The hospitalist model: How it benefits you and your patients

Fewer disruptions in your ambulatory practice, and access to performance data to direct patients to the best-performing hospitals

CEO, Society of Hospital Medicine, Philadelphia, Pennsylvania

In January 2000, the hospitalist model was still largely unknown but beginning to cause a stir in the medical community. Realizing that physicians sometimes have reservations about change, the Society of Hospital Medicine (SHM) formed a National Advisory Board of major physician organizations* to explore the range of concerns office-based practitioners were voicing about this new model (TABLE), and to better understand what was going on in the front lines of health care. Amazingly, within 3 or 4 years much of the initial resistance we had witnessed went away, and each year since then hospital medicine has become a more established part of the health care system. Today, primary care physicians (PCPs) are the biggest drivers of the hospitalist model. What happened?

For one thing, some older doctors or those who are less interested in using hospital-based skills are grateful that someone else is willing to handle inpatient care.¹ Many office-based physicians do not practice enough inpatient care to keep current with its unique requirements. Another plus for PCPs is that phone calls at night decrease and income increases as office visits remain the focus of outpatient care.¹

Moreover, the hospitalist model has been working. The expertise hospitalists have gained through the daily performance of their unique duties has enabled PCPs to speak confidently when telling patients they trust hospitalists just as they do other types of consulting specialists. While the data are still being compiled, surveys show high levels of patient satisfaction with the hospitalist model, related to the fact that physician coverage in the hospital is constant.²

Having experienced the growth of this specialized area from 2 perspectives (PCP and CEO of SHM), I would like to describe for you the state of the hospitalist model and the ways in which it can improve the care of your patients.

TABLE Initial concerns expressed by PCPs about the hospitalist model have not materialized

  Hospital medicine is bringing order to chaos

Managing inpatient care has frequently lacked systems that encourage standardization and eliminate variability in the delivery of care. Physicians in the same practice often have had different routines for admitting patients. With the advent of the hospitalist movement, the value in creating a consistent, organized system became more apparent. The movement toward quality improvement in all areas of health care is another reality helping to drive and reinforce this change.

In facilities where the hospitalist model is just being implemented, some of the patients are still admitted by attending physicians. However, in facilities where the model has been in effect for several years, 10 hospitalists might manage the same number of cases that required several hundred doctors before, and they are able to do so with more uniform processes in place. In these settings, a number of common disorders such as pneumonia, stroke, heart attack, and heart failure are treated with standard protocols based on strong evidence, including such details as how soon to start an intravenous line, the timing of medication administration, and laboratory testing. And, based on the anticipated number of inhospital days, dialogues with all of the appropriate personnel regarding discharge are initiated long before that moment arrives.

SHM is working with the National Quality Forum, the American Medical Association’s Physician Consortium on Performance Improvement (PCPI), and others to set standards for performance in a broad range of clinical and administrative issues. Additionally SHM, in collaboration with the American College of Physicians and other organizations, has developed a consensus statement on transitions of care.

Hospital admission: Preventing “voltage drops” in information exchange

Before the era of hospitalists, admitting a patient required a PCP to leave home or the office, go to the hospital to evaluate the patient, and write admitting orders. In the hospitalist environment, responsibilities and accountability have changed. The hospitalist now can handle all aspects of a patient’s admission. The PCP continues to provide key information, such as the patient’s known medical conditions, medication list, competency level, pain threshold, etc. Hospitalists use standardized formats for reporting to ensure complete patient records that are easily reviewed and updated by any and all caregivers.

If a patient is to undergo an elective procedure, ideally the hospitalist will receive all necessary information before admission. If admission is for an urgent problem, it is the hospitalist’s responsibility to alert the patient’s PCP as soon as possible. A major goal in this new arrangement is for information exchange between the hospitalist and the PCP to occur within one hour of urgent admission, with further feedback from the hospitalist within the first 24 hours.

In some cases patients must be admitted without the PCP’s immediate input (eg, an acute event). But even apart from these occurrences, the area of admission “handoffs” can still be difficult, and there remain opportunities to improve the transition of care.

Hospital stay: Keeping PCPs in the loop, and patients informed

During hospitalization, a hospitalist is expected to keep the PCP informed about a patient’s progress, particularly concerning change in clinical status. Patients and their families are introduced to the hospitalist who is responsible for inpatient care and who will consult with them as appropriate on important decisions. Patient preferences regarding treatment options are solicited and honored as much as possible. “Nothing about me without me” is the axiom underscoring the patient’s right to be kept informed about evolving care.¹

Hospital discharge: Closing the “white space”

“White space” is the time between discharge from the hospital and resumption of ambulatory care. Many patients are not cured when discharged from the hospital; they are simply not ill enough to require additional hospitalization. Very often they have questions that remain unanswered until they visit their PCP for follow-up. This “white space” was a problem area even before the era of hospitalists—fertile ground for the occurrence of adverse events due to poor or delayed follow-up (eg, patient confusion about instructions, physician inaction on test results).^3-5 The solution is unambiguous communication between providers and accountability in following the patient, as described below.

SHM’s approach to better accountability and better care

A number of initiatives under the auspices of SHM are directed at decreasing potential problems encountered by patients in the hospital and after discharge.

Clarity and timely communication are essential. SHM has received a grant from The Hartford Foundation to develop a discharge planning tool that helps providers prepare for a patient’s release from the moment they enter the hospital. A hospitalist should meet with the patient’s family and the PCP to review the case and lay out a course of action:

The patient was admitted for a blood clot in the lung and should be going home in 4 days. Here’s the plan.

The hospitalist reconciles the patient’s medications with the patient:

You came into the hospital with these medications. Here are the ones you will be leaving with. You will continue taking these drugs, you will discontinue these, and you will start these—and here is how and when you should take them. Here is the name and number of the person you should call if you experience symptoms or have any questions at all.

The hospitalist also provides details on follow-up testing and instructions about when to make an appointment with the PCP. Some hospitalist groups then call the patient or the home caregiver within 24 hours of hospital discharge to review the medications and treatment plan and to make sure outpatient visits and testing have been scheduled.

Handoff of accountability. The hospitalist remains in charge and has ultimate responsibility until the moment that the PCP acknowledges discharge of the patient and takes over the patient’s care. Patients should feel confident that at every step a specific caregiver is responsible for them. This kind of accountability transfer requires organization by the hospitalist and openness by the PCP to allow them to jointly deliver and receive information and work together in the process.

Realistic metrics for accountability. As mentioned, SHM is working with the PCPI to develop performance standards, such as ensuring that PCPs deliver critical information to hospitalists at the time of the patient’s admission. Standards are also shaping the PCP’s resumption of patient care at discharge, with the hospitalist providing timely, accurate, and complete information about the hospitalization to the PCP. The PCP should received discharge summaries within 24 to 48 hours of discharge, complete with lists of medications, test results to be followed, timing of follow-up visits, and any nuances of the hospitalization experience. Also critical is provision of an easy and direct communication link with the treating hospitalist should the PCP have any questions. With such measures, we will be able to use the data generated to further improve the delivery of care and systems of care that provide better patient outcomes and increased patient satisfaction.

Fair reimbursement for services. Physicians receive payment per unit of a visit or procedure. Currently, time spent in the coordination of information and time spent on the phone with a patient or a colleague is not reimbursed. SHM is advocating for change in the reimbursement system, and is in discussion with Medicare about the need to cover the postdischarge period and the ways in which this can be accomplished (eg, bundling of events and coordination of care).

The ACP, AAFP, AAP, and others are working to create a Patient-Centered Medical Home. SHM and hospitalists want to work proactively with PCPs and the medical home to reward the work done in transitions of care and coordination of care from inpatient to outpatient status. Patients benefit when the entire health care team is working to smooth out these acute transitions. But, as we all know, such system changes take time, effort, staffing, and technology—and this will require a major restructuring of the current reimbursement model.

Making the system work for you: A PCP’s role

In working with the hospitalist model, your role can change from direct care provider for inpatients to that of the expert who selects the best hospital and the best referral physicians for your acutely ill patients. You and your patients will want to know which hospitals and specialists have the best outcomes for such common conditions as pneumonia, stroke, and heart failure. You can find helpful information to guide your choices at www.hospitalcompare.hhs.gov.

Transparency and public reporting have increasingly motivated hospitals to use the data to improve the performance of their hospitalists, emergency physicians, intensivists, surgeons, and subspecialists. We are entering an era of value-based health care in which data support improved outcomes. In this era, PCPs have an important say in the care their patients receive—both when they deliver it directly and when they refer that care to others.

* The American College of Physicians, American Academy of Family Practice, American Academy of Pediatrics, American College of Emergency Physicians, and several other national physician organizations.

References

1.  Conclusions of the Transitions of Care Consensus Conference. A summary and policy paper derived from a meeting held on July 11-12, 2007, in Philadelphia, PA. Sponsored by the American College of Physicians, the Society of General Internal Medicine, the Society of Hospital Medicine, the American Geriatrics Society, the American College of Emergency Physicians, and the Society of Academic Emergency Medicine.
2. Wachter RM. The hospitalist movement 5 years later. JAMA. 2002;287:487–494.
3. Forster AJ, Murff HJ, Peterson JF, et al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138:161–167.
4. Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005;143:121–128.
5. Coleman EA, Smith JD, Raha D, et al. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005;165:1842–1847.