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Hospital Medicine: The Hub of the Healthcare Continuum

HealthLeaders magazine, June 13, 2010

McDowell: Our problem is that the resistance to doing geographically based hospitalists has been from the hospitalists themselves. That's tough because the biggest dissatisfier to the patient is moving around. But how do you deal with a unit that may have two discharges and two admissions in a day, and another one that has 11, and balancing the workload?

Fleming: One of the things we require in our contracts with the hospitals is that we have a monthly sit-down with hospital administration. It's led by our hospitalist medical department to discuss ways to improve care and reduce inefficiencies using a systematic approach to providing care. You talk about handoffs, you talk about why Mrs. Smith is still here when she should have gone home yesterday. You talk about things that create inefficiencies, and you solve them in real time.

Hamby: The hospitalist is in a good position to know where all the cracks and crannies are in any organization. We have bed huddles when there's a crisis on throughput and workflow.

Fleming: In hospitals that are big enough to have geographic units, we find physician satisfaction, nursing satisfaction, and patient satisfaction to be much higher.

HealthLeaders: Are we looking at a future where, wholesale, physicians are going to want to be employed by the hospital? And if so, will hospitalists become the norm rather than the exception?

Hamby: Yes, we're going to see more physician employment, but that's not necessarily what we need. What we need is doctors and hospitals being more aligned. Employment does not guarantee alignment. We have a series of ongoing experiments with a variety of different models. We have probably 200 or 300 employed docs, a majority of whom are primary care, but we have our hospitalist, our transplant team, and now, a large number of cardiologists, cardiac surgeons, and vascular surgeons. So we have a large contingency of employed physicians, but the ones that have been employed have all come to us. We also have comanagement models, we have joint ventures, we have our PHO, and so we're just trying to learn all the ways to engage with the docs and try to align with the docs.

HealthLeaders: Did any of you consider outsourcing when you were developing your hospitalist programs?

Hamby: I inherited the existing one. When we acquired our most recent facility, we thought about the option of outsourcing versus building our own. We decided to build, because we've done it in three places. There were some difficult times in the early part of that.

Ranney: For us, it ended up being that our medical staff felt they had more control if we built it than if we bought it. One of the main advantages of a consultant is they can take a bullet, you survive, and your program can then morph. So I did give that up, but by doing that, the medical staff drove the process, and so they wanted the local control and they felt like they had better control than with outsourcing.

McDowell: We started it so long ago that it probably would not have made sense, and I don't think there was a company like Cogent around at the time. But knowing what I know, if we were going to be doing it today, starting from scratch with a hospitalist program, or let's say it was a surgicalist or a laborist or something else, I would be exploring both models.

HealthLeaders: How are you delving into hospitalist specialization?

Fleming: We see serving surgeons, cardiologists, gastroenterologists as a great opportunity for our company. Surgeons don't want to take care of hypertension and cardiac disease and all the other things that a patient might have. So in nearly every program, we have what we call surgical comanagement, where we work alongside the surgeon. The orthopedic surgeon does the total hip implant, but we assess the patient, we put the patient on the proper meds, and when the patient comes back from their surgery, we manage the clinical issues. The surgeon manages just the surgical side of it, so the surgeon is happier.

Ranney: There is a tendency, where you've got the volumes to support it, to begin to do that with subspecialties. as well.

HealthLeaders: Does that begin to solve the call problems that hospitals are dealing with?

McDowell: In many of the hospitals in my state, the hiring of either hospital-based physician assistants in specialties, or to work across specialties, was in reaction to requests for call coverage. So many of our hospitals in Connecticut chose that in lieu of paying call compensation.

Hamby: If I'm a hospital CEO and I'm paying my surgeons for call, now we're going to have the hospitalist comanage the surgical patients. I'm going to need more hospitalists. So how do you help a CEO reconcile that business model to expand the role of the hospitalist, but the hospital is not getting any new revenues associated with that?

McDowell: That's the hardest thing. Until recently, at least if the patient had medical problems that were ongoing, and a consult was requested, there was revenue that could be generated from that as long as there was appropriate care and the problems were active. If you can get the patients out faster, if you can get the patient treated more appropriately with reduced complications, then that pays for itself, but that's a hard sell to a CFO or CEO.

Fleming: We try to tailor what we do to the specific situation. But there are many cases where the hospital perceives that quality goes up and costs go down if you have a more organized approach. We have nurse practitioners, we have PAs, and very often, the patients get divided up and the appropriate level caregiver is assigned.

McDowell: Let's put cost aside for the moment. If you go back 25 years, the primary care doctor for every patient saw them in the hospital, even surgical patients. The primary care doctor rounded and handled all of the problems. The primary care doc was the focus. Then we migrated into a situation where there were multiple people touching the patient but rarely coordination. What we're now asking is for the hospitalist to become the in-hospital generalist who oversees, consults, and communicates.

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