Hospitalists key to re-engineering inpatient care

  1. By Alan Puzarne, for, Feb. 13, 2002

    The Journal of the American Medical Association (JAMA) recently published an article reporting the results of several studies of hospitalist, or inpatient management programs, citing their ability to reduce costs by an average of 15% while maintaining quality of care.

    These promising results are just the "tip of the iceberg" of the revolutionary improvements that hospitals - and our healthcare system - are beginning to enjoy as a result of the rapid adoption of hospitalism as a model for inpatient care in the United States.

    These inpatient management programs are capable of producing greater savings than these early studies indicate, while actually improving the quality of care along with patient and physician satisfaction. In addition, these programs offer solutions to some of the vexing problem facing hospitals: caring for the uninsured with limited resources, staffing the ER, triaging patients rapidly and accurately and providing efficient care to risk-based populations such as Medicaid and Medicare patients.

    Hospitals Now Driving Hospitalist Programs

    In the mid-1990s, the first hospitalist programs were started by medical groups and health plans. Today, hospitals are starting their own hospitalist programs because they recognize the benefits to their patients and to their bottom lines. Often, the hospital decides to outsource the management of the program to an outside company specializing in inpatient management, thereby getting the program up and running faster, avoiding the costs of in-house development and management, and side-stepping many of the political issues involved with internally-driven change.

    Consider these two hospitals:

    St. Vincent's Hospital in Santa Fe, N. M., started its hospitalist program in 1999 with 32 physicians committed to referring patients to the hospitalists for care. Two years later that number had risen to more than 60 referring physicians, a majority of the primary care community. Actual patient volume is almost triple what had been projected - more than 3,000 patients annually versus projections of 1,100.

    Baptist Hospital in Pensacola, Fla., began its program in 2001, and within a few months was seeing results. The length of stay for patients managed by Cogent hospitalists was 1.3 days less than for other patients. Average cost of care was $1,100 less. The readmission rates for hospitalist-attended patients was 6% after 30 days, compared to an overall hospital rate of 11%. Patient satisfaction and quality of care had increased, with satisfaction ratings topping 95% or more for patients and physicians.

    On a larger scale, hospitals that are experiencing these kinds of performance enhancements will also see an improvement in other major issues that challenge every hospital:

    More cost-effective care for the uninsured. The problem of uncompensated care is a primary reason why hospitals are turning to inpatient management programs. The efficiencies that can be achieved by these programs eliminate wasted time spent waiting for tests and procedures and for decisions to be made about the next step in treatment. This ensures that the course of the patient's care plan keeps pace with their changing condition. Since these patients often lack primary care physicians, the hospitalist can provide continuity to their care that is often lacking and can result in "bounceback" admissions.

    *Expediting care in the ER.
    Hospitals throughout the nation are struggling with staffing their emergency departments, triaging patients quickly and appropriately, and getting physicians to admit unassigned patients. Delays in the ER can result in wasted resources and a worsening of the patient's condition. Conversely, patients may be admitted to the hospital because it's the easiest - albeit the most expensive - course of action. In contrast, the hospitalist is more available in the facility and may see and evaluate a patient in the ER, ordering the necessary tests and procedures right away and evaluate them to direct the patient to the most appropriate treatment setting.

    *Managing the care of risk-based populations.
    Capitated rates, state-mandated reimbursement levels and diagnostic related groups all impose limits on the compensation that hospitals receive for the care of these patients. The exodus of Medicare+Choice HMOs from many markets means that hospitals are once again the entities "at risk" for seniors returning to traditional Medicare.

    By expediting the appropriate treatment and making the correct patient care decisions quickly, the hospitalist helps these patients move through the system efficiently. The level of experience that the hospitalist physician has in treating very sick patients helps ensure that they receive the intensive level of care they need.

    Infrastructure: The Key to Success

    The key to hospitalist programs' ability to deliver these results lies in the infrastructure that must be developed to support the hospitalist physician. The demands made of a hospitalist are great. When the inpatient physician shoulders the burden for the administrative as well as the clinical chores, it's easy to see why burnout is common. Deteriorating results and high physician turnover are usually the result. When experienced physicians leave, the efficiencies gained from their experience are also lost.

    This scenario is avoided when systems are in place to support the physician and allow them to focus on the clinical care of patients. These systems should include:

    *Clinical support systems that include "best practice" guidelines for the most commonly managed diagnoses. This must include a system to ensure that these guidelines are followed. Ideally, this system would measure how well these guidelines were followed and also identify any barriers that existed to the provision of timely, appropriate care.

    Clinical support teams that include experienced nurse coordinators with the responsibility of working with the hospitalist physician - doing everything from expediting tests and reports to obtaining data necessary to measure outcomes.

    *Communication systems that keep all the members of the care team informed about the patient's changing condition, including the primary care physician. PCPs are legitimately concerned about not knowing what is happening with their patients and about not having the information they need to resume their care after discharge. They need to be informed of landmark events in the patient's condition while the patient is hospitalized and to quickly receive discharge information when the patient leaves the hospital. Communication with discharged patients is also critical to favorable outcomes and patient satisfaction. Patients should be contacted shortly after leaving the hospital to ensure that they have their medications, that they know how to follow their at-home regimen and that they have an appointment to see their PCP.

    Data collection, analysis and reports are necessary to measure program performance and to identify impediments to effective, efficient patient care. User friendly systems must be available to the hospitalist and their support staff to capture this information, which can then be downloaded into the IT system to produce reports that can be used to develop action plans to eliminate obstacles to care. This data will become increasingly important as hospitals are pressured by consumers, policy-makers, health plans and employers to demonstrate how they are improving quality and safety while managing costs

    Winning Support from the PCPs

    For all of these systems to be effective, the hospitalist program must have a substantial volume of patients. Support from the primary care physician community can make or break a hospitalist program.

    When the concept of the hospitalist was first introduced, some primary care physicians were concerned about loss of continuity of care with their patients, losing their clinical skills if they no longer followed hospital patients and potential loss of income if they stopped doing hospital rounds. However, today's primary care physicians - like those at Santa Fe and Baptist - are likely to be the instigators of a hospitalist program. Those who have experienced the benefits of a well-managed program fully supported by an infrastructure like that described above, rate their satisfaction at an average of 98%.

    PCPs are being won over by the hospitalist model because they see that it can deliver high quality care to their patients, and because it can deliver substantial benefit to them as physicians:

    An improved lifestyle, free from having to make hospital rounds.
    More money by focusing on their outpatient practices. The Advisory Board Company, a Washington-based research group, found that while primary care physicians can lose an average of $25,000 annually when they stop making hospital rounds, if they are practicing under capitated contracts they can earn nearly $50,000 more a year when they use the time for outpatient visits.

    Freedom from "unassigned call" duties in the ER, including admitting patients with no insurance and/or no primary care doctor. With the hospitalist available to see these patients, a physician can assign responsibility for these calls to them, thus fulfilling their requirements for membership on the hospital's medical staff and inclusion on panels for HMOs and insurance companies.

    For specialists in tertiary care facilities, hospitalists are more accessible for consultations than primary care physicians who spend most of their time seeing patients in an office some distance from the hospital.
    Already, some 20 % of the members of the American Academy of Family Physicians report that they are referring at least some of their patients to hospitalists. With such acceptance among the primary care community, promising early results and the evolution of a new model that demonstrates greater improvements in quality of care and cost savings, hospitals have a new tool to re-engineer their inpatient care processes and meet the operational and financial challenges of today's healthcare environment.

    Alan Puzarne is CEO of Cogent Healthcare Inc., (, a leading inpatient management company with programs operating in 11 major markets nationwide. He can be reached at
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