Practice Management

SHM founder Win Whitcomb, MD, MHM, chief medical officer of Remedy Partners of Darien, Conn., talks about the annual practice management pre-course in an ever-changing healthcare landscape.

SHM founder Win Whitcomb, MD, MHM, chief medical officer of Remedy Partners of Darien, Conn., talks about the annual practice management pre-course in an ever-changing healthcare landscape.

SHM founder Win Whitcomb, MD, MHM, chief medical officer of Remedy Partners of Darien, Conn., talks about the annual practice management pre-course in an ever-changing healthcare landscape.

New SHM President Robert Harrington Jr., MD, SFHM, talks about his views on hospital medicine, the society and the value of diversity and teamwork.

New SHM President Robert Harrington Jr., MD, SFHM, talks about his views on hospital medicine, the society and the value of diversity and teamwork.

New SHM President Robert Harrington Jr., MD, SFHM, talks about his views on hospital medicine, the society and the value of diversity and teamwork.

Session: Multi-site Hospitalist Leaders: Unique Challenges/What You Should Know

HM15 Presenter/Moderator: Scott Rissmiller, MD

Summation: This standing-room-only session was the result of a popular HMX e-community, which has become an active discussion board. As hospitals and health systems continue to consolidate across the country, there has been a rapid growth of multi-hospital systems. The role of the “Chief Hospitalist,” whose job is to lead multiple hospitalist groups within these systems, is evolving. These “Chief Hospitalists” are growing in number and they, as well as their followers, face unique challenges.

These points regarding organization structure were discussed, and as you look at your own organizational structure, these questions deserve your attention:

1. Purpose of your structure?
2. Is your structure centralized or decentralized?
3. How does your organizational structure support decision-making?
4. How does the structure ensure proper communication?
5. How are resources shared across geography?
6. What is your administrative support structure?
7. How is administrative time allocated for physician leaders?
8. How do you ensure engagement from all providers?
9. How does your organization structure create alignment with the healthcare system?

The following compensation issues were discussed, and can be used as a discussion outline for most groups:

1. How does your compensation (comp) plan align with the goals and values of the system?
2. How does your comp plan account for regional variances?
3. How does the comp plan encourage teamwork and sharing of resources?
4. How does comp plan account for differences in acuity, hospital size, night frequency, etc.?
5. Are goals and incentives group based, site based, or individual based?
6. How does the comp plan fairly reward “non-RVU” work? (teaching, committee service, etc.)
7. Should all site leaders receive the same comp regardless of group size?
8. Does the comp plan incorporate “minimum work standards”/social compact?

Key Points/HM Takeaways:

• Panel discussion was valuable and reassured attendees that there are multiple ways to make groups successful. One common variable of successful groups is open lines of communication at all levels.
• Physician on-boarding is critical and should be utilized to set clear expectations.
• HM Goals/expectations must be aligned with those of the hospital and health system.
• When multiple hospitals are part of a larger system, it is desirable for goals to be aligned across the health system.
• Two-way open communication is necessary for success.
• Try to take a walk in your colleague’s/stakeholder’s shoes:

  • How does my hospital administrative partner see this issue?
  • How does my regional director/system lead see this issue?
  • How does my bedside hospitalist physician/provider see this issue?
  • How would my patients view this issue?

• Issues facing different types of groups, academic vs. community and for profit vs. not for profit, are somewhat variable.
• The leadership Dyad consisting of a physician and practice management professional in partnership is an effective and well-proven management model.

Many thanks to Drs. T.J. Richardson and Dan Duzan for their input and assistance with this session summary. Dr. Richardson is a Regional Medical Director and Dr. Duzan is a Facility Medical Director, both work for TeamHealth.  

Julianna Lindsey is a hospitalist and physician leader based in the Dallas-Fort Worth Metroplex. Her focus is patient safety/quality and physician leadership. She is a member of TeamHospitalist.

Session: Multi-site Hospitalist Leaders: Unique Challenges/What You Should Know

HM15 Presenter/Moderator: Scott Rissmiller, MD

Summation: This standing-room-only session was the result of a popular HMX e-community, which has become an active discussion board. As hospitals and health systems continue to consolidate across the country, there has been a rapid growth of multi-hospital systems. The role of the “Chief Hospitalist,” whose job is to lead multiple hospitalist groups within these systems, is evolving. These “Chief Hospitalists” are growing in number and they, as well as their followers, face unique challenges.

These points regarding organization structure were discussed, and as you look at your own organizational structure, these questions deserve your attention:

1. Purpose of your structure?
2. Is your structure centralized or decentralized?
3. How does your organizational structure support decision-making?
4. How does the structure ensure proper communication?
5. How are resources shared across geography?
6. What is your administrative support structure?
7. How is administrative time allocated for physician leaders?
8. How do you ensure engagement from all providers?
9. How does your organization structure create alignment with the healthcare system?

The following compensation issues were discussed, and can be used as a discussion outline for most groups:

1. How does your compensation (comp) plan align with the goals and values of the system?
2. How does your comp plan account for regional variances?
3. How does the comp plan encourage teamwork and sharing of resources?
4. How does comp plan account for differences in acuity, hospital size, night frequency, etc.?
5. Are goals and incentives group based, site based, or individual based?
6. How does the comp plan fairly reward “non-RVU” work? (teaching, committee service, etc.)
7. Should all site leaders receive the same comp regardless of group size?
8. Does the comp plan incorporate “minimum work standards”/social compact?

Key Points/HM Takeaways:

• Panel discussion was valuable and reassured attendees that there are multiple ways to make groups successful. One common variable of successful groups is open lines of communication at all levels.
• Physician on-boarding is critical and should be utilized to set clear expectations.
• HM Goals/expectations must be aligned with those of the hospital and health system.
• When multiple hospitals are part of a larger system, it is desirable for goals to be aligned across the health system.
• Two-way open communication is necessary for success.
• Try to take a walk in your colleague’s/stakeholder’s shoes:

  • How does my hospital administrative partner see this issue?
  • How does my regional director/system lead see this issue?
  • How does my bedside hospitalist physician/provider see this issue?
  • How would my patients view this issue?

• Issues facing different types of groups, academic vs. community and for profit vs. not for profit, are somewhat variable.
• The leadership Dyad consisting of a physician and practice management professional in partnership is an effective and well-proven management model.

Many thanks to Drs. T.J. Richardson and Dan Duzan for their input and assistance with this session summary. Dr. Richardson is a Regional Medical Director and Dr. Duzan is a Facility Medical Director, both work for TeamHealth.  

Julianna Lindsey is a hospitalist and physician leader based in the Dallas-Fort Worth Metroplex. Her focus is patient safety/quality and physician leadership. She is a member of TeamHospitalist.

Session: Multi-site Hospitalist Leaders: Unique Challenges/What You Should Know

HM15 Presenter/Moderator: Scott Rissmiller, MD

Summation: This standing-room-only session was the result of a popular HMX e-community, which has become an active discussion board. As hospitals and health systems continue to consolidate across the country, there has been a rapid growth of multi-hospital systems. The role of the “Chief Hospitalist,” whose job is to lead multiple hospitalist groups within these systems, is evolving. These “Chief Hospitalists” are growing in number and they, as well as their followers, face unique challenges.

These points regarding organization structure were discussed, and as you look at your own organizational structure, these questions deserve your attention:

1. Purpose of your structure?
2. Is your structure centralized or decentralized?
3. How does your organizational structure support decision-making?
4. How does the structure ensure proper communication?
5. How are resources shared across geography?
6. What is your administrative support structure?
7. How is administrative time allocated for physician leaders?
8. How do you ensure engagement from all providers?
9. How does your organization structure create alignment with the healthcare system?

The following compensation issues were discussed, and can be used as a discussion outline for most groups:

1. How does your compensation (comp) plan align with the goals and values of the system?
2. How does your comp plan account for regional variances?
3. How does the comp plan encourage teamwork and sharing of resources?
4. How does comp plan account for differences in acuity, hospital size, night frequency, etc.?
5. Are goals and incentives group based, site based, or individual based?
6. How does the comp plan fairly reward “non-RVU” work? (teaching, committee service, etc.)
7. Should all site leaders receive the same comp regardless of group size?
8. Does the comp plan incorporate “minimum work standards”/social compact?

Key Points/HM Takeaways:

• Panel discussion was valuable and reassured attendees that there are multiple ways to make groups successful. One common variable of successful groups is open lines of communication at all levels.
• Physician on-boarding is critical and should be utilized to set clear expectations.
• HM Goals/expectations must be aligned with those of the hospital and health system.
• When multiple hospitals are part of a larger system, it is desirable for goals to be aligned across the health system.
• Two-way open communication is necessary for success.
• Try to take a walk in your colleague’s/stakeholder’s shoes:

  • How does my hospital administrative partner see this issue?
  • How does my regional director/system lead see this issue?
  • How does my bedside hospitalist physician/provider see this issue?
  • How would my patients view this issue?

• Issues facing different types of groups, academic vs. community and for profit vs. not for profit, are somewhat variable.
• The leadership Dyad consisting of a physician and practice management professional in partnership is an effective and well-proven management model.

Many thanks to Drs. T.J. Richardson and Dan Duzan for their input and assistance with this session summary. Dr. Richardson is a Regional Medical Director and Dr. Duzan is a Facility Medical Director, both work for TeamHealth.  

Julianna Lindsey is a hospitalist and physician leader based in the Dallas-Fort Worth Metroplex. Her focus is patient safety/quality and physician leadership. She is a member of TeamHospitalist.

Hm15 Presenters: Chuck Ainsworth, MD, MCC,; Dan Virnich, MD, MBA; Roberta Himebaugh, MBA, SFHM; Robert Hickling, MHA; Sendil Krishnan, MD

Summation: The presenters, a group of physicians and administrators for hospital medicine groups, explored three dyad models. These three models were:

1. Office of the Executive, where there is one senior executive and a junior executive;
2. Coordinated Co-Leadership, where each of the two co-leaders has separate direct reports; and
3. Integrated Co-Leadership, where there are two co-leaders and the staff report to the co-leader team.

The discussion ensued to outline the benefit of a dyad leadership model, which can lead to growth and success in advancing the commitment to patient care. The group also emphasized the importance of providing leadership training and education to optimize the dyad leadership model. Bringing together physician and administrator dyads enables an organization to have complimentary expertise to advance hospital medicine programs into the next era.

Hm15 Presenters: Chuck Ainsworth, MD, MCC,; Dan Virnich, MD, MBA; Roberta Himebaugh, MBA, SFHM; Robert Hickling, MHA; Sendil Krishnan, MD

Summation: The presenters, a group of physicians and administrators for hospital medicine groups, explored three dyad models. These three models were:

1. Office of the Executive, where there is one senior executive and a junior executive;
2. Coordinated Co-Leadership, where each of the two co-leaders has separate direct reports; and
3. Integrated Co-Leadership, where there are two co-leaders and the staff report to the co-leader team.

The discussion ensued to outline the benefit of a dyad leadership model, which can lead to growth and success in advancing the commitment to patient care. The group also emphasized the importance of providing leadership training and education to optimize the dyad leadership model. Bringing together physician and administrator dyads enables an organization to have complimentary expertise to advance hospital medicine programs into the next era.

Hm15 Presenters: Chuck Ainsworth, MD, MCC,; Dan Virnich, MD, MBA; Roberta Himebaugh, MBA, SFHM; Robert Hickling, MHA; Sendil Krishnan, MD

Summation: The presenters, a group of physicians and administrators for hospital medicine groups, explored three dyad models. These three models were:

1. Office of the Executive, where there is one senior executive and a junior executive;
2. Coordinated Co-Leadership, where each of the two co-leaders has separate direct reports; and
3. Integrated Co-Leadership, where there are two co-leaders and the staff report to the co-leader team.

The discussion ensued to outline the benefit of a dyad leadership model, which can lead to growth and success in advancing the commitment to patient care. The group also emphasized the importance of providing leadership training and education to optimize the dyad leadership model. Bringing together physician and administrator dyads enables an organization to have complimentary expertise to advance hospital medicine programs into the next era.

HM15  Presenters: John Nelson, MD, MHM; Daniel Hanson, MD, FHM; Darren Thomas, MD

Summation: The presenters, from three entirely different geographic regions across the U.S., walked the audience through several different innovative hospitalist staffing models, from staffing in a multi-hospital system to integrating of advanced practice clinicians to deploying staggered staffing techniques to match the patient demand and enhance continuity of care.

Many multi-hospital systems are challenged to consider creative solutions on how to meet individual hospital staffing needs, while also creating staffing efficiencies across the system, such as cross coverage at night and back-up staffing solutions for increased patient volumes and unexpected staffing vacancies.

Examples to enhance patient continuity were presented throughout, such as pairing together a hospitalist from one week to a hospitalist from an alternate week to care for the same patients.

Similarly, the experts provided a compelling case to consider pairing hospitalist providers with patients, and referring physicians longitudinally across multiple admissions.

Key Takeaways:

1. Patients Come First - consider patient alignment, or continuity, in determing provider scheduling options.

2. Multi-hospital Systems - establish the onboarding parameters needed for providers to be successful in covering more than one hospital and how to build into your scheduling model.

3. Integrate the Care Team - ensure the roles of the integrated provider team (e.g., physicians and advanced practice clinicians) are clearly understood when developing the schedule.

4. Know Your Numbers - clearly understand the workload demands to properly balance the scheduling needs before establishing the schedule.

5. Regular Review - regularly review all of these areas and revise your schedule based on the changing landscape of demands on your hospital medicine group.

HM15  Presenters: John Nelson, MD, MHM; Daniel Hanson, MD, FHM; Darren Thomas, MD

Summation: The presenters, from three entirely different geographic regions across the U.S., walked the audience through several different innovative hospitalist staffing models, from staffing in a multi-hospital system to integrating of advanced practice clinicians to deploying staggered staffing techniques to match the patient demand and enhance continuity of care.

Many multi-hospital systems are challenged to consider creative solutions on how to meet individual hospital staffing needs, while also creating staffing efficiencies across the system, such as cross coverage at night and back-up staffing solutions for increased patient volumes and unexpected staffing vacancies.

Examples to enhance patient continuity were presented throughout, such as pairing together a hospitalist from one week to a hospitalist from an alternate week to care for the same patients.

Similarly, the experts provided a compelling case to consider pairing hospitalist providers with patients, and referring physicians longitudinally across multiple admissions.

Key Takeaways:

1. Patients Come First - consider patient alignment, or continuity, in determing provider scheduling options.

2. Multi-hospital Systems - establish the onboarding parameters needed for providers to be successful in covering more than one hospital and how to build into your scheduling model.

3. Integrate the Care Team - ensure the roles of the integrated provider team (e.g., physicians and advanced practice clinicians) are clearly understood when developing the schedule.

4. Know Your Numbers - clearly understand the workload demands to properly balance the scheduling needs before establishing the schedule.

5. Regular Review - regularly review all of these areas and revise your schedule based on the changing landscape of demands on your hospital medicine group.

HM15  Presenters: John Nelson, MD, MHM; Daniel Hanson, MD, FHM; Darren Thomas, MD

Summation: The presenters, from three entirely different geographic regions across the U.S., walked the audience through several different innovative hospitalist staffing models, from staffing in a multi-hospital system to integrating of advanced practice clinicians to deploying staggered staffing techniques to match the patient demand and enhance continuity of care.

Many multi-hospital systems are challenged to consider creative solutions on how to meet individual hospital staffing needs, while also creating staffing efficiencies across the system, such as cross coverage at night and back-up staffing solutions for increased patient volumes and unexpected staffing vacancies.

Examples to enhance patient continuity were presented throughout, such as pairing together a hospitalist from one week to a hospitalist from an alternate week to care for the same patients.

Similarly, the experts provided a compelling case to consider pairing hospitalist providers with patients, and referring physicians longitudinally across multiple admissions.

Key Takeaways:

1. Patients Come First - consider patient alignment, or continuity, in determing provider scheduling options.

2. Multi-hospital Systems - establish the onboarding parameters needed for providers to be successful in covering more than one hospital and how to build into your scheduling model.

3. Integrate the Care Team - ensure the roles of the integrated provider team (e.g., physicians and advanced practice clinicians) are clearly understood when developing the schedule.

4. Know Your Numbers - clearly understand the workload demands to properly balance the scheduling needs before establishing the schedule.

5. Regular Review - regularly review all of these areas and revise your schedule based on the changing landscape of demands on your hospital medicine group.

HM15 Session: Putting Your Nickel Down: The What, Why, and How of Implementing Physician Value-Based Purchasing in Your Practice

Presenters: Stephen Besch, Simone Karp RPh, Patrick Torcson MD MMM SFHM, Gregory Seymann MD SFHM

Summation: HHS has set a goal of tying increasing percentages of Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements. By the end of 2018 the goal is for 50% of Medicare payments to be tied to these alternative payment models.   For the remaining traditional Medicare payment arrangements, 90% of those will be tied to quality/value incentives by 2018.

Medicare is transforming itself from a “passive payer” to an “active purchaser” of high quality, efficient healthcare. As such- active participation by physicians, physician groups, and hospitals is required for payment eligibility.

At the physician/group level, hospitalists should be reporting PQRS measures. Incentive payments for PQRS ended in 2014, Medicare is now making “negative payment adjustments.” Penalties are equal to a percentage of all Medicare Part B FFS (Fee-for-Service) charges and there is a 2-year delay between reporting or performance failure and penalization.

Physician Value-Based Purchasing (P-VBP) affects all Eligible Providers (EPs) in 2015. P4P (Pay for Performance) assesses both quality and cost. Aim is for budget neutrality via “quality tiering” which rewards “high quality/low cost” practices with penalties from “low quality/high cost” practices. As of now (2015) ACPs and therapists can be penalized under P-VBP.

Key Points/HM Takeaways:

• Hospitalists should be reporting PQRS measures- penalty phase has begun
• Key PQRS Changes for 2015:

  • 6 measures applicable to inpatient billing removed
  • no useful inpatient measures added
  • penalty avoidance requires 9 measures at 50% or higher rates, covering at least 3 of the 6 NQS (National Quality Strategy) domains- including 1 cross-cutting measure
  • all 2015 PQRS data will be posted to Physician Compare website in 2016
  • 3 Examples of hospitalist applicable “cross-cutting measures” are

    • 47-advance care plan
    • 130-documentation of current medications
    • 317-preventative care: bp screening

  • PQRS data must be reported with respect to MAV clusters (Measure Applicability Validation)- reporting only measure that have no MAV cluster is a safe strategy so long as one of the measures is “cross-cutting”
  • Maximum P-VBP penalties automatically apply if group does not report enough PQRS data
  • visit CMS website for more information

HM15 Session: Putting Your Nickel Down: The What, Why, and How of Implementing Physician Value-Based Purchasing in Your Practice

Presenters: Stephen Besch, Simone Karp RPh, Patrick Torcson MD MMM SFHM, Gregory Seymann MD SFHM

Summation: HHS has set a goal of tying increasing percentages of Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements. By the end of 2018 the goal is for 50% of Medicare payments to be tied to these alternative payment models.   For the remaining traditional Medicare payment arrangements, 90% of those will be tied to quality/value incentives by 2018.

Medicare is transforming itself from a “passive payer” to an “active purchaser” of high quality, efficient healthcare. As such- active participation by physicians, physician groups, and hospitals is required for payment eligibility.

At the physician/group level, hospitalists should be reporting PQRS measures. Incentive payments for PQRS ended in 2014, Medicare is now making “negative payment adjustments.” Penalties are equal to a percentage of all Medicare Part B FFS (Fee-for-Service) charges and there is a 2-year delay between reporting or performance failure and penalization.

Physician Value-Based Purchasing (P-VBP) affects all Eligible Providers (EPs) in 2015. P4P (Pay for Performance) assesses both quality and cost. Aim is for budget neutrality via “quality tiering” which rewards “high quality/low cost” practices with penalties from “low quality/high cost” practices. As of now (2015) ACPs and therapists can be penalized under P-VBP.

Key Points/HM Takeaways:

• Hospitalists should be reporting PQRS measures- penalty phase has begun
• Key PQRS Changes for 2015:

  • 6 measures applicable to inpatient billing removed
  • no useful inpatient measures added
  • penalty avoidance requires 9 measures at 50% or higher rates, covering at least 3 of the 6 NQS (National Quality Strategy) domains- including 1 cross-cutting measure
  • all 2015 PQRS data will be posted to Physician Compare website in 2016
  • 3 Examples of hospitalist applicable “cross-cutting measures” are

    • 47-advance care plan
    • 130-documentation of current medications
    • 317-preventative care: bp screening

  • PQRS data must be reported with respect to MAV clusters (Measure Applicability Validation)- reporting only measure that have no MAV cluster is a safe strategy so long as one of the measures is “cross-cutting”
  • Maximum P-VBP penalties automatically apply if group does not report enough PQRS data
  • visit CMS website for more information

HM15 Session: Putting Your Nickel Down: The What, Why, and How of Implementing Physician Value-Based Purchasing in Your Practice

Presenters: Stephen Besch, Simone Karp RPh, Patrick Torcson MD MMM SFHM, Gregory Seymann MD SFHM

Summation: HHS has set a goal of tying increasing percentages of Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements. By the end of 2018 the goal is for 50% of Medicare payments to be tied to these alternative payment models.   For the remaining traditional Medicare payment arrangements, 90% of those will be tied to quality/value incentives by 2018.

Medicare is transforming itself from a “passive payer” to an “active purchaser” of high quality, efficient healthcare. As such- active participation by physicians, physician groups, and hospitals is required for payment eligibility.

At the physician/group level, hospitalists should be reporting PQRS measures. Incentive payments for PQRS ended in 2014, Medicare is now making “negative payment adjustments.” Penalties are equal to a percentage of all Medicare Part B FFS (Fee-for-Service) charges and there is a 2-year delay between reporting or performance failure and penalization.

Physician Value-Based Purchasing (P-VBP) affects all Eligible Providers (EPs) in 2015. P4P (Pay for Performance) assesses both quality and cost. Aim is for budget neutrality via “quality tiering” which rewards “high quality/low cost” practices with penalties from “low quality/high cost” practices. As of now (2015) ACPs and therapists can be penalized under P-VBP.

Key Points/HM Takeaways:

• Hospitalists should be reporting PQRS measures- penalty phase has begun
• Key PQRS Changes for 2015:

  • 6 measures applicable to inpatient billing removed
  • no useful inpatient measures added
  • penalty avoidance requires 9 measures at 50% or higher rates, covering at least 3 of the 6 NQS (National Quality Strategy) domains- including 1 cross-cutting measure
  • all 2015 PQRS data will be posted to Physician Compare website in 2016
  • 3 Examples of hospitalist applicable “cross-cutting measures” are

    • 47-advance care plan
    • 130-documentation of current medications
    • 317-preventative care: bp screening

  • PQRS data must be reported with respect to MAV clusters (Measure Applicability Validation)- reporting only measure that have no MAV cluster is a safe strategy so long as one of the measures is “cross-cutting”
  • Maximum P-VBP penalties automatically apply if group does not report enough PQRS data
  • visit CMS website for more information

HM15 Session  RAPID FIRE PANEL: Hot Topics in Practice Management Updates on Key Issues, Including the Key Characteristics of an Effective HMG

HM15 Presenters: Roy Sittig MD SFHM, Jeffrey Frank MD MBA, Jodi Braun

Summation: Speakers covered timely topics regarding the Accountable Care Act, namely Medicaid Expansion and Bundled Payment arrangements; and reviewed the seminal paper on “Key Principals and Characteristics of an Effective Hospitalist Medicine Group” and lessons learned in implementing those 10 Key Principles.

Medicaid Expansion: EDs serving the 29 Medicaid expansion states are reporting higher volumes, likely due to 11.4million new lives now insured under the ACA. While the ACA does provide for higher Medicaid payment rates thus far, only 34% of providers accept Medicaid, a 21% drop since the ACA went into effect.

Bundled Payment Arrangements:

• Bundled Payment Care Initiative (BPCI) lexicon:

  • Model 2-Episode Anchor (anchor admission) AND 90days post d/c; Medicare pays 98% of usual cost
  • Model 3-90days post d/c AFTER anchor admission; Medicare pays 97% of usual cost
  • Convener-entity that brings providers together and enters into CMS agreement to bear risk for bundles
  • Awardee (entity having agreement with Medicare to assume risk and receive payment via BPCI) and Convener own the Bundle
  • Episode initiator (EI) triggers “bundle period”
  • Bundles based on DRG

10-Key Principles of an Effective Hospitalist Medicine Group:

1. Effective Leadership
2. Engaged Hospitalists
3. Adequate Resources
4. Planning and Management Infrastructure
5. Alignment with Hospital/Health System
6. Care Coordination Across Settings
7. Leadership in Key Clinical Issues in the Hospital/Health System
8. Thoughtful Approach to Scope of Activity
9. Patient/Family-Centered, Team-Based Care; Effective Communication
10. Recruiting/Retaining Qualified Clinicians

Key Points/HM Takeaways:

Medicaid Expansion- many of the 11.4M newly insured lives under the ACA have moved into Medicaid. Only about 1/3 of providers now accept Medicaid- 1 in 5 covered persons now have Medicaid, nearly 20% increase since 2013.

Bundled Payments- Majority of savings opportunity lies in Post-Acute Care. Awardee and Convener make profit is total cost is less than 98% of Target Price. In gainsharing agreements individuals can be reimbursed up to 150% usual Medicare rate. Pay occurs in usual Medicare fashion but is reconciled 60-90 days after end of bundle. For more information: http://innovation.cms.gov/initiatives/bundled-payments/

Effective HM Groups- Three important areas for focus when beginning to address group performance are: engaged hospitalists, planning and management infrastructure, care coordination across settings. These three topics have broad reaching implications into the hospitalist practice and patient care. [Cawley P, et al. Journal of Hospital Medicine 2014; 9(2):123-128]

HM15 Session  RAPID FIRE PANEL: Hot Topics in Practice Management Updates on Key Issues, Including the Key Characteristics of an Effective HMG

HM15 Presenters: Roy Sittig MD SFHM, Jeffrey Frank MD MBA, Jodi Braun

Summation: Speakers covered timely topics regarding the Accountable Care Act, namely Medicaid Expansion and Bundled Payment arrangements; and reviewed the seminal paper on “Key Principals and Characteristics of an Effective Hospitalist Medicine Group” and lessons learned in implementing those 10 Key Principles.

Medicaid Expansion: EDs serving the 29 Medicaid expansion states are reporting higher volumes, likely due to 11.4million new lives now insured under the ACA. While the ACA does provide for higher Medicaid payment rates thus far, only 34% of providers accept Medicaid, a 21% drop since the ACA went into effect.

Bundled Payment Arrangements:

• Bundled Payment Care Initiative (BPCI) lexicon:

  • Model 2-Episode Anchor (anchor admission) AND 90days post d/c; Medicare pays 98% of usual cost
  • Model 3-90days post d/c AFTER anchor admission; Medicare pays 97% of usual cost
  • Convener-entity that brings providers together and enters into CMS agreement to bear risk for bundles
  • Awardee (entity having agreement with Medicare to assume risk and receive payment via BPCI) and Convener own the Bundle
  • Episode initiator (EI) triggers “bundle period”
  • Bundles based on DRG

10-Key Principles of an Effective Hospitalist Medicine Group:

1. Effective Leadership
2. Engaged Hospitalists
3. Adequate Resources
4. Planning and Management Infrastructure
5. Alignment with Hospital/Health System
6. Care Coordination Across Settings
7. Leadership in Key Clinical Issues in the Hospital/Health System
8. Thoughtful Approach to Scope of Activity
9. Patient/Family-Centered, Team-Based Care; Effective Communication
10. Recruiting/Retaining Qualified Clinicians

Key Points/HM Takeaways:

Medicaid Expansion- many of the 11.4M newly insured lives under the ACA have moved into Medicaid. Only about 1/3 of providers now accept Medicaid- 1 in 5 covered persons now have Medicaid, nearly 20% increase since 2013.

Bundled Payments- Majority of savings opportunity lies in Post-Acute Care. Awardee and Convener make profit is total cost is less than 98% of Target Price. In gainsharing agreements individuals can be reimbursed up to 150% usual Medicare rate. Pay occurs in usual Medicare fashion but is reconciled 60-90 days after end of bundle. For more information: http://innovation.cms.gov/initiatives/bundled-payments/

Effective HM Groups- Three important areas for focus when beginning to address group performance are: engaged hospitalists, planning and management infrastructure, care coordination across settings. These three topics have broad reaching implications into the hospitalist practice and patient care. [Cawley P, et al. Journal of Hospital Medicine 2014; 9(2):123-128]

HM15 Session  RAPID FIRE PANEL: Hot Topics in Practice Management Updates on Key Issues, Including the Key Characteristics of an Effective HMG

HM15 Presenters: Roy Sittig MD SFHM, Jeffrey Frank MD MBA, Jodi Braun

Summation: Speakers covered timely topics regarding the Accountable Care Act, namely Medicaid Expansion and Bundled Payment arrangements; and reviewed the seminal paper on “Key Principals and Characteristics of an Effective Hospitalist Medicine Group” and lessons learned in implementing those 10 Key Principles.

Medicaid Expansion: EDs serving the 29 Medicaid expansion states are reporting higher volumes, likely due to 11.4million new lives now insured under the ACA. While the ACA does provide for higher Medicaid payment rates thus far, only 34% of providers accept Medicaid, a 21% drop since the ACA went into effect.

Bundled Payment Arrangements:

• Bundled Payment Care Initiative (BPCI) lexicon:

  • Model 2-Episode Anchor (anchor admission) AND 90days post d/c; Medicare pays 98% of usual cost
  • Model 3-90days post d/c AFTER anchor admission; Medicare pays 97% of usual cost
  • Convener-entity that brings providers together and enters into CMS agreement to bear risk for bundles
  • Awardee (entity having agreement with Medicare to assume risk and receive payment via BPCI) and Convener own the Bundle
  • Episode initiator (EI) triggers “bundle period”
  • Bundles based on DRG

10-Key Principles of an Effective Hospitalist Medicine Group:

1. Effective Leadership
2. Engaged Hospitalists
3. Adequate Resources
4. Planning and Management Infrastructure
5. Alignment with Hospital/Health System
6. Care Coordination Across Settings
7. Leadership in Key Clinical Issues in the Hospital/Health System
8. Thoughtful Approach to Scope of Activity
9. Patient/Family-Centered, Team-Based Care; Effective Communication
10. Recruiting/Retaining Qualified Clinicians

Key Points/HM Takeaways:

Medicaid Expansion- many of the 11.4M newly insured lives under the ACA have moved into Medicaid. Only about 1/3 of providers now accept Medicaid- 1 in 5 covered persons now have Medicaid, nearly 20% increase since 2013.

Bundled Payments- Majority of savings opportunity lies in Post-Acute Care. Awardee and Convener make profit is total cost is less than 98% of Target Price. In gainsharing agreements individuals can be reimbursed up to 150% usual Medicare rate. Pay occurs in usual Medicare fashion but is reconciled 60-90 days after end of bundle. For more information: http://innovation.cms.gov/initiatives/bundled-payments/

Effective HM Groups- Three important areas for focus when beginning to address group performance are: engaged hospitalists, planning and management infrastructure, care coordination across settings. These three topics have broad reaching implications into the hospitalist practice and patient care. [Cawley P, et al. Journal of Hospital Medicine 2014; 9(2):123-128]

In the article “Common Coding Mistakes Hospitalists Should Avoid” in the August 2014 issue of The Hospitalist, the author states:

“For inpatient care, an established problem is defined as one in which a care plan has been generated by the physician (or same specialty group practice member) during the current hospitalization.”

This definition contradicts what I have been told in other coding courses regarding new vs. established problems relative to the examiner. It has been my understanding that when [I am] rotating on service and I have not seen that particular patient during the current admission, all of the current problems are new to me, even if previously identified by another member of my group. This [situation] results in a higher complexity of medical decision-making, which is reflective of the increased time spent learning a new patient when coming on service. I would appreciate clarification from the author.

–Matt George, MD,

medical director, MBHS Hospitalists

Billing and coding expert Carol Pohlig, BSN, RN, CPC, ACS, explains:

Be mindful when attending coding courses that are not contractor sponsored, as they may not validate the geographical interpretations of the rules for providers. There are several factors to consider when crediting the physician with “new” or “established” problems.

CMS documentation guidelines state: “Decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem.¹

• For a presenting problem with an established diagnosis, the record should reflect whether the problem is:

  • Improved, well-controlled, resolving, or resolved or
  • Inadequately controlled, worsening, or failing to change as expected.

• For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of differential diagnoses or as a “possible,” “probable,” or “rule out” diagnosis.

Although Medicare contractors utilize the Marshfield Clinic Scoring Tool when reviewing evaluation and management (E/M) services, a tool that historically refers to the “examiner” when considering the patient’s diagnoses, not all accept this tool-inspired standard, particularly in the advent of electronic health record accessibility and the idea that same-specialty physicians in a group practice are viewed as an individual physician.^2,3

Reviewing information and familiarization of patients is often considered pre-service work and factored into the payment for E/M services. More importantly, the feasibility of an auditor being able to distinguish new vs. established problems at the level of the “examiner” is decreased when auditing a single date of service. Non-Medicare payers who audit E/M services do not necessarily follow contractor-specific guidelines but, rather, general CMS guidelines.

Therefore, without knowing the insurer or their interpretation at the time of service or visit level selection, the CMS-developed standard is the most practical application when considering the complexity of the encounter.

References

1. Centers for Medicare and Medicaid Services. Department of Health and Human Services. Evaluation and management services guide. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads//eval_mgmt_serv_guide-ICN006764.pdf. Accessed November 13, 2014.
2. National Government Services. Evaluation and management documentation training too. Available at: http://www.ngsmedicare.com/ngs/wcm/connect/3632a905-b697-4266-8fc0-2aa2a84fedb2/1074_0514_EM_Documentation_Training_Tool_508.pdf?MOD=AJPERES. Accessed November 13, 2014.
3. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual. Chapter 12 – Physicians/nonphysician practitioners. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed November 13, 2014.

In the article “Common Coding Mistakes Hospitalists Should Avoid” in the August 2014 issue of The Hospitalist, the author states:

“For inpatient care, an established problem is defined as one in which a care plan has been generated by the physician (or same specialty group practice member) during the current hospitalization.”

This definition contradicts what I have been told in other coding courses regarding new vs. established problems relative to the examiner. It has been my understanding that when [I am] rotating on service and I have not seen that particular patient during the current admission, all of the current problems are new to me, even if previously identified by another member of my group. This [situation] results in a higher complexity of medical decision-making, which is reflective of the increased time spent learning a new patient when coming on service. I would appreciate clarification from the author.

–Matt George, MD,

medical director, MBHS Hospitalists

Billing and coding expert Carol Pohlig, BSN, RN, CPC, ACS, explains:

Be mindful when attending coding courses that are not contractor sponsored, as they may not validate the geographical interpretations of the rules for providers. There are several factors to consider when crediting the physician with “new” or “established” problems.

CMS documentation guidelines state: “Decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem.¹

• For a presenting problem with an established diagnosis, the record should reflect whether the problem is:

  • Improved, well-controlled, resolving, or resolved or
  • Inadequately controlled, worsening, or failing to change as expected.

• For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of differential diagnoses or as a “possible,” “probable,” or “rule out” diagnosis.

Although Medicare contractors utilize the Marshfield Clinic Scoring Tool when reviewing evaluation and management (E/M) services, a tool that historically refers to the “examiner” when considering the patient’s diagnoses, not all accept this tool-inspired standard, particularly in the advent of electronic health record accessibility and the idea that same-specialty physicians in a group practice are viewed as an individual physician.^2,3

Reviewing information and familiarization of patients is often considered pre-service work and factored into the payment for E/M services. More importantly, the feasibility of an auditor being able to distinguish new vs. established problems at the level of the “examiner” is decreased when auditing a single date of service. Non-Medicare payers who audit E/M services do not necessarily follow contractor-specific guidelines but, rather, general CMS guidelines.

Therefore, without knowing the insurer or their interpretation at the time of service or visit level selection, the CMS-developed standard is the most practical application when considering the complexity of the encounter.

References

1. Centers for Medicare and Medicaid Services. Department of Health and Human Services. Evaluation and management services guide. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads//eval_mgmt_serv_guide-ICN006764.pdf. Accessed November 13, 2014.
2. National Government Services. Evaluation and management documentation training too. Available at: http://www.ngsmedicare.com/ngs/wcm/connect/3632a905-b697-4266-8fc0-2aa2a84fedb2/1074_0514_EM_Documentation_Training_Tool_508.pdf?MOD=AJPERES. Accessed November 13, 2014.
3. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual. Chapter 12 – Physicians/nonphysician practitioners. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed November 13, 2014.

In the article “Common Coding Mistakes Hospitalists Should Avoid” in the August 2014 issue of The Hospitalist, the author states:

“For inpatient care, an established problem is defined as one in which a care plan has been generated by the physician (or same specialty group practice member) during the current hospitalization.”

This definition contradicts what I have been told in other coding courses regarding new vs. established problems relative to the examiner. It has been my understanding that when [I am] rotating on service and I have not seen that particular patient during the current admission, all of the current problems are new to me, even if previously identified by another member of my group. This [situation] results in a higher complexity of medical decision-making, which is reflective of the increased time spent learning a new patient when coming on service. I would appreciate clarification from the author.

–Matt George, MD,

medical director, MBHS Hospitalists

Billing and coding expert Carol Pohlig, BSN, RN, CPC, ACS, explains:

Be mindful when attending coding courses that are not contractor sponsored, as they may not validate the geographical interpretations of the rules for providers. There are several factors to consider when crediting the physician with “new” or “established” problems.

CMS documentation guidelines state: “Decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem.¹

• For a presenting problem with an established diagnosis, the record should reflect whether the problem is:

  • Improved, well-controlled, resolving, or resolved or
  • Inadequately controlled, worsening, or failing to change as expected.

• For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of differential diagnoses or as a “possible,” “probable,” or “rule out” diagnosis.

Although Medicare contractors utilize the Marshfield Clinic Scoring Tool when reviewing evaluation and management (E/M) services, a tool that historically refers to the “examiner” when considering the patient’s diagnoses, not all accept this tool-inspired standard, particularly in the advent of electronic health record accessibility and the idea that same-specialty physicians in a group practice are viewed as an individual physician.^2,3

Reviewing information and familiarization of patients is often considered pre-service work and factored into the payment for E/M services. More importantly, the feasibility of an auditor being able to distinguish new vs. established problems at the level of the “examiner” is decreased when auditing a single date of service. Non-Medicare payers who audit E/M services do not necessarily follow contractor-specific guidelines but, rather, general CMS guidelines.

Therefore, without knowing the insurer or their interpretation at the time of service or visit level selection, the CMS-developed standard is the most practical application when considering the complexity of the encounter.

References

1. Centers for Medicare and Medicaid Services. Department of Health and Human Services. Evaluation and management services guide. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads//eval_mgmt_serv_guide-ICN006764.pdf. Accessed November 13, 2014.
2. National Government Services. Evaluation and management documentation training too. Available at: http://www.ngsmedicare.com/ngs/wcm/connect/3632a905-b697-4266-8fc0-2aa2a84fedb2/1074_0514_EM_Documentation_Training_Tool_508.pdf?MOD=AJPERES. Accessed November 13, 2014.
3. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual. Chapter 12 – Physicians/nonphysician practitioners. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed November 13, 2014.

A team that could respond quickly to social and behavioral concerns—and not medical issues per se—would have tremendous benefits for patients and caregivers.

I think there has been a steady increase, over the last 20 years or so, in the number of very unhappy, angry, or misbehaving patients (e.g. abusive/threatening to staff). In some cases, the hospital and caregivers have failed the patient. In other cases, their frustration arises out of things outside the hospital’s direct control, such as Medicare observation status, or perhaps the patient or family is just unreasonable or suffering from a psychiatric or substance abuse disorder.

I’m not talking about the common occurrence of a disappointed patient or family who might calmly complain about something. Instead, I want to focus on those patients who, whether we perceive them as justifiably unhappy or not, are so angry that they become very time consuming and distressing to deal with. Maybe they shout about how their lawyer will be suing us and the newspaper will be writing a story about how awful we are. Or they shout and throw things, and staff become afraid of them.

In my May 2013 column, I discussed care plans for patients like this who are admitted frequently, but such plans are not sufficient in every case.

A Haphazard Approach

Most hospitals have an informal process of dealing with these patients; it starts with the bedside nurse and/or doctor trying to apologize or make adjustments to satisfy and calm the patient. If that fails, then perhaps the manager of the nursing unit gets involved. Others may be recruited, such as someone from the hospital’s risk management or “patient advocate” departments and hospital executives such as the CNO, CMO, or CEO. Sometimes several of these people may meet as a group in an effort to come up with a plan to address the situation. But, most institutions do not have a clear and consistent approach to this important work, so the hospital personnel involved end up “reinventing the wheel” each time.

The growing awareness that hospital personnel don’t seem to have a robust and confident approach to addressing this type of situation can increase a patient’s distress, and it may embolden some to become even more demanding or threatening.

And all of this takes a significant toll on bedside caregivers, who often spend so much time dealing with the angry patient that they have less time to devote to other patients, who are in turn at least a little more likely to become unhappy or suffer as a result of a distressed and busy caregiver.

A Consistent Approach: RRT for Non-Medical Distress

I think the potential benefit for patients and caregivers is significant enough that hospitals should develop a standardized approach to managing such patients, and rapid response teams (RRTs) could serve as a model. To be clear, I’m not advocating that RRTs add management of very angry or distressed patients to their current role. Let’s call it an “RRT for non-medical distress.” And, while I think it is a worthwhile idea, and I am in the early steps of trying to develop it at “my” hospital, I’m not aware of any such team in place anywhere now.

To make it practical, I think this team should be available only during weekday business hours and would comprise something like six to 10 people with clinical backgrounds who do mostly administrative work. For example, the team members could include two nursing unit directors, a risk manager, a patient advocate (or patient satisfaction “czar”), a psychiatrist, the hospitalist medical director, the chief medical officer, and a few other individuals selected for their communication skills.

 

One of the team members would be on call for a day or week at a time and would carry the team’s pager during business hours. Any hospital caregiver could send a page requesting the team’s assistance, and the on-call team member would respond immediately by phone or, if possible, in person. After the on-call team member’s initial assessment, the whole team would meet later the same day or early the next day. On most days, a few members of the team would be off and unable to attend the meeting. So, if the team has eight members, each meeting of the team might average about five participants.

Non-Medical Distress RRT Processes

When meeting to establish a plan for addressing an extraordinarily distressed patient/family, the team should follow a standardized written approach. A designated person should lead the conversation—perhaps the on-call team member who responded first—and another should take notes. Using a form developed for this purpose, the note-taker would capture a standardized data set that is likely to be useful in determining a course of action, as well as valuable in helping the team fine-tune its approach by reviewing trends in aggregate data. The form might include things like patient demographics; the patient’s complaints and demands; potential complicating patient issues such as substance abuse, psychoactive drugs, or psychiatric history; location in the hospital; and names of bedside caregivers. Every effort should be made to keep the meetings efficient and as brief as practical—typically 30-60 minutes.

I’m convinced that when deciding how to respond to the situation, the team should try to limit itself to choosing one or more of eight to 10 standard interventions, rather than aiming for an entirely customized response in every case. Among the standardized interventions:

• Service recovery tools, such as a handwritten apology letter;
• A meeting between the patient/family and the hospital CEO or CMO;
• Security guard(s) at the door, on “high alert” to help if called; or
• A behavioral contract specifying the expectations for both patient and hospital staff behavior.

You might think of additional “tools” this team could have in their standardized response set.

Why limit the team as much as possible to a small set of standardized interventions? Developing customized responses in each situation is time consuming and, arguably, has a higher risk of failure, since it will be difficult to ensure that all staff caring for the patient can understand and execute them effectively. And the small set of interventions will make it easier to track their effectiveness over multiple patients so that the whole process can be improved over time.

Set a High Bar

The team should not be activated for every unhappy or difficult patient; that would be overkill and would result in many activations requiring dedicated staff with no other duties to serve on the team each day. Instead, I think the team should be activated only for the most difficult and distressing cases, at least for the first few years. In a 300-bed hospital, this would be approximately one to 1.5 activations per week.

Bedside caregivers would likely feel some reassurance knowing that they can reliably get help managing the most difficult patients, and, if the plan is executed well, these patients may get care that is safer for both themselves and staff. Who knows, medical outcomes might be improved for these patients also.

---

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

A team that could respond quickly to social and behavioral concerns—and not medical issues per se—would have tremendous benefits for patients and caregivers.

I think there has been a steady increase, over the last 20 years or so, in the number of very unhappy, angry, or misbehaving patients (e.g. abusive/threatening to staff). In some cases, the hospital and caregivers have failed the patient. In other cases, their frustration arises out of things outside the hospital’s direct control, such as Medicare observation status, or perhaps the patient or family is just unreasonable or suffering from a psychiatric or substance abuse disorder.

I’m not talking about the common occurrence of a disappointed patient or family who might calmly complain about something. Instead, I want to focus on those patients who, whether we perceive them as justifiably unhappy or not, are so angry that they become very time consuming and distressing to deal with. Maybe they shout about how their lawyer will be suing us and the newspaper will be writing a story about how awful we are. Or they shout and throw things, and staff become afraid of them.

In my May 2013 column, I discussed care plans for patients like this who are admitted frequently, but such plans are not sufficient in every case.

A Haphazard Approach

Most hospitals have an informal process of dealing with these patients; it starts with the bedside nurse and/or doctor trying to apologize or make adjustments to satisfy and calm the patient. If that fails, then perhaps the manager of the nursing unit gets involved. Others may be recruited, such as someone from the hospital’s risk management or “patient advocate” departments and hospital executives such as the CNO, CMO, or CEO. Sometimes several of these people may meet as a group in an effort to come up with a plan to address the situation. But, most institutions do not have a clear and consistent approach to this important work, so the hospital personnel involved end up “reinventing the wheel” each time.

The growing awareness that hospital personnel don’t seem to have a robust and confident approach to addressing this type of situation can increase a patient’s distress, and it may embolden some to become even more demanding or threatening.

And all of this takes a significant toll on bedside caregivers, who often spend so much time dealing with the angry patient that they have less time to devote to other patients, who are in turn at least a little more likely to become unhappy or suffer as a result of a distressed and busy caregiver.

A Consistent Approach: RRT for Non-Medical Distress

I think the potential benefit for patients and caregivers is significant enough that hospitals should develop a standardized approach to managing such patients, and rapid response teams (RRTs) could serve as a model. To be clear, I’m not advocating that RRTs add management of very angry or distressed patients to their current role. Let’s call it an “RRT for non-medical distress.” And, while I think it is a worthwhile idea, and I am in the early steps of trying to develop it at “my” hospital, I’m not aware of any such team in place anywhere now.

To make it practical, I think this team should be available only during weekday business hours and would comprise something like six to 10 people with clinical backgrounds who do mostly administrative work. For example, the team members could include two nursing unit directors, a risk manager, a patient advocate (or patient satisfaction “czar”), a psychiatrist, the hospitalist medical director, the chief medical officer, and a few other individuals selected for their communication skills.

 

One of the team members would be on call for a day or week at a time and would carry the team’s pager during business hours. Any hospital caregiver could send a page requesting the team’s assistance, and the on-call team member would respond immediately by phone or, if possible, in person. After the on-call team member’s initial assessment, the whole team would meet later the same day or early the next day. On most days, a few members of the team would be off and unable to attend the meeting. So, if the team has eight members, each meeting of the team might average about five participants.

Non-Medical Distress RRT Processes

When meeting to establish a plan for addressing an extraordinarily distressed patient/family, the team should follow a standardized written approach. A designated person should lead the conversation—perhaps the on-call team member who responded first—and another should take notes. Using a form developed for this purpose, the note-taker would capture a standardized data set that is likely to be useful in determining a course of action, as well as valuable in helping the team fine-tune its approach by reviewing trends in aggregate data. The form might include things like patient demographics; the patient’s complaints and demands; potential complicating patient issues such as substance abuse, psychoactive drugs, or psychiatric history; location in the hospital; and names of bedside caregivers. Every effort should be made to keep the meetings efficient and as brief as practical—typically 30-60 minutes.

I’m convinced that when deciding how to respond to the situation, the team should try to limit itself to choosing one or more of eight to 10 standard interventions, rather than aiming for an entirely customized response in every case. Among the standardized interventions:

• Service recovery tools, such as a handwritten apology letter;
• A meeting between the patient/family and the hospital CEO or CMO;
• Security guard(s) at the door, on “high alert” to help if called; or
• A behavioral contract specifying the expectations for both patient and hospital staff behavior.

You might think of additional “tools” this team could have in their standardized response set.

Why limit the team as much as possible to a small set of standardized interventions? Developing customized responses in each situation is time consuming and, arguably, has a higher risk of failure, since it will be difficult to ensure that all staff caring for the patient can understand and execute them effectively. And the small set of interventions will make it easier to track their effectiveness over multiple patients so that the whole process can be improved over time.

Set a High Bar

The team should not be activated for every unhappy or difficult patient; that would be overkill and would result in many activations requiring dedicated staff with no other duties to serve on the team each day. Instead, I think the team should be activated only for the most difficult and distressing cases, at least for the first few years. In a 300-bed hospital, this would be approximately one to 1.5 activations per week.

Bedside caregivers would likely feel some reassurance knowing that they can reliably get help managing the most difficult patients, and, if the plan is executed well, these patients may get care that is safer for both themselves and staff. Who knows, medical outcomes might be improved for these patients also.

---

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

A team that could respond quickly to social and behavioral concerns—and not medical issues per se—would have tremendous benefits for patients and caregivers.

I think there has been a steady increase, over the last 20 years or so, in the number of very unhappy, angry, or misbehaving patients (e.g. abusive/threatening to staff). In some cases, the hospital and caregivers have failed the patient. In other cases, their frustration arises out of things outside the hospital’s direct control, such as Medicare observation status, or perhaps the patient or family is just unreasonable or suffering from a psychiatric or substance abuse disorder.

I’m not talking about the common occurrence of a disappointed patient or family who might calmly complain about something. Instead, I want to focus on those patients who, whether we perceive them as justifiably unhappy or not, are so angry that they become very time consuming and distressing to deal with. Maybe they shout about how their lawyer will be suing us and the newspaper will be writing a story about how awful we are. Or they shout and throw things, and staff become afraid of them.

In my May 2013 column, I discussed care plans for patients like this who are admitted frequently, but such plans are not sufficient in every case.

A Haphazard Approach

Most hospitals have an informal process of dealing with these patients; it starts with the bedside nurse and/or doctor trying to apologize or make adjustments to satisfy and calm the patient. If that fails, then perhaps the manager of the nursing unit gets involved. Others may be recruited, such as someone from the hospital’s risk management or “patient advocate” departments and hospital executives such as the CNO, CMO, or CEO. Sometimes several of these people may meet as a group in an effort to come up with a plan to address the situation. But, most institutions do not have a clear and consistent approach to this important work, so the hospital personnel involved end up “reinventing the wheel” each time.

The growing awareness that hospital personnel don’t seem to have a robust and confident approach to addressing this type of situation can increase a patient’s distress, and it may embolden some to become even more demanding or threatening.

And all of this takes a significant toll on bedside caregivers, who often spend so much time dealing with the angry patient that they have less time to devote to other patients, who are in turn at least a little more likely to become unhappy or suffer as a result of a distressed and busy caregiver.

A Consistent Approach: RRT for Non-Medical Distress

I think the potential benefit for patients and caregivers is significant enough that hospitals should develop a standardized approach to managing such patients, and rapid response teams (RRTs) could serve as a model. To be clear, I’m not advocating that RRTs add management of very angry or distressed patients to their current role. Let’s call it an “RRT for non-medical distress.” And, while I think it is a worthwhile idea, and I am in the early steps of trying to develop it at “my” hospital, I’m not aware of any such team in place anywhere now.

To make it practical, I think this team should be available only during weekday business hours and would comprise something like six to 10 people with clinical backgrounds who do mostly administrative work. For example, the team members could include two nursing unit directors, a risk manager, a patient advocate (or patient satisfaction “czar”), a psychiatrist, the hospitalist medical director, the chief medical officer, and a few other individuals selected for their communication skills.

 

One of the team members would be on call for a day or week at a time and would carry the team’s pager during business hours. Any hospital caregiver could send a page requesting the team’s assistance, and the on-call team member would respond immediately by phone or, if possible, in person. After the on-call team member’s initial assessment, the whole team would meet later the same day or early the next day. On most days, a few members of the team would be off and unable to attend the meeting. So, if the team has eight members, each meeting of the team might average about five participants.

Non-Medical Distress RRT Processes

When meeting to establish a plan for addressing an extraordinarily distressed patient/family, the team should follow a standardized written approach. A designated person should lead the conversation—perhaps the on-call team member who responded first—and another should take notes. Using a form developed for this purpose, the note-taker would capture a standardized data set that is likely to be useful in determining a course of action, as well as valuable in helping the team fine-tune its approach by reviewing trends in aggregate data. The form might include things like patient demographics; the patient’s complaints and demands; potential complicating patient issues such as substance abuse, psychoactive drugs, or psychiatric history; location in the hospital; and names of bedside caregivers. Every effort should be made to keep the meetings efficient and as brief as practical—typically 30-60 minutes.

I’m convinced that when deciding how to respond to the situation, the team should try to limit itself to choosing one or more of eight to 10 standard interventions, rather than aiming for an entirely customized response in every case. Among the standardized interventions:

• Service recovery tools, such as a handwritten apology letter;
• A meeting between the patient/family and the hospital CEO or CMO;
• Security guard(s) at the door, on “high alert” to help if called; or
• A behavioral contract specifying the expectations for both patient and hospital staff behavior.

You might think of additional “tools” this team could have in their standardized response set.

Why limit the team as much as possible to a small set of standardized interventions? Developing customized responses in each situation is time consuming and, arguably, has a higher risk of failure, since it will be difficult to ensure that all staff caring for the patient can understand and execute them effectively. And the small set of interventions will make it easier to track their effectiveness over multiple patients so that the whole process can be improved over time.

Set a High Bar

The team should not be activated for every unhappy or difficult patient; that would be overkill and would result in many activations requiring dedicated staff with no other duties to serve on the team each day. Instead, I think the team should be activated only for the most difficult and distressing cases, at least for the first few years. In a 300-bed hospital, this would be approximately one to 1.5 activations per week.

Bedside caregivers would likely feel some reassurance knowing that they can reliably get help managing the most difficult patients, and, if the plan is executed well, these patients may get care that is safer for both themselves and staff. Who knows, medical outcomes might be improved for these patients also.

---

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

Hospital medicine leaders have long acknowledged the disconnects in medical care that occur at discharge. The demand for greater efficiency in hospital-based care is what has driven the hospitalist movement and its inexorable growth the past two decades.

Efforts to overcome discontinuity of care have included more timely discharge summaries, phone calls to primary care physicians (PCPs) and specialists at the time of discharge, and hospitalist-staffed post-discharge clinics. In a 2002 article, Robert Wachter, MD, MHM, and Steven Pantilat, MD, SFHM, of the University of California San Francisco (UCSF), suggested that PCPs make continuity visits to the hospital once or twice to maintain their involvement and help coordinate the care of their patients.¹

A new “Perspectives” piece in The New England Journal of Medicine proposes that PCPs act as medical consultants to the hospitalist team while their patients are in the hospital, making a consulting visit “within 12 to 18 hours after admission to provide support and continuity to them and their families.”² Authors Allan Goroll, MD, MACP, and Daniel Hunt, MD, propose that the PCP be asked to write a succinct consultation note in the hospital chart, highlighting key elements of the patient’s history and recent tests—with the goal of complementing and informing the hospitalist’s admission workup and care plan—while being paid as a consultant.

“It’s a fairly straightforward proposal,” says Dr. Hunt, chief of the hospital medicine unit at Massachusetts General Hospital (MGH) in Boston. “We’re not looking for PCPs to take care of every aspect of inpatient care. It’s really just to bring in the PCP’s expertise and nuanced understanding of the patient at a vulnerable time for the patient.”

The idea might seem a little ironic given the fact that hospitalists were created in part to relieve busy PCPs from having to visit the hospital. But some see it as a way forward.

“I wouldn’t call it a step backward,” says Joseph Ming Wah Li, MD, SFHM, FACP, director of the hospital medicine program at Beth Israel Deaconess Medical Center (BIDMC) in Boston and a former SHM president. “Is it feasible? Realistically, in most settings today, I don’t think it is. But I would love it. I don’t really know enough about the patients I take care of in the hospital.”

The Barrier of “Not Enough Time”

Dr. Hunt says the biggest barrier to this proposal is the time that PCPs would have to carve out to make physical trips to the hospital.

“That ultimately comes down to reimbursement,” he says.

MGH, which is well situated with medical practices in or near the main hospital building, has piloted an approach similar to the NEJM proposal with a primary care group that comes in to see its patients in the first day or two after admission and then again on the day before discharge.

“But they are essentially doing it out of the goodness of their hearts,” Dr. Hunt explains. “What we’ve seen from this experiment are much better transitions of care and much better decision making around big decisions, such as end-of-life care or surgical interventions.”

Hospitalists at MGH and the PCPs spent a year and a half talking through the specifics of how their arrangement would work.

 

“We made a commitment, as hospitalists, to communicate directly by phone with the PCPs,” he says. “That commitment lasted about a week, and then we quickly converted to a daily e-mail. That works, because both parties are communicating substantial information in these e-mails.”

Dr. Hunt says the key is recognizing the “huge” value PCPs bring to an inpatient stay. And, while physical trips to the hospital or e-mails might not work for every hospitalist or PCP, the connecting of information and insight is often worth the investment.

“There are other ways [to communicate], such as video conferencing and Skype, where doctors could participate more efficiently in the care of their hospitalized patients,” he says, adding that hospitalists should reach out to PCPs, both when a patient enters the hospital and as part of a larger discussion about how to improve communication and continuity of care.

The PCP Perspective

Boston internist Gila Kriegel, MD, might seem like a throwback. She says she wants to visit her patients when they are in the hospital, if at all possible. In fact, hospitalists in Boston say Dr. Kriegel allows them to take care of her patients “almost begrudgingly.”

“She is so involved in their care,” Dr. Li says. “She tells me everything I need to know about them. She’d be here every day if she weren’t juggling other responsibilities.”

A PCP since 1986, Dr. Kriegel’s story illustrates the complexities of an evolving healthcare system. She’s based in an academic setting, which she calls a “kind of ivory tower.”

“But I was fortunate in 1989, after my first son was born and I went part-time, to have a colleague who offered to see my inpatients on the days I wasn’t working,” she explains. “Then a woman colleague of mine also went part-time, and we agreed to cross-cover for each other.”

Eventually, Dr. Kriegel was approached by Dr. Li’s hospitalist group, which offered to manage her hospitalized patients.

“For the first six months to a year, I’d go see my patients in the hospital on a social visit. I’d even write notes in the chart, until they told me, ‘You are not responsible for the care in the hospital. The hospitalist is,’” she recalls. “For me, it was a big loss to stop going to the hospital. Most PCPs I know like seeing their patients through the course of the illness.”

Then again, she also admits how difficult it is to see her patients in the hospital.

Still, she managed to stay connected. “When I stopped going to see my patients, I asked the hospital staff to give me the patient’s bedside phone number, and I’d call them in the hospital to let them know I was up on what was happening,” she says.

Technology, coincidentally, inserted a barrier: She wasn’t able to access hospitalists’ daily notes in the BIDMC electronic health records. That’s when Dr. Kriegel began e-mailing the hospitalists. In the end, even that form of communication wasn’t fully satisfying.

“The current system requires me to do the outreach,” she explains. “If you ask hospitalists about communication, they’d say they’re already doing it. But a discharge summary isn’t the same as knowing in real time what’s happening with my patients.”

“I’d love to make virtual visits to the patient in the hospital, by phone or computer link—even more so if I could get paid for my time. But I want to stay involved.”

Ripe for Innovation

Dr. Wachter, chief of hospital medicine at UCSF, who writes an HM-focused blog [wachtersworld.com], says the continuity visit is a good idea but also understands the difficulties in the new healthcare paradigm.

 

“It’s not easy to work out the logistics, and it depends on the geography,” he says. “We also need to be considering telemedicine. But something to enhance continuity is ripe for innovation.”

He says consultation or continuity visits offer ways to improve care with a relatively small expenditure.

“We still see a few PCPs come in when their patients are hospitalized. It’s very reassuring to their patients,” he says. “For the complicated cases where an ongoing relationship matters, those encounters are fabulous.”

---

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Goroll AH, Hunt DP. Bridging the hospitalist-primary care divide through collaborative care. New Engl J Med. 2015;372(4):308-309.
2. Wachter RM, Pantilat SZ. The “continuity visit” and the hospitalist model of care. Dis Mon. 2002;48(4):267-272.

Hospital medicine leaders have long acknowledged the disconnects in medical care that occur at discharge. The demand for greater efficiency in hospital-based care is what has driven the hospitalist movement and its inexorable growth the past two decades.

Efforts to overcome discontinuity of care have included more timely discharge summaries, phone calls to primary care physicians (PCPs) and specialists at the time of discharge, and hospitalist-staffed post-discharge clinics. In a 2002 article, Robert Wachter, MD, MHM, and Steven Pantilat, MD, SFHM, of the University of California San Francisco (UCSF), suggested that PCPs make continuity visits to the hospital once or twice to maintain their involvement and help coordinate the care of their patients.¹

A new “Perspectives” piece in The New England Journal of Medicine proposes that PCPs act as medical consultants to the hospitalist team while their patients are in the hospital, making a consulting visit “within 12 to 18 hours after admission to provide support and continuity to them and their families.”² Authors Allan Goroll, MD, MACP, and Daniel Hunt, MD, propose that the PCP be asked to write a succinct consultation note in the hospital chart, highlighting key elements of the patient’s history and recent tests—with the goal of complementing and informing the hospitalist’s admission workup and care plan—while being paid as a consultant.

“It’s a fairly straightforward proposal,” says Dr. Hunt, chief of the hospital medicine unit at Massachusetts General Hospital (MGH) in Boston. “We’re not looking for PCPs to take care of every aspect of inpatient care. It’s really just to bring in the PCP’s expertise and nuanced understanding of the patient at a vulnerable time for the patient.”

The idea might seem a little ironic given the fact that hospitalists were created in part to relieve busy PCPs from having to visit the hospital. But some see it as a way forward.

“I wouldn’t call it a step backward,” says Joseph Ming Wah Li, MD, SFHM, FACP, director of the hospital medicine program at Beth Israel Deaconess Medical Center (BIDMC) in Boston and a former SHM president. “Is it feasible? Realistically, in most settings today, I don’t think it is. But I would love it. I don’t really know enough about the patients I take care of in the hospital.”

The Barrier of “Not Enough Time”

Dr. Hunt says the biggest barrier to this proposal is the time that PCPs would have to carve out to make physical trips to the hospital.

“That ultimately comes down to reimbursement,” he says.

MGH, which is well situated with medical practices in or near the main hospital building, has piloted an approach similar to the NEJM proposal with a primary care group that comes in to see its patients in the first day or two after admission and then again on the day before discharge.

“But they are essentially doing it out of the goodness of their hearts,” Dr. Hunt explains. “What we’ve seen from this experiment are much better transitions of care and much better decision making around big decisions, such as end-of-life care or surgical interventions.”

Hospitalists at MGH and the PCPs spent a year and a half talking through the specifics of how their arrangement would work.

 

“We made a commitment, as hospitalists, to communicate directly by phone with the PCPs,” he says. “That commitment lasted about a week, and then we quickly converted to a daily e-mail. That works, because both parties are communicating substantial information in these e-mails.”

Dr. Hunt says the key is recognizing the “huge” value PCPs bring to an inpatient stay. And, while physical trips to the hospital or e-mails might not work for every hospitalist or PCP, the connecting of information and insight is often worth the investment.

“There are other ways [to communicate], such as video conferencing and Skype, where doctors could participate more efficiently in the care of their hospitalized patients,” he says, adding that hospitalists should reach out to PCPs, both when a patient enters the hospital and as part of a larger discussion about how to improve communication and continuity of care.

The PCP Perspective

Boston internist Gila Kriegel, MD, might seem like a throwback. She says she wants to visit her patients when they are in the hospital, if at all possible. In fact, hospitalists in Boston say Dr. Kriegel allows them to take care of her patients “almost begrudgingly.”

“She is so involved in their care,” Dr. Li says. “She tells me everything I need to know about them. She’d be here every day if she weren’t juggling other responsibilities.”

A PCP since 1986, Dr. Kriegel’s story illustrates the complexities of an evolving healthcare system. She’s based in an academic setting, which she calls a “kind of ivory tower.”

“But I was fortunate in 1989, after my first son was born and I went part-time, to have a colleague who offered to see my inpatients on the days I wasn’t working,” she explains. “Then a woman colleague of mine also went part-time, and we agreed to cross-cover for each other.”

Eventually, Dr. Kriegel was approached by Dr. Li’s hospitalist group, which offered to manage her hospitalized patients.

“For the first six months to a year, I’d go see my patients in the hospital on a social visit. I’d even write notes in the chart, until they told me, ‘You are not responsible for the care in the hospital. The hospitalist is,’” she recalls. “For me, it was a big loss to stop going to the hospital. Most PCPs I know like seeing their patients through the course of the illness.”

Then again, she also admits how difficult it is to see her patients in the hospital.

Still, she managed to stay connected. “When I stopped going to see my patients, I asked the hospital staff to give me the patient’s bedside phone number, and I’d call them in the hospital to let them know I was up on what was happening,” she says.

Technology, coincidentally, inserted a barrier: She wasn’t able to access hospitalists’ daily notes in the BIDMC electronic health records. That’s when Dr. Kriegel began e-mailing the hospitalists. In the end, even that form of communication wasn’t fully satisfying.

“The current system requires me to do the outreach,” she explains. “If you ask hospitalists about communication, they’d say they’re already doing it. But a discharge summary isn’t the same as knowing in real time what’s happening with my patients.”

“I’d love to make virtual visits to the patient in the hospital, by phone or computer link—even more so if I could get paid for my time. But I want to stay involved.”

Ripe for Innovation

Dr. Wachter, chief of hospital medicine at UCSF, who writes an HM-focused blog [wachtersworld.com], says the continuity visit is a good idea but also understands the difficulties in the new healthcare paradigm.

 

“It’s not easy to work out the logistics, and it depends on the geography,” he says. “We also need to be considering telemedicine. But something to enhance continuity is ripe for innovation.”

He says consultation or continuity visits offer ways to improve care with a relatively small expenditure.

“We still see a few PCPs come in when their patients are hospitalized. It’s very reassuring to their patients,” he says. “For the complicated cases where an ongoing relationship matters, those encounters are fabulous.”

---

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Goroll AH, Hunt DP. Bridging the hospitalist-primary care divide through collaborative care. New Engl J Med. 2015;372(4):308-309.
2. Wachter RM, Pantilat SZ. The “continuity visit” and the hospitalist model of care. Dis Mon. 2002;48(4):267-272.

Hospital medicine leaders have long acknowledged the disconnects in medical care that occur at discharge. The demand for greater efficiency in hospital-based care is what has driven the hospitalist movement and its inexorable growth the past two decades.

Efforts to overcome discontinuity of care have included more timely discharge summaries, phone calls to primary care physicians (PCPs) and specialists at the time of discharge, and hospitalist-staffed post-discharge clinics. In a 2002 article, Robert Wachter, MD, MHM, and Steven Pantilat, MD, SFHM, of the University of California San Francisco (UCSF), suggested that PCPs make continuity visits to the hospital once or twice to maintain their involvement and help coordinate the care of their patients.¹

A new “Perspectives” piece in The New England Journal of Medicine proposes that PCPs act as medical consultants to the hospitalist team while their patients are in the hospital, making a consulting visit “within 12 to 18 hours after admission to provide support and continuity to them and their families.”² Authors Allan Goroll, MD, MACP, and Daniel Hunt, MD, propose that the PCP be asked to write a succinct consultation note in the hospital chart, highlighting key elements of the patient’s history and recent tests—with the goal of complementing and informing the hospitalist’s admission workup and care plan—while being paid as a consultant.

“It’s a fairly straightforward proposal,” says Dr. Hunt, chief of the hospital medicine unit at Massachusetts General Hospital (MGH) in Boston. “We’re not looking for PCPs to take care of every aspect of inpatient care. It’s really just to bring in the PCP’s expertise and nuanced understanding of the patient at a vulnerable time for the patient.”

The idea might seem a little ironic given the fact that hospitalists were created in part to relieve busy PCPs from having to visit the hospital. But some see it as a way forward.

“I wouldn’t call it a step backward,” says Joseph Ming Wah Li, MD, SFHM, FACP, director of the hospital medicine program at Beth Israel Deaconess Medical Center (BIDMC) in Boston and a former SHM president. “Is it feasible? Realistically, in most settings today, I don’t think it is. But I would love it. I don’t really know enough about the patients I take care of in the hospital.”

The Barrier of “Not Enough Time”

Dr. Hunt says the biggest barrier to this proposal is the time that PCPs would have to carve out to make physical trips to the hospital.

“That ultimately comes down to reimbursement,” he says.

MGH, which is well situated with medical practices in or near the main hospital building, has piloted an approach similar to the NEJM proposal with a primary care group that comes in to see its patients in the first day or two after admission and then again on the day before discharge.

“But they are essentially doing it out of the goodness of their hearts,” Dr. Hunt explains. “What we’ve seen from this experiment are much better transitions of care and much better decision making around big decisions, such as end-of-life care or surgical interventions.”

Hospitalists at MGH and the PCPs spent a year and a half talking through the specifics of how their arrangement would work.

 

“We made a commitment, as hospitalists, to communicate directly by phone with the PCPs,” he says. “That commitment lasted about a week, and then we quickly converted to a daily e-mail. That works, because both parties are communicating substantial information in these e-mails.”

Dr. Hunt says the key is recognizing the “huge” value PCPs bring to an inpatient stay. And, while physical trips to the hospital or e-mails might not work for every hospitalist or PCP, the connecting of information and insight is often worth the investment.

“There are other ways [to communicate], such as video conferencing and Skype, where doctors could participate more efficiently in the care of their hospitalized patients,” he says, adding that hospitalists should reach out to PCPs, both when a patient enters the hospital and as part of a larger discussion about how to improve communication and continuity of care.

The PCP Perspective

Boston internist Gila Kriegel, MD, might seem like a throwback. She says she wants to visit her patients when they are in the hospital, if at all possible. In fact, hospitalists in Boston say Dr. Kriegel allows them to take care of her patients “almost begrudgingly.”

“She is so involved in their care,” Dr. Li says. “She tells me everything I need to know about them. She’d be here every day if she weren’t juggling other responsibilities.”

A PCP since 1986, Dr. Kriegel’s story illustrates the complexities of an evolving healthcare system. She’s based in an academic setting, which she calls a “kind of ivory tower.”

“But I was fortunate in 1989, after my first son was born and I went part-time, to have a colleague who offered to see my inpatients on the days I wasn’t working,” she explains. “Then a woman colleague of mine also went part-time, and we agreed to cross-cover for each other.”

Eventually, Dr. Kriegel was approached by Dr. Li’s hospitalist group, which offered to manage her hospitalized patients.

“For the first six months to a year, I’d go see my patients in the hospital on a social visit. I’d even write notes in the chart, until they told me, ‘You are not responsible for the care in the hospital. The hospitalist is,’” she recalls. “For me, it was a big loss to stop going to the hospital. Most PCPs I know like seeing their patients through the course of the illness.”

Then again, she also admits how difficult it is to see her patients in the hospital.

Still, she managed to stay connected. “When I stopped going to see my patients, I asked the hospital staff to give me the patient’s bedside phone number, and I’d call them in the hospital to let them know I was up on what was happening,” she says.

Technology, coincidentally, inserted a barrier: She wasn’t able to access hospitalists’ daily notes in the BIDMC electronic health records. That’s when Dr. Kriegel began e-mailing the hospitalists. In the end, even that form of communication wasn’t fully satisfying.

“The current system requires me to do the outreach,” she explains. “If you ask hospitalists about communication, they’d say they’re already doing it. But a discharge summary isn’t the same as knowing in real time what’s happening with my patients.”

“I’d love to make virtual visits to the patient in the hospital, by phone or computer link—even more so if I could get paid for my time. But I want to stay involved.”

Ripe for Innovation

Dr. Wachter, chief of hospital medicine at UCSF, who writes an HM-focused blog [wachtersworld.com], says the continuity visit is a good idea but also understands the difficulties in the new healthcare paradigm.

 

“It’s not easy to work out the logistics, and it depends on the geography,” he says. “We also need to be considering telemedicine. But something to enhance continuity is ripe for innovation.”

He says consultation or continuity visits offer ways to improve care with a relatively small expenditure.

“We still see a few PCPs come in when their patients are hospitalized. It’s very reassuring to their patients,” he says. “For the complicated cases where an ongoing relationship matters, those encounters are fabulous.”

---

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Goroll AH, Hunt DP. Bridging the hospitalist-primary care divide through collaborative care. New Engl J Med. 2015;372(4):308-309.
2. Wachter RM, Pantilat SZ. The “continuity visit” and the hospitalist model of care. Dis Mon. 2002;48(4):267-272.