Hospitalist and Practice Solutions Hospital Medicine 2012 A Primer.

Hospitalist and Practice Solutions

Hospital Medicine 2012

A Primer


Objectives

Definitions and Nomenclature

Historical Review

Driving Forces and Evolution of The Hospitalist Movement

Reasons for Program Creation

Value of Hospitalist Programs

Challenges Facing Hospitalist Programs

Tools and Strategies for a Successful Hospital Program

Program Ownership

Staffing and Scheduling

Recruitment and Retention

Essentials to Program Success

Concluding Thoughts


Definition of “Hospitalist”

1997Hospitalists are physicians who spend more than 25% of their time based in a hospital setting, where they serve as the physicians of record after accepting “hand-offs” of hospitalized patients from primary care physicians, returning these patients to the care of the primary physicians at the time of hospital discharge.

1999

A hospitalist’s primary professional focus is the care of the hospitalized patient. Accepts referrals (“hand-offs”) of patients from outpatient physicians and returns the patient back to the same doctor at discharge. Often consults on other hospitalized patients and may be trained in internal medicine, family practice, pediatrics or other fields.

2000

Hospitalists are physicians whose primary professional focus is the general medical care of hospitalized patients. They may engage in clinical care, teaching, research or leadership in the field of general Hospital Medicine.


Hospitalist Glossary:

“Hand-off”

Transfer of patient between PCP & Hospitalist

“Voltage Drop”

Loss of Information across the hospital threshold

“Fumble”

Loss of continuity in the care of a patient at the time of the handoff” due to a “voltage drop”

“Black Hole”

The time from hospital discharge until the first appointment with the PCP


A Historical Review

April 2003

NAIPSHM(Society of Hospital Medicine)

August 15, 1996

The New England Journal of Medicine Article: “The Emerging Role of “Hospitalists” in the American Health Care System”

April 10, 1997

First unofficial meeting of Hospitalists at the Holiday Inn in San Francisco, NAIP(National Association of Inpatient Physicians) formed

“Before the Dawn”

Intensivists

Osteopathic Model

Group Practice Model


Hospitalist Growth

1997 23 1999 800 2000 1400 2001 1750 2002 3508 2003 4076 2005 12,000+ 2010 30,000+

2012 40,000+


Driving Forces Behind the Hospitalist Movement - circa 1990s

Changing approaches to care * Managed care driven

* Need for increased inpatient/outpatient access and availability * Need for increased inpatient & outpatient expertise -inpatients increasingly sick & unusual -sicker patients managed in an outpatient setting

Need for efficient and cost effective outpatient and inpatient care

Need for quality improvement Geographical barriers Physician lifestyle

* Recruitment & Retention


The Evolution of the Hospitalist System


Five Stages:

Stage I: PCP’s manage their own hospital care

Stage II: PCP’s develop a hospital rotation system

Stage III: Physician handoff to other practices

Stage IV: Dedicated hospitalists, voluntary handoffs

Stage V: Dedicated hospitalists, mandatory handoffs

These stages are not necessarily a desirable progression!

The Evolution of the Hospitalist System


Stage I: PCP’s Manage Their Own Care

Potential Advantages:

Inpatient/outpatient continuity

Patients see their own PCP in the hospital

PCP’s retain inpatient skills

Potential Disadvantages

PCP’s may lack acute care skills impacting quality and cost

PCP’s less likely to be easily accessible throughout the hospital day

PCP’s incentives to invest time in QI, practice guidelines, etc, more limited

Hospital care pulls PCP’s away from office patients

Job satisfaction at risk (especially for younger physicians)


Stage II: PCP’s Develop a Hospital Rotation System


“Hospital PCP” available throughout the day

Other PCP’s available in office through the day

Patients may know the hospital physician

Potential Disadvantages:

Loss of continuity

The PCP is still less likely to develop acute care skills for best outcomes & lowest cost or to be fully invested in hospital QI

The PCP is less likely to be invested in collaboration with the hospital regarding Value-Based Purchasing and Do Not Pay initiatives

The PCP may not be interested in developing financial relationships with the hospital (e.g. Accountable Care Organizations)


Stage III: Physicians Handoff to Other Practices


Increased PCP availability in an outpatient setting

Improved primary care physician “quality of life”

Enhanced recruitment and retention of primary care providers


Loss of continuity

Patients may not return to PCP on discharge


Stage IV: Dedicated Hospitalists, Voluntary Handoffs


Hospitalist available all day to patients, families, consultants and referring physicians

Honed acute care skills

Hospitalist invested in hospital QI, practice guidelines

Accountable for hospital quality/cost

Investment in the hospital’s financial performance (e.g. Participation in an Accountable Care Organization)


Discontinuity- information “voltage drop”

Potential patient dissatisfaction in not seeing their physician

PCP’s more likely to lose acute inpatient skills


Stage V: Dedicated Hospitalists, Mandatory Handoffs

Potential Advantages

Same as II,III & IV

Develop better communication system

Promote social skills

CME to retain acute skills

Potential Disadvantages

Same as II,III & IV, but now true for all patients

Decreased incentives for hospitalists to be terrific?


Why Start a Hospitalist Program?


Top Ten Reasons to Start A Hospitalist Program*

1. Hospital costs are too high, especially when hospital payments are fixed (under DRGS) or nonexistent (no insurance)

2. Lengths of stay are too long, especially when the hospital is full and beds that are opened can be filled with other patients

3. Primary care physicians are demanding that a hospitalist program be created so they can concentrate on their office practices

4. The entire staff, often led by subspecialists, is rebelling against participating in the unassigned call roster

* Reprinted from Health Forum Journal, Vol. 44 No. 4, July/August 2001,Copyright 2001, by Health Forum, Inc.


5. Concerns have been raised about the quality of hospital care, perhaps supported by benchmarking data on process measures or outcomes such as readmissions and mortality rates

6. In teaching programs , there are concerns that the inpatient residents are being taught by either infrequent ward attendings who may know little more hospital medicine than the residents, or by fragmented group of PCPs coming to the hospital to see their patients

7. An absence of physicians helping the hospital tackle key systems issues, such as process improvement, pain management, and patient safety, which is thwarting positive change

Top Ten Reasons to Start A Hospitalist Program


Top Ten Reasons to Start A Hospitalist Program

8. Nursing retention and recruitment is an issue. (Hospitalists generally ease the work of the nurses, who can interact with a small number of hospitalists in the offices down the hall, rather than dozens of PCP’s in offices across town.)

9. Patients are being discharged to a hospital-based or nearby skilled nursing facility

and it makes sense for members of the hospitalist program to staff the site

10. In an academic medical center, developing a cadre of clinician researchers focused on key issues in hospital care that cut across disease and organ-system lines can be attractive


Additional Considerations to Start A Hospitalist Program

1. Enhance recruitment and retention of both primary care and specialist physicians2. Improve patient satisfaction3. Retain patients within the community 4. Expand market share5. Expand services offered within the hospital6. Improve throughput and efficiency7. Address CMS “Do Not Pay” and “Value-Based Purchasing” initiatives8. Enhance and/or support development of an Accountable Care Organization9. Provide leadership within the hospital10. Address resident work hour restrictions11. Competitive positioning


What Value do Hospitalists Bring?

Patients

Greater access to physicians(in pt & out pt)

More intense care

Potential to enhance quality and patient safety

Potential for decreased costs

Improved patient satisfaction

Who Benefits?



Hospital

Increase admissions (“new patients”)

Decrease LOS

Cost Savings

Greater consistency of inpatient medical care “Increase in hospital beds”

Oversight of 23 hour observation unit

Increase revenue

Systems improvement

*QI

*Case management

*Discharge planning

Competitive Positioning

Medical records

Clinical Operations

*ED

*Nursing

*Medical Staff

Strategy to address increasing link between quality-care patterns and reimbursement



Emergency Department

Improve “throughput”

Potential answer to dreaded ED call

Improved departmental performance (e.g. decreased patient wait times will improve patient satisfaction with the ED)

Improved departmental job satisfaction (e.g. provider and non-provider staff)

Nursing

Working with finite number of physicians

Access/availability of on-site physicians

Consistency of care patterns

Improved departmental job satisfaction



Medical StaffGive physicians more control over their time

Recruitment and retention tool

Increase revenue

Improve quality of life

Unassigned ED call

Committee responsibilities

Professional satisfaction

Long term Care/SNFConsistency of medical direction

Enhanced integration with acute units

PayorsIncrease efficiency and quality while decreasing costs


PCP/Patient Considerations

CONS

Lost revenue

Decreased inpatient skills

Loss of contact with hospital

Loss of collegial/peer interaction

Loss of continuity of care

Undermining of PCP

Patient dissatisfaction

PROS

Increase practice efficiency

Increase outpatient access

Increase quality with potential to decrease outpatient costs

PCP can devote more time to sicker outpatients

Focus on preventative medicine

Increase patient panels

Expanded options for office hours

Increase opportunity for revenue

Improve lifestyle and job satisfaction

Supported recruitment and retention of practice associates

Patient satisfaction


Specialist Considerations

Cons Lost revenue

Turf battles

Loss of collegial interactions that can lead to outpatient referrals

Pros

“Real Consults”

Increase efficiency and access

Increase revenue

Access and ease of medical consultation

Relief from constipation


Challenges Facing Fledging Hospitalist Programs


Typical Stumbling Blocks

Lack of appropriate planning

Performing a feasibility study

Development of a strategic and business plan

Delineating ownership and administrative oversight

Implementation plan with timeline

Lack of consensus building and buy-in with key stakeholders

Medical staff

Hospital staff

Hospital administration



Lack of practice structure, direction, and organization Mission and objectives Budget Staffing model and expectations ( number of providers)

Job descriptions Provider contracts

Program protocols– Communication– Admission and discharge (e.g. Transitions of care)– Scope of service

Quality assurance/performance review plan

Practice policies and procedures



Lack of leadership and support Hospitalist Clinical/Medical Director

Medical staff leadership (e.g. VPMA, Medical Staff President)

Hospital administration

Lack of provider “ownership” Accountability is not enough

“Autonomize” and incentivize providers



Lack of practice culture

Dedicated office space

Non-clinical support staff

Systems to track quality and financial data, resource utilization, and physician coding

Coding, billing and collection systems with practice management expertise

Practice brochures

Practice website

Lack of recruitment and retention plan



Lack of marketing plan

PCP/referral network

Medical staff

Community at large

Outreach


Strategies and Tools for a Successful Hospitalist Program



Identify the driving forces leading to program development

Define the program’s mission, vision, goals, and scope of service

Develop both a fiscally sound and realistic business plan

Engage both medical staff and community physician leaders

Engage key hospital non-physician stakeholders

Engage hospitalist program leadership in joint strategic planning initiatives



Empower the hospitalists to be leaders of the institution and medical staff

Develop and implement evidence-based clinical guidelines

Champion COE (Computerized Order Entry)

RRT leaders

Champion medication reconciliation initiatives

Address throughput issues

Embrace the EMR (Electronic Medical Record)

Hospitalists = leaders of the institution



Clearly communicate the hospitalist’s responsibility to deliver added value benefits*

Admit unassigned patients

Provide consistent coverage (24-7?)

Improve quality of care

Provide oversight of patient safety initiatives

Serve as educators for the hospital staff

Improve resource utilization

Maximize patient flow and throughput

Lead the hospital medical staff

*Quid pro quo for the institution’s financial support of the practice



Place hospitalists on key committees and in medical staff leadership positions

Develop a hospitalist residency teaching program/tract

Support the development of the hospitalist as a medical staff leader

Attend leadership development conferences

Attend administrative development conferences

Attend business and accounting workshops

Develop mentoring programs

Develop a leadership tract within the institution



Clearly state the hospitalist budget and utilization expectations

Allow participation of the hospitalist Clinical Director for “ownership” purposes

Reserve a seat for the hospitalist CD on the Medical Executive Committee

Develop a users group PCP’s/Referring providers

ED providers

Specialist providers

Administrative representative


Hospitalist Program Governance


Various Hospitalist Ownership Models

Employment model - Hospital owned and run practice

Private practice model - Physician owned and run practice (e.g. local oversight)

Outsource model – National management company - a “turn-key” operation

Hybrid (subsidy) model - Physician owned, sponsoring hospital provides subsidy


Hospitalist Staffing and Scheduling



Considerations Program budget

Anticipated Average Daily Census

Anticipated growth

Program scope of service

Quality of care and patient safety

Night and weekend coverage parameters

Recruitment pool

Provider retention

Provider “type”

Practice model



Practice models and call schedules House officer model

Traditional rotating call

Block scheduling (e.g. 7-on/7-off)

Shift scheduling

Nocturnist model



Contrary to public opinion size doesn’t matter!

For smaller institutions: Program ownership and governance can be shared Program staffing can be shared Program coverage can be shared

Telemedicine Electronic ICU model Silo approach Utilization of non-physician providers

Think outside the box if working with spheres!





Familiarize yourself with hospitalist workforce demographics Familiarize yourself with both the factors influencing and challenges associated with

hospitalist recruitment Identify your hospitalist candidate pool Familiarize yourself with both the values and expectations of your candidate pool Identify where the hospitalist candidates are located Develop longitudinal relationships with recruiters Develop a comprehensive recruitment, retention, and orientation plan Understand the hospitalist’s role in recruitment and retention in your local community Appreciate that recruitment can be an expensive and time consuming proposition Appreciate that provider turnover can lead to program instability and poor outcomes

Remember recruitment is an ongoing initiative!


Essentials To The Success of a Hospitalist Program

Establish the goals of the programClarify stakeholder expectationsEngage physician leaders (e.g. hospitalist practice, medical staff, outpatient network)Design a system that is customized to your communityGarner a broad base of support before starting the programDevelop a short and long term plan with timelinesEstablish “partnerships” between the hospitalists and outpatient referral networkDevelop systems supporting transitions of careSupport timely outpatient follow-upDevelop a proactive practice management plan and system for ongoing program supportEmploy hospitalists in whom PCP’s have clinical & personal confidenceIncentivize and empower the hospitalistsKeep your outpatient physicians engaged with the hospital


Conclusions

Preparation and planning are job one Identify the driving forces leading to hospitalist program development Define your program’s mission, vision, goals, and scope of service Develop short and long term strategic goals Develop a fiscally sound business plan Consensus build and collaborate with key stakeholders Utilize physician leaders (e.g. champions) within the medical community Hire a strong Clinical Director Develop sound clinical and practice management policies and procedures Foster a practice culture that’s conducive to goal attainment Pay particular attention to recruitment and retention

Develop a system that integrates the hospitalist practice with the healthcare network!


Contact information

Kenneth G. Simone, DO, SFHM


Email: [email protected]

or [email protected]

Website: http://www.hospitalistpracticesolutions.com Phone: 207-949-2319

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Hospitalist and Practice Solutions Hospital Medicine 2012 A Primer.

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