Framing the Issue:
- Hospitalists are well-positioned to improve the value of inpatient care.
- Hospital leaders must work with hospitalist groups to identify value-improvement goals and support each other in pursuit of those goals.
- Two "Choosing Wisely" lists identify common tests and procedures ordered by hospitalists that may not offer high-value care.
- The Society for Hospital Medicine recently published an assessment tool to help hospital leaders evaluate the effectiveness of their hospitalist group.
Hospitalists had just begun tiptoeing into a few hospitals in 1999 when the Institute of Medicine released its "To Err is Human" report, awakening the nation to the need for a safer health care system.
In the 15 years since, the hospitalist movement and the quality movement have grown up together and, in some ways, have been mutually supportive. As the quality movement morphs into a focus on value — the quality of care divided by its cost — hospitalists have an inherent motivation to be engaged, says Robert M. Wachter, M.D., chief of the division of hospital medicine and chief of the medical service at UCSF Medical Center in San Francisco.
For most hospitalist — or hospital medicine — groups, financial support from hospitals is part of the business model. "That means that every hospitalist group in the country recognizes that it has to make the case that having hospitalists in the building adds value," Wachter says.
Putting the spotlight on patient transitions
Perhaps the most common value initiative has been working to improve patients' transitions from hospital to home or other post-acute care setting, thereby reducing the likelihood that they will be readmitted within a few days or weeks. "In fact, the hospital medicine movement in some ways helped to birth that whole concept of transitions of care," says Patrick J. Cawley, M.D., CEO of the Medical University of South Carolina Medical Center in Charleston.
Cawley, a past president of the Society of Hospital Medicine, points to hospitalists' leadership in quality improvement strategies like SHM's Project BOOST and Project RED (Re-Engineered Discharge). Nevertheless, many hospitals continue to struggle with failed discharges that result in high 30-day readmission rates. Likewise, many hospitalists treat inpatients without valuable information from primary care physicians, because timely notification and record-sharing is not routine.
"Good care requires a two-way communication; the programs that do it best focus on that and they involve all the primary care physicians in the community who are using the hospital medicine program," Cawley says. "I've seen hospital medicine programs do it really, really well and I've seen some that haven't done it well."
Beyond care transitions, hospitalists have many opportunities to improve the value of the care they deliver, but it won't happen without the active involvement of hospital leadership.
"Every hospital needs to make sure that a senior leader is assigned for monitoring the goals of the hospital medicine program," Cawley says. "My advice is: 'Don't take these hospital medicine contracts for granted.' You need to oversee them constantly, and you need to revisit them on a frequent basis for them to work most effectively."
A key to success is making sure that the hospital and hospitalist program are supporting one another's goals, says Philip Vaidyan, M.D., director of hospital medicine at St. Mary's Health Center, a major teaching hospital that is part of SSM Health Care in St. Louis.
"Hospitals shouldn't be just saying, 'We need to accomplish all those things, but you do it,'" says Vaidyan, who serves as practice group leader for the IPC hospitalist team at St. Mary's. [IPC is a national physician group practice company.] "They should be engaging the hospitalists or a hospitalist company by saying, 'These are the institutional goals. What things do you need to accomplish these goals? How is your recruitment? Your retention? What can we do to get the best hospitalists to want to join your group?"
Structural change brings positive results
St. Mary's hired Vaidyan in 2005 to develop a hybrid commercial-academic hospitalist program in which the hospitalists both teach and provide patient care. In the years since, he has spearheaded structural changes in care delivery designed to improve the value of patient care.
The first was the creation of a new care model to replace the inefficiency of nurses having to call physicians every time they have questions about a patient.
"Now, the hospitalists and nurses are rounding together at the patient bedside using a checklist to make sure everything gets covered, and patients and their families are allowed to participate in the care planning," Vaidyan says. "With this model, a nurse knows what to do with regard to that patient for the rest of the day."
Discharge planning is part of every patient visit, and the physician–nurse rounds have led to improved patient experience scores for both nurses and doctors, he says.
Another big structural change came a few years later when St. Mary's created a hospitalist unit, where 30 patients who are treated by hospitalists are clustered together. Two or three hospitalists are assigned to work in that unit exclusively, which facilitates collaboration with the nurses, case managers and social workers based on the unit.
After 18 months, the hospitalist unit's average all-cause, 30-day readmission rate dropped by 22 percent to 11.5 percent. In contrast, a similar St. Mary's unit that did not adopt the hospitalist-exclusive model experienced only a 5 percent decrease during the same period.
Building on that success, the IPC team began assigning hospitalists to each of the hospital's 30 units.The goal is that 80 percent of a hospitalist's physicians will be located on a single unit, reducing the physician's time traveling throughout the hospital and facilitating strong relationships with nurses and other unit-based caregivers.
"Instead of having your patients in 15 different units, you have most of your patients in one unit, and just a few patients elsewhere," Vaidyan says. "We cut a lot of waste out of people's time and empowered the doctors and nurses to do rounding together much more easily."
The benefit is measured in the readmission statistics: For the IPC hospitalist team at St. Mary's, the all-cause, 30-day readmission rate is below 10 percent. For congestive heart failure patients, the rate is below 18 percent; for pneumonia patients, below 15 percent; and for heart attack patients, below 5 percent.
Post-discharge clinic helps to reduce readmissions
When patients who are being discharged from Hoag Hospital Newport Beach (Calif.) are scheduled for an appointment at the health center's post-discharge clinic within the next 72 hours, they often wonder what it's all about.
But after their visit to the post-discharge clinic, they consider it to be highly worthwhile.
"Patient satisfaction scores are 5 out of 5, and that has been consistent from the day of opening this clinic," says Salina Wolf, M.D., of Pacific Hospitalist Associates. "After being evaluated and managed, they feel as though this is the best program that they ever encountered."
PHA, the hospitalist group at Hoag Hospital, staffs the post-discharge clinic under contract with Greater Newport Physicians, an independent physician association responsible for the total cost of caring for a population of HMO patients. In the first 10 months after the clinic opened, the all-cause, 30-day readmission rate for patients who visited the clinic dropped by 50 percent.
The multidisciplinary clinic responds to the reality that many newly discharged patients do not even know why they were hospitalized, let alone how to care for themselves once they're out of the hospital. The IPC's case managers schedule a post-discharge visit before a patient leaves the hospital, and a typical visit lasts at least 90 minutes.
Each patient is seen by a hospitalist, who evaluates health status; a pharmacist, who performs medication reconciliation; a registered nurse, who provides wound care and arranges home health or physical therapy services; and a social worker, who can arrange a move to an assisted living or nursing home facility, if necessary. While a patient is there, clinic staff members schedule follow-up appointments with his or her primary care physician and specialists as appropriate.
"I think every patient who is discharged from the hospital should be seen within 72 hours to help prevent rehospitalization," Wolf says. "Seeing them within those first three days is when you're going to catch the major pitfalls, such as new medications that may affect their heart rate or blood pressure. If someone doesn't catch that within the first 72 hours, the patients start exhibiting symptoms and are likely to head back to the emergency department."
Planning to reduce readmissions
The neurohospitalist group at UCSF Medical Center has halved the 30-day readmission rate for neurology patients, bringing it to about 10 percent, through a series of interventions introduced in the past few years.
Perhaps the most significant success factor is not the individual interventions, but the systematic and multidisciplinary approach. Every case in which a patient is readmitted within 30 days is reviewed by the department's morbidity and mortality committee.
"We dissect every readmission as to why it happened, the barriers to success, whether it was avoidable and how we could have made this better," says S. Andrew Josephson, M.D., director of the neurohospitalist program. "Through that process, we've identified several themes."
Among them: Patients often fail to adhere to their medication regimens or discharge care plans, their conditions deteriorate before they realize it, and they cannot schedule a prompt follow-up visit with their outpatient neurologist.
3 steps to help patient after they are discharged
That analysis prompted Josephson and his colleagues to develop several protocols designed to help patients succeed after they leave the hospital:
• Pharmacists and nurses use the teach-back method to make sure patients understand their medication regimens and post-discharge care plans.
• Nurses call patients within 72 hours of discharge to see how they are doing and answer their questions.
• Every patient is scheduled to visit the UCSF neurology discharge clinic within 10 days after discharge. A neurohospitalist — typically the physician in charge of his or her inpatient care — follows up on tests that were planned, makes sure the patient is taking medications properly and assesses the patient's health status.
Meanwhile, a team of neurohospitalists, quality analysts, nurses, social workers, case managers and pharmacists meets each month to work on readmissions.
The team reviews a readmissions dashboard that shows not only the readmission number, rate and trends over time, but also the percentage of patients who received each of the interventions.
"Everyone looking at the same dashboard can see how we are doing as a group," Josephson says. "That allows us to see if there are trends or opportunities for improvement."
— Lola Butcher is a freelance writer in Springfield, Mo.
Since the inception of hospital medicine not quite 20 years ago, most American hospitals have launched hospitalist programs. But there is wide variation in the capabilities and performance of those programs. And, until now, there have been few guidelines to indicate what a good program looks like. That changed in February when the Journal of Hospital Medicine published "The key principles and characteristics of an effective hospital medicine group: An assessment guide for hospitals and hospitalists." The framework, developed by the Society of Hospital Medicine, consists of 47 characteristics organized under 10 principles. Characteristics that hospital leaders can use to evaluate their hospitalist program include:
The hospital medicine group has at least one designated practice leader with dedicated administrative time and an important role within the hospital and medical staff leadership.
Hospitalists actively participate in regularly scheduled meetings to address key issues for the practice. They receive meaningful feedback about their individual performances and contributions to the hospital, and know the performance status of the hospital.
Effective management infrastructure
The hospitalist group has an annual budget and is supported by practice management information technology.
The group is adequately staffed to meet its needs for nonclinician administrative management and clerical support. It generates periodic reports that characterize its performance. The group is supported by appropriate practice management information technology, clinical information technology and data analytics.
Alignment with the hospital and/or health system
The group develops annual goals that align with the goals of the hospital, and its compensation model aligns hospitalist incentives with those goals. They collaborate with the hospital's patient relations and/or risk-management staff to implement practices that reduce errors and improve the patient's perception of the hospital. They also periodically solicit satisfaction feedback from key stakeholder groups and use it to develop and implement improvement plans.
Coordination across care settings
The group has systems in place to ensure effective communication with the patient's primary care provider and other caregivers. The group contributes to the hospital's efforts to improve care transitions.
Hospitalists actively seek to maximize the effectiveness of care by implementing evidence-based practices and reducing unwarranted variation in care. They improve hospital efficiency by optimizing length of stay and improving patient flow. The group helps to improve the patient and family experience and reduce clinical resource utilization and cost per stay. Hospitals support continuous quality improvement and actively participate in initiatives to measurably improve quality and patient safety.
Scope of activities
To meet the changing needs of the hospital, the group has a plan for evolving the scope of hospitalist clinical activities. The respective roles of hospitalists and physicians in other specialties who treat their patients, including patients that are co-managed, are clearly defined.
Effective practice model
Hospitalists provide care that respects and responds to patient and family preferences and values. They engage in team-based decision-making with members of the clinical care team. They use effective and efficient internal handoff processes for both change of shift and change of responsible provider.
Recruitment and retention
Hospitalist compensation is market-competitive, and the group measures, monitors and fosters its hospitalists' job satisfaction and professional development.
Beyond transitions of care
Wondering where to get started in improving the value of care delivered by hospitalists? The Society of Hospital Medicine has already scoped it out.
In early 2013, SHM joined the Choosing Wisely campaign launched by the ABIM Foundation the previous year in recognition of the fact that many common high-cost medical services do not improve the quality of patient care. Each of dozens of medical societies participating in Choosing Wisely has identified a "Top Five" list of tests and procedures in its specialty that are performed frequently despite questionable evidence of their value.
SHM went one better: It created a Top Five list for pediatric hospital care and adult hospital medicine. Each list was created by an expert panel based on survey responses from more than 8,000 hospitalists. John Bulger, D.O., chief quality officer for the Geisinger Health System, spearheaded the adult medicine panel, and Ricardo Quinonez, M.D., associate professor at Baylor College of Medicine/Texas Children's Hospital, led the pediatric team.
While the SHM recommendations may seem like a simple to-do list, the reality is that changing medical practice requires a carefully executed approach that involves education, process changes, monitoring, measurement of progress and reinforcement to make sure the new behavior becomes institutionalized.
In issuing its lists, SHM encouraged hospitalists to develop quality improvement initiatives as a way of adopting the recommendations. To further support its recommendations, SHM plans to publish protocols, order sets, checklists and other tools to help change hospitalist practice.
Adult Hospital Medicine Recommendations
- Do not place — or leave in place — urinary catheters for incontinence or convenience or monitoring of output for noncritically ill patients.
- Do not prescribe medications for stress ulcer prophylaxis to medical inpatients unless they are at high risk for gastrointestinal complications.
- Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms of active coronary disease, heart failure or stroke.
- Do not order continuous telemetry monitoring outside of the intensive care unit without using a protocol that governs continuation.
- Do not perform repetitive complete blood count and chemistry testing in the face of clinical and lab stability.
Pediatric Hospital Medicine Recommendations
- Do not order chest radiographs in children with uncomplicated asthma or bronchiolitis.
- Do not routinely use bronchodilators in children with bronchiolitis.
- Do not use systemic corticosteroids in children younger than 2 years with an uncomplicated lower respiratory tract infection.
- Do not routinely treat gastroesophageal reflux in infants with acid-suppression therapy.
- Do not use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen.