4 Strategies for Managing Hospitalists

This article appears in the April 2013 issue of HealthLeaders magazine.

Years ago, doctors would make rounds to supervise care for dozens of hospitalized patients. Now physicians often want to orchestrate care from their office, so they'll make fewer trips to the hospital—or none at all. Many especially don't want to be called at 3 a.m. to report to the hospital for one of their patients, or even get involved in certain procedures beyond their specialties.

Increasingly, hospitalists are gaining more responsibilities in areas such as monitoring patients day to day, ordering tests, performing surgeries, handling specialized care, or taking on leadership roles. Their specializations are many—from laborists who handle OB-GYN cases to surgicalists who specialize in trauma care and neurohospitalists who handle brain cases, as well as nocturnalists, who work strictly on the overnight shift.

Hospitalists are among healthcare's fastest growing specialties, with at least 60% of hospitals now employing these professionals. Since 2003, when there were an estimated 8,000 hospitalists, the specialty has grown to about 30,000, according to the Society of
Hospital Medicine.

Those urging expansion of hospitalist programs see them as a way to reduce length of stay while improving patient satisfaction. In addition, some hospitalists are specializing in acute care transitions for uninsured patients who have no primary care physicians, and for elderly patients who are cared for in hospitals then nursing homes.

"The whole field has exploded in the last 10 years or so. It's been born out of logistical need," says Louis J. Lux, MD, chief of hospital medicine at the 156-bed St. David's Round Rock (Texas) Medical Center. "Doctors used to follow patients into the hospital when they got sick. Now, the overwhelming majority is choosing to stay in the office. It's hard to be in two places at once," says Lux, also cofounder of Central Texas Hospitalists in Round Rock, a hospitalist physician group.

Philip Vaidyan, MD, FACP, director of hospital medicine in the department of internal medicine at the 525-bed SSM St. Mary's Health Center in St. Louis, says some hospitals see hospitalists as "quarterbacks" who enhance relationships with primary care physicians, coordinate care with multidisciplinary teams, and overcome the fragmentation of care. These specialists are playing an increasingly important role in keeping tabs on patients after they are discharged from hospitals to help prevent 30-day readmissions, he says. "We're seeing a majority of patients in the hospital," says Vaidyan, referring to the gamut of patients cared for by hospitalists.

Vaidyan himself is an example of how hospitalists are playing more of a leadership role in hospitals, especially those who are contracted from outside hospitalist groups. In addition to his role at St. Mary's, Vaidyan also is practice group leader of a team from IPC The Hospitalist Company, a North Hollywood, Calif.–based hospitalist physician provider group.

Shifting roles
The diminishing amount of time doctors are spending at hospital bedsides is reflected in national surveys. The average physician devotes only 12% of his or her time to hospital consultations with patients, according to the Society of Hospitalist Medicine. Hospitalists are becoming more central to coordinating care. St. David's Round Rock Medical Center and St. Mary's are among the hospitals that are increasing their general and specialized hospitalists on staff and the number of patients those doctors see.

"What's driving the growth of hospitalists these days is that patients who are in the hospital with very complex conditions … need to be seen multiple times a day, so someone is needed right there," Vaidyan says. "Hospitalists also are essential for providing patient safety and quality, and they play a major role in residency education. You need to have folks dedicated to the hospital with all the multidisciplinary team members, the nursing staff, the case managers, the social work consultants." In 2005, St. Mary's started its hospitalist program with four physicians and by early 2013, it had 13 hospitalists and four nurse practitioners working with them. The team increased care from 30 patients per day to at least 140, he adds.

At the same time, hospitalists are filling gaps in specialized care. St. David's Round Rock Medical Center, for instance, employs 11 hospitalists compared to three a few years ago, and it also has specialists, including three surgical specialists for trauma cases and a neurologist.

Hospitals use employed hospitalists, but also contract with local or national physician groups that provide such services. Some have exclusive contracts with individual hospitals and provide full coverage. Occasionally, though, hospitals have had to overcome turf issues among various hospitalist groups. That's why the 1,423-bed Lee Memorial Health System in Fort Myers, Fla., reduced the number of contracted hospitalist groups working for it to improve efficiency and consolidation, says Scott Nygaard, MD, MBA, chief medical officer for physician services at Lee Memorial Health System.

From their perspective, hospitals are seeing more synergistic opportunities, and they have "crossed the divide for better outcomes and quality measures," insists John Donahue, president and CEO of the Brentwood, Tenn.–based Cogent HMG, a hospitalist group. For such companies, "it's a great growth opportunity to be in the market. The pitch to hospitals to hire more hospitalists is: 'If you are underperforming, we can take you to the next level,'" Donahue explains.

E. Allen Joslyn, MD, is hospitalist director of inpatient specialists for Cornerstone Health Care, a multispecialty group practice with more than 300 physicians and midlevel providers in High Point, N.C., and a hospitalist at the 335-bed High Point Regional Hospital. He says when he became a hospitalist seven years ago, he was uncertain about the field's potential. Over time, he has seen the opportunity for improved coordination and quality of care. Now Joslyn says he is riding a wave of "explosive growth of hospitalists, which really has not outpaced the hospital demand.

"Hospitalists are definitely sought, and hospitals are moving toward value-based care, what the C-suite is hungry for," he says.

Success key No. 1: Revamping the program
In 2011, Lee Memorial Health System had many hospitalist groups—at least six—but they were in disarray, often competing against each other and not coordinating care throughout the system, which includes four hospitals. What's more, the patients were unhappy. As a result, the health system changed its contracting procedures, imposed monitoring programs, and contracted with one major hospitalist group instead of different groups, says Nygaard.

"We were traditionally, and maybe excessively, competitive," Nygaard says, referring to the use of multiple hospitalist groups. At first, the hospital decided that having many different hospitalist groups seemed to be the best fit for its different campuses. The hospitalists had overseen at least 50% of the hospital admissions.

Initially, "while there were standards for hospitalist medicine approved by the medical staff, in terms of desired outcomes and communication, in my opinion, none of it was being managed well," Nygaard says. "We had to bring some order to what we were doing."

Not only did the health system internally find problems with coordination and care offered by the hospitalists, but patients responding to surveys showed they were highly dissatisfied, Nygaard says. Indeed, an annual medical survey ranked hospitalists as "very low in performance," he adds.

"We had a lot of patient complaints on a routine basis because of a lack of coordination and lack of understanding what the hospitalists are and how they were supposed to really work effectively. There was no measurable benefit to what they had. And when you look at quality metrics, core measures, and HCAHPS, we were going to lose a lot of money. It wasn't that the hospitalists were solely accountable for that, but they were part of it."

At the outset, the hospital took steps to revamp its relationship with hospitalists. "We developed a mutually agreed-upon scorecard to measure quality enhancement and put measurable targets in there," Nygaard recalls. A joint operating committee was appointed for each campus, which included administrative leadership and a hospital medical group executive committee, to examine the hospitalist structure. "The board and the medical executive committee of the hospital approved a resolution to allow Lee Memorial Health System to contract with hospitalist groups directly," Nygaard adds. "We put some expectations in the service agreement that allow us to manage the hospitalists' program better."

Next, Lee Memorial Health System formed a relationship with a new physician group—Inpatient Specialists of Southwest Florida—to manage and provide hospitalist services across the four-hospital health system. This Fort Myers, Fla.–based group of 35 hospitalists oversees hospitalist care at each of the hospitals. ISSF was formed through a partnership of hospitalist affiliates of Cogent and Hospitalist Group of Southwest Florida.

As for patient satisfaction, Nygaard says, Lee Memorial Health System is working toward improvements. In Hospital Compare data, when asked if doctors were "always" ready to help out, Lee Memorial Health System scored 73%; lower than Florida, 77%, and the rest of the nation, 81%. However, when rated for always excellent care, Lee Memorial Health System received 20%; higher than Florida, 17%, and the rest of the nation, 15%.

"We're not there yet but, our figures are showing that patients are becoming satisfied," Nygaard says. The latest internal patient satisfaction poll shows patient satisfaction with hospitalists at 100%, he adds.

In Mesa, Ariz., the 342-bed Banner Baywood Medical Center also reduced the number of hospitalist groups working for the hospital, says Larry Spratling, MD, chief medical officer. There was much infighting, competition, and ultimately uncertainty in delivery of care, he adds.

"Several years ago, there was basically a chaotic situation: entrepreneuring physicians and competing hospitalist groups working for their market share," he says. "The competition was pretty intense, and we weren't getting the service in terms of hospital needs."

In addition, the hospitalists at Banner Baywood "were trying to increase the patient volume by claiming a larger share of patients admitted without a previously established attending physician," Spratling recalls. "We chose, for unassigned patient care, to contract with the best performing group. The other groups, without a contract, experienced a decline in patient volume and were noncompetitive," he says.

Success key No. 2: Transition to acute care
To improve care coordination and reduce readmissions, particularly among patients discharged to skilled nursing or rehab centers, hospitals are tasking hospitalists with coordinating care, especially for patients without primary care physicians. "We are increasingly seeing patients who don't have primary care physicians, who don't have insurance, who have low health literacy," says Vaidyan of St. Mary's. The hospital implemented Project BOOST (Better Outcomes for Older adults through Safe Transitions), a program to help prevent discharge medication errors and reduce readmissions. Project BOOST is sponsored by the Society of Hospital Medicine and aimed at improving transitions of care.

Because of concerns about readmissions, healthcare facilities are also contracting with hospitalist companies, such as IPC and Cogent, both of which provide hospitalist services to dozens of hospitals. For the most part, hospitals are working to incorporate hospitalists into postacute care to reduce the "revolving door" of readmissions, says Jerome Wilborn, MD, FCCP, a national medical director of postacute care for IPC.

Donahue, the Cogent CEO, says the discharge strategy for patients is becoming increasingly important to prevent readmissions. "We put a discharge plan in place and coordinate with primary care, home health agencies, visiting nurses, and family members."

Hospitalist groups are tapping into electronic health records to enable smooth transition of care and to ensure that laboratory results are finalized following a patient discharge, Donahue and Wilborn say. In addition, once patients are discharged, follow-up information is sent to primary care physicians. If a patient doesn't have a PCP, hospitalists work as the primary care physician to oversee follow-up care, or connect with other physicians if the patient needs additional observation or care in a nursing home. Vaidyan says St. Mary's has worked closely with community programs and nursing homes to improve handoff of patients following hospital discharge.

Some hospitals are also looking to expand the role of hospitalists who do double duty, working in clinics and in hospitals. These hospitalists are known as extensivists. In a 2011 study of patients treated by extensivists in California, the Agency for Healthcare Research and Quality found a length of stay of 4.5 days compared to the average 5.6 in Medicare patients.

The University of Chicago Medical Center has initiated a study of 2,000 patients in a program known as Comprehensive Care, says David Meltzer, MD, PhD, chief of the section of hospital medicine at the University of Chicago. The project is focusing on patients with chronic conditions who are likely to need frequent hospital care. "Many people think that the doctor-patient relationship is the key to better health," he says. "If that is true, patients who are often in the hospital might get better care if they could see the same doctor in clinic and in the hospital," Meltzer says.

Success key No. 3: Unit scheduling
A few years ago, at St. Mary's Health Center, the hospitalists were in the building, but they were scattered all over, "having patients in 13 different units," Vaidyan recalls. Indeed, hospitalists were often assigned patients on different floors and in different units, wasting time and resources, as hospital officials saw it. "It wasn't productive," says Vaidyan.

"We redesigned our program in which a hospitalist would have 80% of their patients in one unit," Vaidyan says. "The idea is that the hospitalist can stay in that unit for an extended time to build a relationship with the nursing staff and multidisciplinary team members. The process has led to improved patient satisfaction."

At St. Mary's, an internal report compared patient satisfaction in hospitalist cases to nonhospitalist ones. The use of hospitalists increased patient satisfaction from 41% in 2008 to 55% in 2010 under a HCAHPS survey, according to St. Mary's. During that same period, a nonhospitalist unit improved only from 41% to 49%.

The hospital is continuing to strive for improvement in patient satisfaction scores, Vaidyan says. Overall, the hospital received 81% patient satisfaction scores, similar to scores in the rest of Missouri as well as the rest of the United States, according to Hospital Compare.

Although the dilemma seemed simple, the location of the hospitalists had a cascading impact from efficiency to patient satisfaction. Moving the hospitalists to be nearer the patients had a psychological advantage: Suddenly patients saw the hospitalists as physicians who were right there, caregivers who would be mindful of their needs. To resolve the problem, St. Mary's assigned hospitalists to a specific unit, including a special 20-bed area specifically reserved for them and RNs.

Banner Baywood also uses a so-called "unit-based assignment model, says Spratling, who praises the model. "Instead of rounding on patients scattered throughout the hospital in multiple units, the hospitalist is assigned to round on all the patients in a convenient 26-bed unit. The new model creates a new rounding priority that enables the hospitalist to discharge patients earlier in the day, resulting in improved patient flow," he adds.

"There was a basic dysfunction that was overcome," Spratling says. "Patients were waiting to go home, and they'd wait and wait, and before you knew it, it was 4 p.m. Often, it was then too late to arrange for home healthcare if they needed it or to get them to a skilled nursing facility if needed. We made the changes so the patients could be discharged in the morning, and we didn't have 'rush hour' discharges at the hospital at 5 p.m."

 With its revised scheduling, the hospital was able to receive an average of 40 more patients for inpatient procedures. The hospital did not merely set the stage for efficiency but it also improved relationships among the case managers, social workers, "as well as face-to-face time, having a true interdisciplinary team working with the family and patient," Spratling says.

At Banner Baywood, patient satisfaction scores for the unit are 99%, about 15 percentage points higher than the 84% for the rest of the facility, according to the hospital. Both St. Mary's and Banner Baywood Medical Center credited the rounding changes to improved patient satisfaction scores.

Success key No. 4: Team-based approach
Hospitalists are becoming pivotal players in carrying out team-based care. They are involved in admissions and discharges of patients, especially when patients don't have a primary care physician. In some cases, hospitals are characterizing hospitalists as "captains" of teams to coordinate care as they take leadership positions.

Having hospitalists in leadership roles helps to ensure proper coordination, as well as coordinating patient safety data and core measures, says Lux, the chief of hospital medicine at St. David's Round Rock Medical Center. At his facility, hospitalists have "a place at the table" in hospital governance, he says. Hospitalists are assigned roles on the medical executive committee, which represents all major departments in the hospital.

"We're having a permanent seat, and it's rotated after two years," Lux says of the medical executive committee. "We have become the universal admitters to hospitals, and we're admitting patients and assigning them to other specialists. It's important there is regular interface with other medical disciplines."

Hospitalists are on other major committees like quality and pharmaceutical. They are also on the hospital's cancer committee because of the increasing role that palliative care plays, he adds. "This is one area that can touch many patients," Lux says, noting that half of Americans die in hospitals. "That whole dynamic falls within the role of hospital medicine. It's a critical relationship and taking on more importance, especially as hospitals are becoming more concerned about readmissions for illnesses such as congestive heart failure," Lux notes.

Such collaboration is important because of hospitalists' workload, say officials at various hospitals. In an early 2013 Johns Hopkins University study, four in 10 hospitalists reported their workloads exceeded safe levels at least once a month. In a research letter published in JAMA Internal Medicine, Henry J. Hichtalik, MD, and Peter Pronovost, MD, and others said that 36% of 506 hospitalist respondents reported workload assignments exceeding safe levels at least once a week.

Nygaard at Lee Memorial Health System says workloads have been a consistent issue for hospitalists, but he and other organizations are working to resolve the problems through scheduling changes. "We're trying to have our hospitalists have 18 to 20 patients, but any more is a lot for an individual physician," he says. "We had one physician who had 30 to 40 patients, and that was too much. The acuity of these patients is high."

In Arizona, Banner Baywood Medical Center also is embracing the team-based model to improve coordination with hospitalists, but CMO Spratling says the process isn't easy.

"It was very hard for the older docs to get used to working as a member of a team of physicians. We determined that a team of unit-based physicians could improve not only patient flow but also patient and staff satisfaction, as well as physician efficiency. With all the patients in one location, travel and communication delays were removed. That was what we wanted."

Reprint HLR0413-7

This article appears in the April 2013 issue of HealthLeaders magazine.