A, Austin PC, Forster AJ. Proportion of hospital readmissions deemed avoidable: a 
systematic review. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne 2011;183:E391-402. 
22 Joynt KE, Orav EJ, Jha AK. Thirty-day readmission rates for Medicare beneficiaries by race and site of care. Jama 2011;305:675-81. 
 
 21 
Table 4: Design of the difference-in-difference analysis 
 Treatment Group Control Group 
4 PCU- and 3 Windsor-based 
1/1/2014 - 12/31/2014 
PCPs serving as physicians-of- 3 PCU- and 3 Windsor-based PCPs 
Pre-implementation record 
1/1/2015 - 12/31/2015 4 PCU- and 3 Windsor-based 
3 PCU- and 3 Windsor-based PCPs 
Post-implementation PCPs serving as consultants 
 
 
 
Results 
 
On average, PCP consultants had a readmission rate of 17.7% in 2014. Their counterparts had an 
average readmission rate of 17.8%. Although both groups had similar readmission rates before 
the implementation of the PCP Consultant Program, the average readmission rate for the non-
consults rose up to 22.9% in 2015, compared to 17.3% for the PCP consultants (Figure 5). There 
was a 5% decrease in the average readmission rate for the PCP consultants, compared to their 
counterparts, after the program was implemented on January 1, 2015 (Table 5). Adding other 
explanatory variables to the model did not significantly impact the difference-in-difference 
estimator (Table 6).  Nonetheless, patients whose primary language is not English appear to 
have a 7.9% decrease in the likelihood of being readmitted (p<0.05). 
 
0.25 
0.2 
0.15 
0.1 
Non-consultants 
0.05 PCP consultants 
0 
2014 2015 
Time (Year) 
 
Figure 5: Average readmission rates of PCP consultants and non-consultants, compared over 
time. Year 2014: pre-implementation, Year 2015: post-implementation. 
 
 22 
Readmission Rate 
 
Table 5: Difference-in-difference analysis describing the relationship between readmission rates 
of PCP consultants and non-consultants, across two time periods.  
Time difference  
 2014 2015 
w/ in group 
0.177 0.173 -0.004 
PCP consultants 
(0.014) (.015) (0.021) 
0.178 0.229 0.050 
Other PCPs (0.018) (0.020) (0.027) 
Group difference at a 0.001 0.056 -0.054 
point in time (0.023) (0.025) (0.034) 
 
 
 
 
Table 6: Difference-in-difference analysis describing the relationship between readmission rates 
and various explanatory variables 
 Readmission Rate  
-0.001 -0.001 -0.002 0.001 
PCP Consultant 
(0.023) (0.024) (0.024) (0.024) 
0.050 0.051 0.050 0.047 
2015 
(0.027)** (0.027)** (0.027)** (0.027)** 
-0.054 -0.054 -0.054 -0.051 
PCP Consultant * 2015 
(0.034)* (0.034)* (0.034)* (0.034)* 
-0.00001 0.0002 0.0003 
Age  (0.0005) (0.001) (0.0005) 
  -0.012 -0.008 Female 
(0.017) (0.017) 
-0.079 
Native language is not English    (0.017)*** 
0.178 0.179 0.184 0.191 
_cons (0.018) (0.031) (0.033) (0.033) 
R2 0.0031 0.0031 0.0033 0.0120 
N 2185 2185 2185 2185 
*p<0.15, **p<0.10, ***p<0.05 
 23 
On average, PCP consultants had an average of of 119 ED admissions in 2014 (Table 7). Their 
counterparts had an average of 131 ED admissions in 2014. Both groups had a decrease in ED 
admissions in 2015: 102 patients per physician or the PCP consultants and 106 patients per 
physician for the non-consultants (Figure 6). As summarized in Table 7, the non-consultants’ 
average number ED admissions per PCP decreased over time by 7.7 patients more than the 
PCP-consultants’ average number of ED admissions per PCP decreased over time. This 
difference-in-difference estimator was not statistically significant (p=0.79). 
 
140 
120 
100 
80 
60 Non-consultants 
PCP consultants 
40 
20 
0 
2014 2015 
Time (Year) 
 
Figure 6: Average number of ED visits per physician, compared between PCP consultants and 
non-consultants, before the implementation of the pilot program (2014) and after (2015).  
 
 
Table 7: Difference-in-difference analysis describing the relationship between average number 
of ED admissions per PCP, across two time periods. 
Time difference  
 2014 2015 
w/ in group 
119.43 102.00 -17.43 
PCP consultants 
(19.52) (10.96) (23.87) 
131.17 106.00 -25.17 
Other PCPs 
(11.74) (13.73) (16.06) 
Group difference at a 11.74 4.00 7.74 
point in time (23.81) (18.01) (28.83) 
 24 
Average ED Visits per Physician 
Discussion 
 
The difference-in-different analysis revealed that the non-consultants’ average readmission rate 
increased over time by 5% more than the PCP consultants’ average readmission rate over time. 
This difference-in-difference estimator was not statistically significant (p=0.11), but it suggests 
that the PCP Pilot Program may have contributed to keeping the readmission rates low for the 
PCP consultants while the readmission rates for the non-consultants increased in 2015. This 
finding is consistent with the proposed impact of the PCP Consultant Program, in which the 
consultants provide continuity of care by facilitating and coordinating post-discharge care.  
 
Controlling for some of the available variables in the dataset, including age, gender, and 
primary language, in the regression model did not significantly change the difference-in-
difference estimator in change readmission rates. This suggests that the difference in the 
average readmission rates still remains independent of the variables included in the analysis. 
However, severity of illness, which may have affected the readmission rates (i.e. non-
consultants had a disproportionately higher number of severely ill patients, who are more likely 
to be readmitted), was not included in the current analysis.  
 
The non-consultants’ average number ED admissions per PCP decreased over time by 7.7 
patients more than the PCP-consultants’ average number of ED admissions per PCP decreased 
over time. This difference-in-difference estimator was not statistically significant (p=0.79). Other 
possibly influential variables were not factored into this regression model for predicting the 
number of ED admissions. It is also important to note that reducing the number of non-
emergent ED visits is prioritized over reducing the total number of ED visits. The current 
analysis could not distinguish non-emergent ED visits from those that required emergent 
attention in the ED.  
 
Another limitation of the current analyses is that the control group (non-consultants) is an 
imperfect match for the treatment group (PCP consultants) for comparison of patient outcomes. 
Anecdotally, the PCP consultants have sicker patient panels that may have clinical outcomes 
that are different from the non-consultants’ patient panels. Further studies should include 
severity of illness as a variable in the regression analysis. Moreover, a logistical assessment of 
the clinical outcomes of the patients seen by the PCP consultants compared to the non-
consultants may yield a stronger analysis of the impact of the pilot program.  
Key Takeaways 
 
• The non-consultants’ average readmission rate increased over time by 5% more than 
the PCP consultants’ average readmission rate over time (p=0.11) 
• The non-consultants’ average number ED admissions per PCP decreased over time by 
7.7 patients more than the PCP-consultants’ average number of ED admissions per 
PCP decreased over time (p=0.78) 
 25 
D. Feasibility Assessment: Cost of Care Provided by PCP 
Consultants 
 
Background 
 
Cost analyses provide an important insight into the overall cost of implementing a program, 
costs for specific program components, and costs per program participants.23 Costs are defined 
as the monetary value of the resources used to implement and sustain a program, not just the 
money spent. Cost analyses also establish a foundation for other types of economic analysis, 
such as cost-effective or cost-benefit analyses.  
 
In this section, the cost of the PCP Consultant Program for the seven participating PCPs is 
estimated using the billing data from the first six months of the pilot program. To test the 
feasibility of either sustaining the current pilot program or expanding the program, the 
monetary value of the reimbursement was examined. The perspective of the cost analysis 
conducted in this section was defined as the Cambridge Health Alliance (CHA), which would 
reimburse its PCP consultants until a third-party payer, such as an insurance company or 
Medicare, shares the cost of providing continuity visits.  
 
It is important to establish a value not only for how much the reimbursing organization would 
need to pay the PCP consultants for their billed services, but also for the program’s use of 
resources at no cost. For example, the time that a PCP consultant spends making a continuity 
visit might otherwise be spent in the clinic to see a number of outpatients. In this analysis, 
however, it was assumed that the PCPs knew the financial tradeoffs of their time spent as 
consultants for their hospitalized patients.  
 
After determining the cost of the PCP Consultant Program, the overcall cost of expanding the 
pilot program will be estimated to inform the client of the overall budget. This information will 
be used to determine whether the cost of the expansion can be justified by the benefits as 
described in the previous sections.  
 
 
Methodology 
 
All PCP consultants were asked to bill their consult services since January 1st, 2015. For the 
purpose of the cost analysis, billing data were collected for first six months of the pilot program, 
from January 1st to June 30th, 2015. For each PCP consultant’s billed visit, the following data 
were collected: (1) patient name, (2) diagnosis, and (3) relative value units (RVUs), which are a 
measure of value used in the United States Medicare reimbursement formula for physician 
services. All data collected were de-identified before the analysis.  
 
 
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  
23 Yates, B.T. (2009). Cost-inclusive evaluation: A banquet of approaches for including costs, benefits, and cost- effectiveness and 
cost-benefit analyses in your next evaluation. Evaluation and Program Planning, 32(1), 52-54. Retrieved from 
http://brianyates.net/info/ yates_banquet_of_approaches.pdf. 
 26 
Results 
 
From January 1st to June 30th, 2015, 118 claims were billed by the PCP consultants for a total of 
94 patients. PCP consultants provided services to patients with complex conditions (Figure 7). 
One out of seven PCP consultants did not bill for her services; it was confirmed that this PCP 
provided multiple consult services during the above time frame, but she did not submit billing 
forms for reimbursement. 
 
Figure 7: Sample primary diagnoses by ICD-9 codes for patients seen by PCP consultants 
•  Cerebral artery occlusion 
•  TIA 
•  COPD with acute exacerbation 
•  Acute kidney failure 
•  End state renal disease 
•  MS 
•  Psychiatric illnesses: schizophrenia, depressive DO, amnestic DO 
•  Substance abuse: alcohol withdrawal 
•  Hemorrhagic GI tract 
•  Cardiomyopathies 
•  Pneumonia 
•  Dissection of aortic aneurysm 
•  Complications of HIV: cellulitis, abscess  
•  Afib 
•  Hypoclycemia, volume depletion 
•  Encounter for palliative care 
•  UTI 
 
Excluding the one PCP who did not bill for any consult visit, the six PCPs, on average, provided 
consult service to 2.6 patients and billed 3.3 claims per month. For every fourth patient, each 
PCP submitted two claims on average. As shown in Table 8, there is a wide variation in the 
number of claims submitted by the PCPs. This variation appears to correlate with the PCP’s 
clinic site: the four PCPs, whose clinic is based at the hospital (Primary Care Unit – “PCU”) 
visited 35% of their hospitalized patients on average, while the three PCPs, whose clinic is one 
mile away from the hospital, visited 11% of their hospitalized patients on average. 
 
A variation in RVU per patient among the PCPs was also noted. The average RVU per patient 
was 3.39, the average RVU per claim 2.70. RVU can be translated into a monetary value, based 
on the conversion factor (CF) determined by the reimbursing agent. In this case, CHA, the 
reimbursing agent, is to set the CF for the PCP’s services. For the current cost analysis, the 
standard CF ($35.8279) for Medicaid reimbursement set by the Centers for Medicare & 
Medicaid Services for 2016 was used to estimate the yearly cost of the program.24 The estimated 
cost of the pilot program, consisting of 6 PCP consultants who billed for their services, is $22,836 
per year.  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  
24 http://www.healthindustrywashingtonwatch.com/2015/11/articles/regulatory-developments/medicare-medicaid-services-
regulations/cms-finalizes-medicare-physician-fee-schedule-rates-policies-for-2016/ 
 27 
Table 8: Summary of billing data for each of the PCP consultants from January 1st to June 30th, 
2015  
% of admitted 
# of patients 
 patients # of claims Total RVU RVU/patient 
claimed 
claimed  
PCP #1* 22 35% (22/63) 31 81.04 3.68 
PCP #2 2 8% (2/25) 2 2.78 1.39 
PCP #3 5 12% (5/41) 9 19.17 3.83 
PCP #4* 20 34% (20/59) 20 61.16 3.06 
PCP #5* 41 49% (41/84) 51 146.40 3.57 
PCP #6* 4 9% (4/43) 5 8.14 2.04 
PCP #7 0 0% (0/28) 0 0 0 
TOTAL 94 30% 118 318.69 3.39 
*PCPs whose clinic is based at the Primary Care Unit (PCU), located in the Cambridge Hospital 
where patients are hospitalized.  
 
 
Table 9: Assumptions for estimating the cost of expanding the PCP Consult Program 
Assumptions Sources 
Each year, 4620 patients are hospitalized to the Medicine 
Service at the two CHA hospitals (includes Family Admission data from  
Medicine) 2/12/2015 – 2/12/2016 
Approximately 75% of the hospitalized patients have PCPs Dr. David Bor,  
affiliated with CHA (both Internal Medicine and Family Chief of Medicine 
Medicine) 
650 patients, whose PCPs are based at the Primary Care 
Admission data from  
Unit (PCU), are admitted to the Medicine Service at the 1/1/2015-12/31/2015 
CHA Cambridge Hospital each year 
Billing data submitted by PCU-
PCPs based at PCU visit 35% of their hospitalized patients based PCP consultants from 
1/1/2015-6/30/2015 
Billing data submitted by 
PCPs based at other community clinics visit 11% of their Windsor-based PCP consultants 
hospitalized patients 
from 1/1/2015-6/30/2015 
Billing data submitted by PCP 
Each patient seen by PCP consultant is billed for $121 consultants from  
1/12015-6/30/2015 
 28 
To estimate the cost of expanding the program to include all 100 PCPs affiliated with CHA 
consultants, various assumptions were made as summarized in Table 9. Although 30% of PCP 
consultants’ hospitalized patients were visited and billed on average, this figure was not used to 
estimate the overall “consult rate” of all CHA-affiliated PCPs who would be participating in the 
expanded program. As discussed previously, the average consult rate of the PCPs at the PCU 
was 35%, compared to the 11% consult rate of the PCPs at Windsor. This practice difference is 
likely related to the location of the PCU, which makes it more convenient for the PCU-based 
PCPs to visit their hospitalized patients than for the other PCPs. Based on these assumptions, 
the total number of patients (on both Medicine and Family Medicine Services at the two CHA 
hospitals), who would receive a continuity visit, was estimated to be 538 per year. 
650 patients  228 patients  
with PCU-based (35% of 650 patients) 
PCPs would be visited by PCU-based PCPs 
3465 patients  
4620 
patients with PCPs affiliated 
with CHA 310 patients  
2815 patients  (11% of 2815 
with PCPs based at patients) would be 
other community visited by PCPs 
clinics based at other 
community clinics 
Figure 8: Estimation of the total number of likely PCP consultations per year with the expansion 
of the PCP Consult Program. 
 
For each hospitalized patient seen by the PCP consultant, the average amount of money 
reimbursed was $121, which may change with the number of claims per patient and the 
complexity of the services provided by the consultant (Table 10). Based on these figures, the 
estimated cost of expanding the program to include approximately 100 full-time PCPs in the 
CHA network is $65,098 per year, if all the assumptions hold true. 
 
Table 10: Estimated cost for the pilot program and for the expansion of the program 
Per year for the pilot program* $22836 
Per each hospitalized patient $121 
Per year for all CHA-affiliated PCPs** $65,098 
*6 PCP consultants in the pilot program (excluding one PCP who did not bill for consult services) 
**If expansion were to include approximately 100 full-time PCPs affiliated with CHA 
 29 
Discussion 
 
The cost analysis conducted from the perspective of CHA, the reimbursing agent, was based on 
the data collected form the first six months of the pilot program, which was driven by seven 
PCPs invested in making continuity visits to their hospitalized patients.  It is important to note 
that the approximated annual cost of $65,098 for expanding the program to include 100 CHA-
affiliated PCPs is founded on various estimations (Table 11). These values may be 
overestimated, as justified in Table 11, resulting in an overall overestimation of the annual cost 
of reimbursing 100 PCPs for their consult services. Moreover, not all PCPs may bill for their 
consult work, as happened in the pilot study. Billing omission would also result in an actual 
cost that is less than the estimated cost of $65,098.  
 
Other factors that would influence the overall cost of expanding the program may include the 
distance between the clinic and the hospital, the weather, the willingness of the participating 
PCPs, and the actual CF determined by the reimbursing agent. Although omitted in this 
analysis, it would be important to analyze the demographics of the patients visited by the PCP 
consultants, who billed for their services. Further analysis should explore whether particular 
demographics may identify patients who would most benefit from PCP consultation.   
 
Table 11: Likely directions of the estimations made in the cost analysis 
Over- or Under-
Estimations Reasons 
estimation 
PCPs based at other • The 11% consult rate is based on the 
community clinics visit PCPs at Windsor, which is only one 
11% of their Overestimation mile away from the hospital. Other 
hospitalized patients clinics are located farther from the 
hospitals. 
All 100 PCPs willingly • Higher proportion of CHA-affiliated 
participates in the Overestimation PCPs whose clinics are not based at one 
program, if expanded of the participating hospitals – making 
it difficult for them to visit their patients 
• Conversion factor set by CF is likely to 
Each patient seen by be lower than the Medicaid CF used for 
PCP consultant is billed Overestimation this cost analysis 
for $121 • Not every PCP will bill for their consult 
services 
 
Key Takeaways 
 
• Per year cost of the pilot program with six PCPs: $22836  
• Per year cost of expanding the program to include all 100 CHA-affiliated PCPs: 
$65,098, which may be an overestimation 
 30 
Criteria & Policy Analysis 
 
 
In previous sections, program evaluation was conducted in four steps: (1) need assessment, (2) 
process evaluation, (3) outcome evaluation, and (4) feasibility assessment.  Parallel to these 
stages, four criteria were created: 
Policy Analysis Criteria 
 
1. Patient Satisfaction: Patients desire PCP involvement 
2. Operational feasibility: Consultation process is clear and well practiced by PCPs, 
hospitalists, and residents 
3. Impact on patient outcomes: PCP consultants improve patient outcomes 
4. Financial feasibility: PCP consultants can be reimbursed for their services 
 
These criteria were used to analyze the three policy options:  
Policy Options 
 
• Option A, “Expansion”: Expand the pilot program to include all CHA-affiliated PCPs, 
thereby allowing them to provide formal consult services for their patients on the 
medicine wards at the CHA hospitals. They will be reimbursed appropriately for their 
services.  
• Option B “Continuation”: Do not expand the pilot program, but continue it while 
incorporating the recommendations to improve the consultation process.  
• Option C “Discontinuation”: Discontinue the pilot program.  
 
To predict the outcomes, several assumptions were made as described in Table 12. Based on 
these assumptions, an outcome matrix was created to compare the three policy options across 
the four selected criteria (Table 13).  
 
Table 12: Likely directions of the estimations made in the policy analysis 
Assumptions Explanations 
77% of the patients whose PCPs are involved Underestimation: Patients who has had PCP 
in their inpatient care would appreciate the involvement in the past are more likely to 
consultation appreciate the consultation 
All patients who prefer PCP involvement Overestimation: Not all PCP consultations 
would report higher patient satisfaction after would translate into favorable inpatient 
the consultation experience 
538 patients would be seen by PCP Overestimation: Unclear whether all PCPs 
consultants each year would serve as consultants 
PCP consultants would be paid at the rate of Overestimation: Unclear what CHA or other 
the standard Medicare conversion factor potential reimbursing agents would agree to 
($35.8279) pay per RVU 
 31 
Table 13: Outcome Matrix for three policy options compared across the four selected criteria 
 
 32 
The option of expanding the program (Option A) is predicted to have the greatest impact 
(increased patient satisfaction and decreased readmission rate), when applied to all PCPs who 
would be eligible to participate in the program as consultants. However, there are uncertainties 
embedded in these predictions (Table 14). Of these uncertainties, the following four 
uncertainties warrant further investigation before expanding the program.  
 
1. PCPs’ willingness to participate in the program: Without PCPs’ buy-in, the program 
would not succeed in produce the positive results as predicted. 
2. Resources for process implementation: It is unclear whether there are enough resources 
to train PCPs, hospitalists, and residents at two CHA hospitals. The training process 
would entail a gradual culture change that accepts PCPs as valuable consultants. 
Moreover, a robust, well-structured training is needed to re-educate the participants of 
the program of the ideal role of PCP consultants and the consultation process.  
3. Patient outcomes related to the program: Although readmission rates are predicted to 
decrease, it is unclear whether patients who receive consultation are specifically less 
likely to be readmitted. Meanwhile, other “unintended consequences” may affect the 
practice patterns of PCP consultants, who may feel pressured to see their hospitalized 
patients and spend more time away from their clinic patients.  
4. Reimbursement: Although the expansion is predicted to cost $65,000 per year, it is 
unclear whether CHA would be committed to reimbursing all PCP consultants and 
whether this reimbursement structure would be sustainable.  
 
 
Table 14: Uncertainties that are embedded in the predicted outcomes and feasibility of 
expanding the pilot program 
 Uncertainties 
• Patients desire PCP involvement in their inpatient care 
• The expanded program has the potential to improve patients’ satisfaction level 
• PCPs in the CHA network are willing to provide consult services in the expanded program 
• PCPs, hospitalists, and residents understand the role of PCP consultants 
• All participating members understand and practice the standardized consultation process 
(pre-consultation, consultation, and post-consultation) 
• The expanded program improves patient outcomes (not limited to readmission rates and 
ED visits) 
• Improved outcomes reduce healthcare costs 
• Billing information can be recorded for all PCPs participating in the expanded program 
• CHA is willing to reimburse all PCPs for their consult services (~$65,000/year) 
*In red are uncertainties that warrant further investigation before the expansion 
 
 33 
Financial Patient Operational Patient 
Feasibility Outcomes Feasibility Satisfaction 
The predicted positive outcomes may not be realized or sustained in an expanded program. If 
the program is expanded without assessing the PCPs’ willingness to participate in the program, 
securing the resources for implementing the program, examining the impact on patient 
outcomes, and identifying a stable reimbursement structure, the program may face an abrupt 
end.   
 
The option of continuing the pilot program (Option B) is more viable, especially given the 
financial commitment from CHA. Although the pilot program’s predicted impact on patient 
satisfaction and patient outcomes are marginal (4% of all patients admitted to the Medicine 
Service), it offers other benefits, such as: (1) creating a culture that values primary care, and (2) 
training young physicians to interface with primary care providers more frequently, especially 
in the CHA Internal Medicine Residency Program, which is well known for its strong training 
in primary care. Lastly, some of the operational challenges have already been identified in the 
current analysis, which can be used to improve and refine the pilot program. In the following 
section, the final policy recommendation will be presented along with a series of concrete steps 
to improve the current program.  
 
 34 
Recommendations 
 
Final Recommendation 
 
CHA should not expand the pilot PCP Consultant Program. However, the pilot program 
should be continued for another calendar year while the recommendations to improve the 
consultation process are incorporated.  
 
 
Next Steps for Process Improvement 
 
The specific recommendations for each of the three phases of the consultation process are 
described in Figure 9. Of these recommendations, four most important ones are detailed below: 
 
1. Define role of the PCP consultant:  
a. Problem: Currently, there is no consensus in regards to the role of the PCP 
consultant. As the inpatient care system transitioned to the hospitalist model in 
January 2015, the PCPs, who had been the physicians-of-record, have found 
themselves with significantly diminished involvement in the care of their 
hospitalized patients. However, with these PCPs serving as consultants, their 
role on the wards became unclear even with their new title as “consultants.” 
b. Suggestions: PCP consultants’ role should be to provide expertise in medical 
and social areas of patient care based on their long, meaningful relationships 
with their patients. PCP consultants should be tasked to visit once or twice 
during a patient’s hospitalization, providing care the PCP considers relevant, 
which may include a focused exam, insight into prior care, emotional support 
based upon a long-term care relationship, discussion of care decisions with the 
patient and family, and assistance in planning after-hospital care. After concisely 
documenting the findings, PCP consultants should communicate their 
recommendations to the inpatient team. This clear definition of the PCP 
consultant’s role must be shared with all participants of the program.  
 
2. Define the PCP consultant’s scope of recommendations:  
a. Problem: PCPs may make recommendations that are more relevant to the 
outpatient management of the patient’s medical problems and less relevant to 
the acute management that requires hospitalization. Although prioritizing the 
acute medical issues is important, PCPs’ recommendations may also be 
important for the patient’s health longitudinally.  
b. Suggestions: PCP consultants and hospitalists need to agree on the scope of 
recommendations that are appropriate for inpatient PCP consultation. Suggested 
types of recommendations include: transition of care, goals of care, pain 
management, medication reconciliation, facilitation of family meetings, and 
collaboration with complex patients and family members. A focus group with 
both the participating PCPs and the hospitalists would be the first step to 
reaching a mutual agreement. Moreover, PCPs should be aware that their 
recommendations are subject to rejection, just as other specialty consultants’ 
recommendations would be considered by the inpatient team.  
 35 
  
3. Allow team-based agenda setting: 
a. Problem: The inpatient team is responsible for setting the care agenda for all 
hospitalized patients. However, the PCP consultant also has a vested interest in 
shaping the agenda as the patient’s long-term provider.   
b. Suggestions: Before visiting their hospitalized patients, PCP consultants should 
discuss with the inpatient team to understand and contribute to the care agenda 
for their patients. PCP consultants’ recommendations and contributions should 
focus on achieving the team agenda.  
 
4. Standardize communication and closing the loop: 
a. Problem: PCP consultants are required to leave an electronic note, documenting 
each visit, but the quality of these notes varies by PCPs and visits. As a result, 
inpatient team members often do not rely on PCP consultants’ notes. Moreover, 
some hospitalists identify a gap in communication because PCP consultants often 
relay their recommendations only to residents (whom PCPs mentor in the 
residency program).  
b. Suggestions: CHA Department of Medicine should design and implement a 
better, succinct electronic note template that is actually useful to the inpatient 
team. While ensuring that PCPs communicate with at least one member on the 
inpatient team (standard practice for consultants in other specialties), hospitalists 
should be reminded that it is okay for PCP consultants to communicate with the 
residents, not necessarily with the hospitalists.  
 
 
Figure 9: Process recommendations for all PCPs consultants, hospitalists, and residents. 
 36 
Once PCP consultants’ role and their scope of recommendations are better defined, it is 
recommended that Dr. Bor (or other leaders in the Department of Medicine) convenes a 
meeting with the participating PCP consultants to review the proposed consultation process 
as outlined in Figure 10. This outline, along with the description of the PCP consultants’ 
role, must also be shared with all hospitalists and residents at CHA (Appendix D). 
 
 
 
Figure 10: Detailed description of the proposed PCP consultation process 
 
 
 
 37 
Other Next Steps 
 
In addition to improving the consultation process, CHA Department should take the following 
steps towards making a case for expanding the pilot program: 
 
1. Emphasize data gathering and analysis of patient outcomes: CHA needs to invest in 
gathering data specific to patient outcomes for those visited by the PCP consultants. By doing 
so, a more robust, longitudinal analysis can be conducted to assess the impact of the pilot 
program. Comparing the outcomes of the patients seen in 2015 (and 2016) to their outcomes 
pre-implementation of the program would be more useful to predicting the overall impact of 
expanding the program.  
 
2. Assess PCP engagement and willingness to serve as consultants: A major assumption made 
in predicting the success of expanding the pilot program is that a large number of primary care 
physicians would be interested in serving as consultants for their hospitalized patients. The 
current PCP consultants in the pilot program are those who had consistently served as 
physicians-of-record before the hospital-wide policy change on January 1, 2015, which 
prompted the creation of the pilot program. Naturally, these PCP consultants have been willing 
to continue their role in inpatient care, whereas other PCPs may not be as engaged in the 
program compared to the current PCP consultants in the pilot program. Before expanding the 
program, CHA Department of Medicine must survey all PCPs in its network to assess their 
willingness to participate in the program as consultants. This survey can collect other useful 
information such as the barriers to serve as consultants and the reasons that compel them to 
visit certain patient populations. 
 
3. Secure a sustainable reimbursement model: Although CHA has committed to reimburse the 
services provided by the PCP consultants in the pilot program, it is unclear how long this 
financial commitment would last. To consider continuing the pilot program for the indefinite 
future or expanding the program to include more PCPs, CHA Department of Medicine must 
find a more secure and sustainable reimbursement model. Some national organizations, 
including the American Academy of Family Physicians (AAFP), have publically appealed to the 
nation’s largest insurers, asking for coverage of hospital consults conducted by PCPs on behalf 
of hospitalists for their hospitalized patients.25 Similarly, CHA can work with professional 
organizations, such as the American College of Physicians (ACP) or the Society of General 
Internal Medicine (SGIM), to lobby private insurers to reimburse for PCP consult services. 
Moreover, Medicaid and Medicare should be asked to include PCP consultation as a billable 
service for PCPs caring for publically insured patients. 
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  
25 http://www.the-hospitalist.org/article/family-physicians-propose-payment-for-pcps-hospital-consult-visits/ 
 38 
Appendices 
 
Appendix A: Questions for semi-structured patient interviews 
 
With the patient’s consent, the research assistants asked the following questions during each 
interview: 
1. How many days have you been in the hospital? 
2. Who is your primary care physician (PCP)? 
3. How long have you been going to this doctor? 
4. Is this the doctor that you usually see if you need a check-up, want advice about a 
health problem or get sick or hurt? 
5. In the last 12 months, how many times did you visit this doctor to get care for 
yourself? 
6. On a scale of 0-10, where 0 is the worst doctor possible and 10 is the best provider 
possible, which number would you use to rate your PCP? 
7. During this hospital stay, was your PCP involved in your care? 
8. If yes, how was the PCP involved? – by telephone, came by to say hello, or was very 
involved in decision making 
9. Was it helpful to have your PCP involved?  
10. If yes, in what ways was the PCP helpful? 
11. If no, are there ways in which the PCP involvement interfered with your care? 
12. We are trying to learn how patients feel about having their PCP involved in their 
inpatient care.  How do you feel about this? 
13. Are there any ways that your care might have been different during this 
hospitalization if your PCP was involved in your care? 
14. Gender 
15. On a scale of 0-10, where 0 is poor health and 10 is excellent health, which number 
would you use to rate your overall health in general? 
16. What is your preferred language? 
17. Are you Hispanic or Latino origin or descent? 
18. What is your race?  
 39 
Appendix B: Resident survey on how they perceive PCP involvement as consultants  
 
For each of the following items, please respond based on your experience in caring for your recently 
hospitalized patient. 
    
 
1.  First 2 letters of patient’s last name: 
   
    
2.  Last 2 numbers of patient’s MRN: 
   
    
3.  I participated on this patients care in the following manner: 
 
 
                              Very much                                       Somewhat                                       Not much 
 
    1   2   3   4   5   6   7   8   9   
Provided comfort to 
the patient based 
on our prior                   
           
relationship 
Provided 
information to the 
house officers 
about the patient’s                   
  medical issues that 
           
they had not 
  known.   
Facilitated 
discharge planning 
and coordination of                   
           
care post-discharge 
Expedited 
discharge                   
           
Delayed discharge                   
         
   
    
4.  Other ways in which I was able to help: 
   
  
  5. Process of consultation worked: 
 
                                                     Poorly                                    Okay                                     Excellent 
 
    1   2   3   4   5   6   7   8   9 
    
Choose one                   
            
    
  Thank you for taking the time to complete this survey. We truly appreciate it. Please be sure to click 
"DONE' at the bottom of this page so that your responses are recorded. Again, thank you. 
 
 40 
Appendix C: Diff-in-diff analysis for readmission rates 
 
 
 
Readmission Rate = Bo + B1Yr2015 + B2Pilot + B3Yr2015*Pilot + E 
 
• Intercept: predicted probability of readmission rate of non-pilot PCPs in 2014 
• B1: difference in the probability of readmission rate of non-pilot PCPs between 2014 and 
2015 
• B2: difference in the predicted probability of readmission rate between non-pilot PCPs 
and pilot PCPs in 2014 
• B3: difference in difference estimator, the difference in readmission rate between pilot 
and non-pilot PCPs after 2015 
 
 
 
 41 
Appendix D: Recommended one-page description of the program to be used to discuss process 
improvement or expansion.  
 
PCP Consult Program:  
PCP Consult Program incorporates CHA-affiliated PCPs as consultants for their patients 
admitted to the Medicine Service. This program was piloted at the CHA Cambridge Hospital, 
and is now intended to be implemented at both the Cambridge Hospital and the Whidden 
Memorial Hospital. This program provides a structured, compensated process for PCPs to visit 
their patients and to give recommendations to improve patient care during and after 
hospitalization through providing continuity of care.  
 
Role of the PCP Consultant: 
PCP consultants’ role is to provide expertise in medical and social areas of patient care based on 
their long, meaningful relationships with their patients. PCP consultants visit once or twice 
during a patient’s hospitalization, providing care the PCP considers relevant, which may 
include a focused exam, insight into prior care, emotional support based upon a long-term care 
relationship, discussion of care decisions with the patient and family, and assistance in planning 
after-hospital care. After concisely documenting the findings, PCP consultants would 
communicate their recommendations to the inpatient team.  
 
PCP Consultation Process: 
 
 1. PCP is notified via ADT when the patient is admitted 
 2. PCP identifies the clinical/social need for a consult 
 3. Referring member of the inpatient team may request a consult via 
  EPIC 
 Pre-Consultation 4. PCP may consult proactively (without a request from the inpatient 
 team) 
 
 1. PCP visits within 1-2 days of admission or after acute change in 
 patient status 
 2. PCP first meets with the inpatient team and identifies the areas of 
 clinical or social question under consideration 
 3. PCP generates additional information needed by performing a 
 Consultation focused history and physical examination and conferring with 
 family/other supports. 
 4. PCP defers on sharing plans with the patient until discussing with 
 the inpatient team 
 1. PCP shares new information (or insight into prior care) and 
 recommendations with the inpatient team immediately after 
 seeing the patient 
 2. PCP concisely documents findings and recommendations in EPIC 
 3. PCP provides f/u support, i.e. attending family meetings and 
 assisting coordination of after-hospital care 
 Post-Consultation 4. Inpatient team communicates any changes in status or plans with 
 PCP 
 5. PCP submits bill to be credited with proxy RVUs for inpatient 
 consult visit encounters 
 
 
 42