Hospitalist Presentation

Hospitalists

Thomas Pineo, DO Administrative Director

UPMC Horizon Hospitalist Program

A New Member of Your Medical Staff

Introduction• What is a Hospitalist?

• Why have Hospitalists become so prevalent?

• What barriers do Hospitalist programs face?

• What are some trends in Hospitalist Management Groups?

• What challenges does the Medical Staff Office face in this new era of Hospitalist Medicine?

What is a Hospitalist?• A physician who works exclusively in the Hospital.

• Hospitalists are the first specialty based on patient location rather than organ system.

• They coordinate all aspects of a patient’s care from admission to discharge.

• They are mostly board certified Internists but there are also Family Medicine trained physicians, specialists such as Pulmonary, Nephrology, and ID, and also Pediatricians for Children’s Hospitals.

Who is on the team?59.2% of HMGs have at least one Family Doctor

2014 State of Hospital Medicine Report, Society of Hospital Medicine

Harbuck, SM, Follmer, AD, et al. Estimating the number and characteristics of Hospitalist physicians in the United States and their possible workforce implications. AAMC. 8/12. 12:3.

What does a Hospitalist do?• Hospitalists are in the Hospital 24/7.

• Hospitalists admit patient, round in the hospital, meet with families, work on discharge planning, and discharge to a lower or higher level of care depending on the patient’s needs.

• Hospitalists cover inpatient Rehabilitation and Transitional Care Units.

• Hospitalists assist in the ED during times of acuity surges.

• Some hospitalists do procedures.

Discharge Planning• One of the most important jobs of a Hospitalist is

to discharge a patient well.

• Coordination of care with the PCP, documentation of the hospital stay, ordering home care, providing support at home in the form of PT, OT, ST, and wound care.

• Arranging TeleHealth where appropriate.

• Meet all Core Measures.

Discharge Planning Bullets• The patient was risk stratified using the “HOSPITAL” readmission risk assessment tool.• The patient was educated about the diagnosis.• Clinician follow-up appointments were made.• Post discharge testing was scheduled.• In-hospital testing was discussed with the patient.• If there are pending results, did the patient know who to contact for the results?• Post discharge services such as home care, PT, and OT were organized.• The discharge medications were confirmed/reconciled.• The discharge plan was reconciled with national guidelines:

• COPD patient was prescribed ICS/LABA and Spiriva.• HF patient was prescribed ACEI or ARB or Nitrate/NTG and Beta-Blocker (or had contraindications).• AMI patient was prescribed Beta-Blocker, Statin, and Aspirin or Plavix (or had contraindications).• Stroke patient was prescribed Aspirin or Plavix or Aggrenox and Statin (or had contraindications).• Orthopedic patient was prescribed appropriate VTE prophylaxis.

• The patient knows what to do if problems arise following discharge.• The patient’s understanding of their discharge instructions were assessed using “Teach-Back”.• A discharge plan was given to the patient which contains the reason for hospitalization, medication list,

clinician contact information, a list of scheduled appointments, information about pending tests at the time of discharge, and a calendar labeled with scheduled appointments and tests.

• A complete discharge summary was transmitted to the PCP.• The patient was called post discharge to reinforce the discharge plan, to review meds, and to problem solve.• A “Transitions Coach” was involved in this patient’s post discharge care.• This patient had a HgbA1c of > 9.0 and received inpatient diabetes education.• This patient received Home Care.• This patient was prescribed TeleHealth (if appropriate for HF, CKD).• This patient was offered Hospice, if appropriate.

Metric Value PointsHgb <12 1

Oncology Patient 2Sodium <135 1

Procedure 1Index Type Admission, Nonelective 1

Adm x 12 mos 0 01-5 2>5 5

LOS > 5 Days 2Donze J, Aujesky D, Williams D. Potentially Avoidable 30-Day Hospital Readmissions in Medical Patients. JAMA. 2013; 5/25,

E1-E7

“HOSPITAL” Risk Assessment Tool

Score Readmission Risk

0-4 Low

5-6 Mod

>6 High

Donze J, Aujesky D, Williams D. Potentially Avoidable 30-Day Hospital Readmissions in Medical Patients. JAMA. 2013; 5/25, E1-E7

“HOSPITAL” Risk Assessment Tool

Hospital Leadership• Hospitalists participate at all levels of medical

staff leadership and provide administrative support for a multitude of inpatient activities.

• HMG Program Leadership, Readmissions, Utilization, Pharmacy & Therapeutics, Patient Safety, Medical Care Committee, Ethics, Medical Executive Committee, Information Technology, Recruitment, Credentials, Critical Care, Quality Counsel, GME, etc.

How do APP's bill?29.3% of HMGs have NP/PAs billing independently.


Just Covering Shifts?• Just a warm body? Not anymore …

• Group rounding

• Covering the work of advanced practice providers

• Cost containment initiatives

• Administrative activities

Why are there so many Hospitalists?

• In 1996 there were a few hundred.

• Now there are over 30,000!

• This is the fastest growing speciality in the history of medicine.

• There are over 600,000 physicians in the US with about 1/3 practicing in primary care.

Are there enough Hospitalists?• In 2003 30% of US Hospitals were using a

Hospitalist Program.

• In 2012, this rose to 60%.

• In 2014, this rose to 70%.

• About 30% of American hospitals do not have hospitalist programs at this time.

American Hospital Association (AHA) 2014 Hospital Statistics edition

What has driven this growth?

• Economic factors.

• Patient safety factors.

• Hospital leadership.

• Medical staff retention and recruitment.

Economic Factors

• Average US 30-day readmission rates are 18% for Medicare Beneficiaries.

• $17 Billion/year.

• 19% of Medicare discharges are followed by an adverse event within 30 days and 2/3 are drug events felt to be preventable.

Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patient in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):

1418-1428.

PCP: Time Spent With PatientsL. Kane, C. Peckham, Medscape Physician Compensation Report: 2014 Results, MedScape 2014, accessed January 17, 2015, http://www.medscape.com/features/slideshow/compensation/2014/public.

Perc

enta

ge o

f Res

pond

ents

0%

10%

20%

30%

< 9 mins 9-12 mins 3-16 mins 17-20 mins21-24 mins >24 mins

13%11%

25%

29%

18%

3%

http://www.medscape.com/features/slideshow/compensation/2014/public

Readmissions were reduced Project RED

Ann Intern Med. 2009;150(3):178-187.Project RED

Economic Alignment

• Hospitals are paid by the admission.

• Hospitalists are paid by the day.

• PCPs are paid by the visit.

• LOS has become a major factor in Hospital economics.

Patient Safety Factors

• Hospitalists are physically in the Hospital and available to both patients and their families 24/7.

• Hospitalists are filling a gap once filled by residents.

• Patients are seen and consults are provided faster.

Patient SafetyHospitalists are uniquely able to care for the sickest patients which cost systems the most money.

Davis, Kenneth M., MD. et al. “Effects of Hospitalists on Cost, Outcomes, and Patient Satisfaction in a Rural Health System.”

Am J Med 108. (2000): 621 – 626.

Co-managed patients with Orthopedic surgeon and Hospitalists vs PCP had faster time to consultation, faster time to surgery, fewer minor complications, and shorter LOS.

Roy, Archana, M.D., et al. “Associations Between the Hospitalist Model of Care and Quality-of-Care – Related Outcomes in Patients

Undergoing Hip Fracture Surgery.” Mayo Clinic Proceedings 81.1. (2006): 28 – 31.

Patient Safety• “The data in this report shows a substantial nine percent

decrease in harms experienced by patients in hospitals in 2012 compared to the 2010 baseline, and an eight percent decrease in Medicare Fee-for-Service (FFS) 30-day readmissions. National reductions in adverse drug events, falls, infections and other forms of harm are estimated to have prevented nearly 15,000 deaths in hospitals, and saved $4.1 billion in costs, and prevented 560,000 patient harms in 2011 and 2012.”

U.S. Department of Health & Human Services. May 7, 2014. Accessed March 23, 2015. http://innovation.cms.gov/Files/reports/patient-safety-results.pdf.

http://innovation.cms.gov/Files/reports/patient-safety-results.pdf

Medical Staff Communication

• Communicating a new initiative or training for a new clinical tool is easier when you have 15 employed Hospitalists as opposed to 150 self-employed medical staff members.

Medical Staff Recruitment and Retention

• The majority of young physicians seek to work in either inpatient or outpatient settings. Most either do not want to or are not trained to do both.

• Primary care recruitment pool increases by approximately a factor of 5 with a Hospitalist program.

• Specialists were doing some of the work more appropriately done by Hospitalists.

Hospitalist Cons• $.

• Discontinuity created by a new face - though sometimes a fresh and critical look will find new problems.

• Lack of Hospitalist workforce.

• Stressful shifts and physician burnout.

Are Hospitalists Good for Patients?

• Meeting a physician for the first time when you are your sickest can be unsettling.

• Human relationships are still important.

• Life and death decisions are made in the hospital and we need to trust our physicians.

• Caring for and about patients transcends any of our economic or technical pursuits.

MSO Issues• Hospitalists tend to work in multiple facilities.

• A Hospitalists’ perspective tends to be more regional and less local.

• Credentialing needs to be more portable, less facility specific.

• Mechanisms need to be in place to protect facilities and patients from bad physicians while not impeding physician mobility.

HMGs With Turn Over0%

17.5%

35%

52.5%

70%

Physicians Physician assistant Nurse practitioners

9%

42.6%

61.9%


Conclusions• The Hospital is our nation’s only 24/7 safety net.

• The Hospitalist movement started as an economic experiment an has become a specialty which has taken on patient safety, healthcare leadership, cost containment initiatives, and hospital quality.

• We must guard against the loss of interpersonal factors.

• Overcome barriers such as a limited work force, Hospitalist program cost, physician burnout, and communication between providers.

Conclusions• The fluctuating demand for hospital related

services, the growing scrutiny placed on hospitals for quality and spending, and the lack of an alternative safety net system all create a fertile opportunity for discourse, action, leadership, and Medical Staff Office guidance and support for many years to come.

Thank you! Questions?

Hospitalist Presentation

Documents

Transcript of Hospitalist Presentation