How HPG coordinates care with specialists and hospitals

For a homebound senior with heart failure, diabetes, and a recent hip fracture, a typical week might involve HPG as the primary care provider, a cardiologist, an orthopedic surgeon, a physical therapist, and a home health aide, plus a pharmacy and a hospital system that has records from last month's admission. When these parties operate independently, the result is duplicate orders, missed medication changes, conflicting instructions, and readmissions that could have been prevented. Coordination is not a courtesy; for medically complex patients, it is a clinical necessity. This post explains how HPG structures care coordination in practice.

The problem with fragmented care for homebound patients

A 2019 JAMA study found that the average Medicare beneficiary with five or more chronic conditions sees 14 different physicians per year, yet fewer than half receive a care summary after a specialist visit.¹ For homebound patients, who cannot easily follow up in person, fragmentation is particularly dangerous. A new antihypertensive prescribed by a cardiologist can counteract the diuretic the primary care physician is titrating for heart failure. A specialist who is unaware of a patient's cognitive decline may give discharge instructions the patient cannot follow.

HPG's coordination model is built on a single premise: the primary care physician is the hub. Every specialist, hospital system, and ancillary service communicates through HPG, and every clinical encounter is reflected in the patient's longitudinal record.

Specialist referrals: how HPG manages the process

When a homebound patient requires specialist evaluation, HPG's case management team handles the referral from end to end. This includes:

HPG's specialist partner network in Central Florida

HPG maintains established referral relationships with several specialty practices in the Central Florida region, allowing for faster scheduling and bidirectional clinical communication.

Hospital admissions: what HPG does before, during, and after

Before an admission

When a patient's clinical status suggests a hospitalization may be approaching, HPG's team attempts to intervene early. The remote patient monitoring program flags deteriorating trends before they become emergencies. The clinical team can adjust medications, schedule an urgent home visit, or arrange an observation stay, avoiding a full inpatient admission in some cases.

During a hospitalization

HPG maintains communication with the hospital care team during admissions. The hospital's attending physician receives the patient's current medication list, active diagnoses, and advance directive documentation from HPG. This reduces the frequency of duplicate workup and conflicting orders. HPG's SNFIST program extends this coordination to skilled nursing facility stays following hospitalization.

After discharge: the highest-risk window

HPG's transitional care program schedules a physician home visit within 7 days of hospital discharge. This visit covers:

• Complete medication reconciliation, comparing discharge medications to prior medications and identifying discrepancies
• Review of discharge instructions and clarification of any points the patient or family did not understand
• Clinical re-assessment of the condition that caused the admission
• Communication with the discharging hospital team to close any open orders or pending results
• Setting a visit schedule for the following 30 days based on clinical stability

Research from the New England Journal of Medicine demonstrates that structured transitional care programs reduce 30-day readmission rates by 20 to 30%.² The post-discharge window is the highest-yield opportunity in all of geriatric care coordination.

Pharmacy coordination: the pharmacist's role

Polypharmacy, defined as five or more concurrent medications, is present in over 40% of adults over 65 and is a major contributor to adverse drug events and hospitalizations.³ HPG's clinical pharmacist conducts comprehensive medication reviews for patients on complex regimens, identifies potentially inappropriate medications using the Beers Criteria, and communicates with the patient's pharmacy to align refill schedules and reduce the likelihood of a patient running out of a critical medication.

Advance care planning: coordination that matters most

For patients with advanced illness, the most important coordination happens before a crisis. HPG's physicians engage patients and families in advance care planning conversations during home visits, document code status and healthcare surrogate designations in the electronic record, and ensure that out-of-hospital DNR forms are completed for patients who choose them. These documents are shared with hospitals, skilled nursing facilities, and specialist practices so that the patient's stated wishes are followed across every setting.