A new report from the American Medical Association (AMA) outlines a list of five responsibilities physicians in outpatient settings should consider when caring for patients who have recently completed a hospital stay. The list was developed by a panel of experts convened to examine how to improve safety and reduce the rate of hospital readmissions for patients transitioning from an inpatient hospital stay back into their homes. It is part of the recommendations contained in “There And Home Again, Safely,” released on Feb. 6 by the AMA’s Center for Patient Safety.

The responsibilities outpatient physicians should consider include: Assessment of the patient’s health; goal-setting to determine desired outcomes; supporting self-management to ensure access to resources the patient may need; medication management to oversee needed prescriptions; and care coordination to bring together all members of the health care team.

“When a patient leaves the hospital to go home, they are transitioning back into the care of their outpatient primary care and specialty physicians,” AMA President Jeremy Lazarus, M.D., said in a statement. “These physicians play integral roles in helping patients fully recover, and coordination between inpatient and outpatient teams is key to ensuring success. Physicians in ambulatory care settings must first have access to information about their patients’ hospital stays to ensure continuous, high quality care. The lists of actions recommended in this report can then serve as a guide as physicians care for recovering patients.”

This report comes on the heels of an announcement from Medicare that it will accept the newly created Current Procedural Terminology (CPT) codes for care coordination to pay physicians for the management of patients who have recently been discharged from a hospital or skilled nursing facility. The American Medical Association CPT Editorial Panel created the codes to capture transitional care management services, including time spent discussing a care plan, connecting patients to community services, transitioning them from inpatient settings and preventing readmissions.