Quality

It’s great to be a Tennessee Volunteer. I said, It’s great to be a Tennessee Volunteer!

The crowd, a sea of orange, packs into Neyland Stadium in Knoxville, Tenn., brimming with pride, dedicated to the team they call the Vols. Neyland Stadium, built in 1921, comfortably seats more than 100,000 brash fans on most fall weekends during the college football season. These die-hard fans pack the stadium regularly, hoping to catch a glimpse of victory.

Throughout the decades of Tennessee Volunteers football, numerous coaches have spent countless hours thinking about how to realize those victories. And they have also spent a lot time thinking about how to keep their players safe. Each coach has had different styles and tactics, but all had one thing in common: They were clearly invested in keeping their players safe. A safe player is a good player, one who can make the full season without injury. As such, before each practice and each game, the players don the gear required to play the safest game possible.

This gear is expensive, difficult to put on, difficult to keep on, makes them run slower, and makes them sweat heavier. When you think about it, it is a wonder that they wear it at all—unless you consider the fact that each precisely placed article takes them one step closer to surviving the game intact, and making it to the next victory. Just like any other type of protective equipment, football equipment has evolved over the course of time. The helmet, for example, is now custom-fit for each player with calipers, and then subsequent additions are applied to ensure durability, shock resistance, and comfort. Relatively new additions include eye shields (to protect the eyes and reduce glare) and even radio devices (to allow the coach to relay last-minute critical information to the quarterback). These helmets are all customized to the players’ position, to allow for the best balance between protection and visibility.

And the helmet is just the beginning. The remaining bare minimum amount of gear needed for standard player safety includes a mouthpiece, jaw pads, neck roll, shoulder pads, shock pads, rib pads, hip pads, knee pads, and cleats. All told, the weight of all this equipment is between 10 and 25 pounds and takes up to an hour to fully gear up. But nonetheless, it has become such a mainstay, of centralized importance to the game, that each team has a dedicated equipment manager. They are charged with providing, maintaining, and transporting the best gear for every member of the team. The equipment manager is a vital resource for the team and the sport.

Despite the extra weight and inconvenience that their gear can burden them with, you don’t see a single football player “skimp” on it. And it would certainly be obvious to all those around them if they ran onto the field without their helmet. Over the years, the football industry has not abandoned gear that they thought was less than perfect, too heavy, too bulky, or made the player perform with less agility. They just made the gear better, lighter, more comfortable, and more protective.

You Can Do This

In a similar fashion, hospital providers have become increasingly interested in keeping themselves—and the patient—safe. But have we come to consensus on who the coach and equipment managers should be, and what the essential elements of the gear should be? I would argue there are a number of coaches and equipment managers in the hospital setting whose mission is to keep their “players” safe. The players are both patients and providers, as generally a “safe provider” is one who makes and implements solid decisions, and who is housed within a safe, predictable, and highly-reliable system, is also one who can and will keep their patients safe.

 

We may not think of ourselves as such, but hospitalists can be extremely effective coaches and equipment managers. They can help create and maintain safe and effective gear for themselves and those patients and providers around them. They can be a mentor for displaying how vitally import this gear is and can work to improve it when it proves to be imperfect.

Although we don’t tend to think of these things as “safety gear,” these things do, in fact, keep us and our patients safe. Some of these include:

• Computerized physician order entry (CPOE) with decision support (or order sets without CPOE);
• Checklists;
• Procedural time-outs;
• Protocols;
• Medication dosing guidelines;
• Handheld devices (for quick lookup of medication doses, side effects, predictive scoring systems, medical calculators, etc.); and
• Gowns and gloves.

Additional “gear” for the patients can include:

• Arm bands for identification and medication scanning;
• Telemetry;
• Bed alarms;
• IV pumps with guard rails around dosing;
• Antibiotic impregnated central lines; and
• Early mobilization protocols.

The Next Level

To take the medical industry to the next level of safe reliability, we need all providers to accept and embrace the concept of “safety gear” for themselves and for their patients. We need to make it perfectly obvious when that gear is missing. It should invoke a reaction of ghastly fear when we witness anyone (provider, patient, or family) skimping on their gear: removing an armband for convenience, bypassing a smart pump, or skipping decision support in CPOE. And for the current gear that is imperfect, slows us down, beeps too often, or reduces our agility, the solution should include improving the gear, not ignoring it or discounting its importance.

So before you go to work today (every day?), think about what you need to keep yourself and your patients safe. And get your gear on.

---

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

It’s great to be a Tennessee Volunteer. I said, It’s great to be a Tennessee Volunteer!

The crowd, a sea of orange, packs into Neyland Stadium in Knoxville, Tenn., brimming with pride, dedicated to the team they call the Vols. Neyland Stadium, built in 1921, comfortably seats more than 100,000 brash fans on most fall weekends during the college football season. These die-hard fans pack the stadium regularly, hoping to catch a glimpse of victory.

Throughout the decades of Tennessee Volunteers football, numerous coaches have spent countless hours thinking about how to realize those victories. And they have also spent a lot time thinking about how to keep their players safe. Each coach has had different styles and tactics, but all had one thing in common: They were clearly invested in keeping their players safe. A safe player is a good player, one who can make the full season without injury. As such, before each practice and each game, the players don the gear required to play the safest game possible.

This gear is expensive, difficult to put on, difficult to keep on, makes them run slower, and makes them sweat heavier. When you think about it, it is a wonder that they wear it at all—unless you consider the fact that each precisely placed article takes them one step closer to surviving the game intact, and making it to the next victory. Just like any other type of protective equipment, football equipment has evolved over the course of time. The helmet, for example, is now custom-fit for each player with calipers, and then subsequent additions are applied to ensure durability, shock resistance, and comfort. Relatively new additions include eye shields (to protect the eyes and reduce glare) and even radio devices (to allow the coach to relay last-minute critical information to the quarterback). These helmets are all customized to the players’ position, to allow for the best balance between protection and visibility.

And the helmet is just the beginning. The remaining bare minimum amount of gear needed for standard player safety includes a mouthpiece, jaw pads, neck roll, shoulder pads, shock pads, rib pads, hip pads, knee pads, and cleats. All told, the weight of all this equipment is between 10 and 25 pounds and takes up to an hour to fully gear up. But nonetheless, it has become such a mainstay, of centralized importance to the game, that each team has a dedicated equipment manager. They are charged with providing, maintaining, and transporting the best gear for every member of the team. The equipment manager is a vital resource for the team and the sport.

Despite the extra weight and inconvenience that their gear can burden them with, you don’t see a single football player “skimp” on it. And it would certainly be obvious to all those around them if they ran onto the field without their helmet. Over the years, the football industry has not abandoned gear that they thought was less than perfect, too heavy, too bulky, or made the player perform with less agility. They just made the gear better, lighter, more comfortable, and more protective.

You Can Do This

In a similar fashion, hospital providers have become increasingly interested in keeping themselves—and the patient—safe. But have we come to consensus on who the coach and equipment managers should be, and what the essential elements of the gear should be? I would argue there are a number of coaches and equipment managers in the hospital setting whose mission is to keep their “players” safe. The players are both patients and providers, as generally a “safe provider” is one who makes and implements solid decisions, and who is housed within a safe, predictable, and highly-reliable system, is also one who can and will keep their patients safe.

 

We may not think of ourselves as such, but hospitalists can be extremely effective coaches and equipment managers. They can help create and maintain safe and effective gear for themselves and those patients and providers around them. They can be a mentor for displaying how vitally import this gear is and can work to improve it when it proves to be imperfect.

Although we don’t tend to think of these things as “safety gear,” these things do, in fact, keep us and our patients safe. Some of these include:

• Computerized physician order entry (CPOE) with decision support (or order sets without CPOE);
• Checklists;
• Procedural time-outs;
• Protocols;
• Medication dosing guidelines;
• Handheld devices (for quick lookup of medication doses, side effects, predictive scoring systems, medical calculators, etc.); and
• Gowns and gloves.

Additional “gear” for the patients can include:

• Arm bands for identification and medication scanning;
• Telemetry;
• Bed alarms;
• IV pumps with guard rails around dosing;
• Antibiotic impregnated central lines; and
• Early mobilization protocols.

The Next Level

To take the medical industry to the next level of safe reliability, we need all providers to accept and embrace the concept of “safety gear” for themselves and for their patients. We need to make it perfectly obvious when that gear is missing. It should invoke a reaction of ghastly fear when we witness anyone (provider, patient, or family) skimping on their gear: removing an armband for convenience, bypassing a smart pump, or skipping decision support in CPOE. And for the current gear that is imperfect, slows us down, beeps too often, or reduces our agility, the solution should include improving the gear, not ignoring it or discounting its importance.

So before you go to work today (every day?), think about what you need to keep yourself and your patients safe. And get your gear on.

---

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

It’s great to be a Tennessee Volunteer. I said, It’s great to be a Tennessee Volunteer!

The crowd, a sea of orange, packs into Neyland Stadium in Knoxville, Tenn., brimming with pride, dedicated to the team they call the Vols. Neyland Stadium, built in 1921, comfortably seats more than 100,000 brash fans on most fall weekends during the college football season. These die-hard fans pack the stadium regularly, hoping to catch a glimpse of victory.

Throughout the decades of Tennessee Volunteers football, numerous coaches have spent countless hours thinking about how to realize those victories. And they have also spent a lot time thinking about how to keep their players safe. Each coach has had different styles and tactics, but all had one thing in common: They were clearly invested in keeping their players safe. A safe player is a good player, one who can make the full season without injury. As such, before each practice and each game, the players don the gear required to play the safest game possible.

This gear is expensive, difficult to put on, difficult to keep on, makes them run slower, and makes them sweat heavier. When you think about it, it is a wonder that they wear it at all—unless you consider the fact that each precisely placed article takes them one step closer to surviving the game intact, and making it to the next victory. Just like any other type of protective equipment, football equipment has evolved over the course of time. The helmet, for example, is now custom-fit for each player with calipers, and then subsequent additions are applied to ensure durability, shock resistance, and comfort. Relatively new additions include eye shields (to protect the eyes and reduce glare) and even radio devices (to allow the coach to relay last-minute critical information to the quarterback). These helmets are all customized to the players’ position, to allow for the best balance between protection and visibility.

And the helmet is just the beginning. The remaining bare minimum amount of gear needed for standard player safety includes a mouthpiece, jaw pads, neck roll, shoulder pads, shock pads, rib pads, hip pads, knee pads, and cleats. All told, the weight of all this equipment is between 10 and 25 pounds and takes up to an hour to fully gear up. But nonetheless, it has become such a mainstay, of centralized importance to the game, that each team has a dedicated equipment manager. They are charged with providing, maintaining, and transporting the best gear for every member of the team. The equipment manager is a vital resource for the team and the sport.

Despite the extra weight and inconvenience that their gear can burden them with, you don’t see a single football player “skimp” on it. And it would certainly be obvious to all those around them if they ran onto the field without their helmet. Over the years, the football industry has not abandoned gear that they thought was less than perfect, too heavy, too bulky, or made the player perform with less agility. They just made the gear better, lighter, more comfortable, and more protective.

You Can Do This

In a similar fashion, hospital providers have become increasingly interested in keeping themselves—and the patient—safe. But have we come to consensus on who the coach and equipment managers should be, and what the essential elements of the gear should be? I would argue there are a number of coaches and equipment managers in the hospital setting whose mission is to keep their “players” safe. The players are both patients and providers, as generally a “safe provider” is one who makes and implements solid decisions, and who is housed within a safe, predictable, and highly-reliable system, is also one who can and will keep their patients safe.

 

We may not think of ourselves as such, but hospitalists can be extremely effective coaches and equipment managers. They can help create and maintain safe and effective gear for themselves and those patients and providers around them. They can be a mentor for displaying how vitally import this gear is and can work to improve it when it proves to be imperfect.

Although we don’t tend to think of these things as “safety gear,” these things do, in fact, keep us and our patients safe. Some of these include:

• Computerized physician order entry (CPOE) with decision support (or order sets without CPOE);
• Checklists;
• Procedural time-outs;
• Protocols;
• Medication dosing guidelines;
• Handheld devices (for quick lookup of medication doses, side effects, predictive scoring systems, medical calculators, etc.); and
• Gowns and gloves.

Additional “gear” for the patients can include:

• Arm bands for identification and medication scanning;
• Telemetry;
• Bed alarms;
• IV pumps with guard rails around dosing;
• Antibiotic impregnated central lines; and
• Early mobilization protocols.

The Next Level

To take the medical industry to the next level of safe reliability, we need all providers to accept and embrace the concept of “safety gear” for themselves and for their patients. We need to make it perfectly obvious when that gear is missing. It should invoke a reaction of ghastly fear when we witness anyone (provider, patient, or family) skimping on their gear: removing an armband for convenience, bypassing a smart pump, or skipping decision support in CPOE. And for the current gear that is imperfect, slows us down, beeps too often, or reduces our agility, the solution should include improving the gear, not ignoring it or discounting its importance.

So before you go to work today (every day?), think about what you need to keep yourself and your patients safe. And get your gear on.

---

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

Patient Transfers

Hospitalist billing depends on several factors. Know your role and avoid common mistakes Patient transfers can occur for many reasons: advanced technological services required, health insurance coverage, or a change in the level of care, to name a few. Patient care that is provided in the acute-care setting does not always terminate with discharge to home. Frequently, hospitalists are involved in patient transfers to another location to receive additional services: intrafacility (a different unit or related facility within the same physical plant) or interfacility (geographically separate facilities). The hospitalist must identify his or her role in the transfer and the patient’s new environment.

Physician billing in the transferred setting depends upon several factors:¹

• Shared or merged medical record;
• The attending of record in each setting;
• The requirements for care rendered by the hospitalist in each setting; and
• Service dates.

Intrafacility Initial Service

Let’s examine a common example: A hospitalist serves as the “attending of record” in an inpatient hospital where acute care is required for an 83-year-old female with hypertension and diabetes who sustained a left hip fracture. The hospitalist plans to discharge the patient to the rehabilitation unit. After transfer, the rehabilitation physician becomes the attending of record, and the hospitalist might be asked to provide ongoing care for the patient’s hypertension and diabetes.

What should the hospitalist report for the initial post-transfer service? The typical options to consider are:²

• Inpatient consultation (99251-99255);
• Initial hospital care (99221-99223); and
• Subsequent hospital care (99231-99233).

Report a consultation only if the rehab attending requests an opinion or advice for an unrelated, new condition instead of previously treated conditions, and the requesting physician’s intent is for opinion or advice on management options rather than the a priori intent for the hospitalist to assume the patient’s medical care. If these requirements are met, the hospitalist may report an inpatient consultation code (99251-99255). Alternatively, if the intent or need represents a continuity of medical care provided during the acute episode of care, report the most appropriate subsequent hospital care code (99231-99233) for the hospitalist’s initial rehab visit and all follow-up services.

Initial hospital care (99221-99223) codes can only be reported for Medicare beneficiaries in place of consultation codes (99251-99255), as Medicare ceased to reimburse consultation codes.³ Most other payors who do not recognize consultation services only allow one initial hospital care code per hospitalization, reserved for the attending of record.

Interfacility Initial Service

Hospitalist groups provide patient care and coverage in many different types of facilities. Confusion often arises when the “attending of record” during acute care and the “subacute” setting (e.g. long-term acute-care hospital) are two different hospitalists from the same group practice. The hospitalist receiving the patient in the transfer facility may decide to report subsequent hospital care (99231-99233), because the group has been providing ongoing care to this patient. In this scenario, the hospitalist group could be losing revenue if an admission service (99221-99223) was not reported.

 

An initial hospital care service (99221-99223) is permitted when the transfer is between:

• Different hospitals;
• Different facilities under common ownership which do not have merged records; or
• Between the acute-care hospital and a PPS (prospective payment system)-exempt unit within the same hospital when there are no merged records (e.g. Medicare Part A-covered inpatient care in psychiatric, rehabilitation, critical access, and long-term care hospitals).⁴

In all other transfer circumstances not meeting the elements noted above, the physician should bill only the appropriate level of subsequent hospital care (99231-99233) for the date of transfer.¹ Do not equate “merged records” to commonly accessible charts via an electronic medical record system or an electronic storage system. If the medical record for the patient’s acute stay is “closed” and the patient is given a separate medical record and registration for the stay in the transferred facility, consider the transfer stay as a separate admission.

Billing Two Services on Day of Transfer

Whether the transfer is classified as intrafacility or interfacility, an individual hospitalist or two separate hospitalists from the same group practice may provide the acute-care discharge and the transfer admission. A hospital discharge day management service (99238-99239) and an initial hospital care service (99221-99223) can only be reported if they do not occur on the same day.¹ Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician; if more than one evaluation and management (face to face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported.⁵

The Exception

CMS will allow a single hospitalist or two hospitalists from the same group practice to report a discharge day management service on the same day as an admission service. When they are billed by the same physician or group with the same date of service, contractors are instructed to pay the hospital discharge day management code (99238-99239) in addition to a nursing facility admission code (99304-99306).⁶

Conversely, if the patient is admitted to a hospital (99221-99223) following a nursing facility discharge (99315-99316) on the same date by the same physician/group, insurers will only reimburse the initial hospital care code. Payment for the initial hospital care service includes all work performed by the physician/group in all sites of service on that date.

---

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is faculty for SHM’s inpatient coding course.

References available online at the-hospitalist.org

Patient Transfers

Hospitalist billing depends on several factors. Know your role and avoid common mistakes Patient transfers can occur for many reasons: advanced technological services required, health insurance coverage, or a change in the level of care, to name a few. Patient care that is provided in the acute-care setting does not always terminate with discharge to home. Frequently, hospitalists are involved in patient transfers to another location to receive additional services: intrafacility (a different unit or related facility within the same physical plant) or interfacility (geographically separate facilities). The hospitalist must identify his or her role in the transfer and the patient’s new environment.

Physician billing in the transferred setting depends upon several factors:¹

• Shared or merged medical record;
• The attending of record in each setting;
• The requirements for care rendered by the hospitalist in each setting; and
• Service dates.

Intrafacility Initial Service

Let’s examine a common example: A hospitalist serves as the “attending of record” in an inpatient hospital where acute care is required for an 83-year-old female with hypertension and diabetes who sustained a left hip fracture. The hospitalist plans to discharge the patient to the rehabilitation unit. After transfer, the rehabilitation physician becomes the attending of record, and the hospitalist might be asked to provide ongoing care for the patient’s hypertension and diabetes.

What should the hospitalist report for the initial post-transfer service? The typical options to consider are:²

• Inpatient consultation (99251-99255);
• Initial hospital care (99221-99223); and
• Subsequent hospital care (99231-99233).

Report a consultation only if the rehab attending requests an opinion or advice for an unrelated, new condition instead of previously treated conditions, and the requesting physician’s intent is for opinion or advice on management options rather than the a priori intent for the hospitalist to assume the patient’s medical care. If these requirements are met, the hospitalist may report an inpatient consultation code (99251-99255). Alternatively, if the intent or need represents a continuity of medical care provided during the acute episode of care, report the most appropriate subsequent hospital care code (99231-99233) for the hospitalist’s initial rehab visit and all follow-up services.

Initial hospital care (99221-99223) codes can only be reported for Medicare beneficiaries in place of consultation codes (99251-99255), as Medicare ceased to reimburse consultation codes.³ Most other payors who do not recognize consultation services only allow one initial hospital care code per hospitalization, reserved for the attending of record.

Interfacility Initial Service

Hospitalist groups provide patient care and coverage in many different types of facilities. Confusion often arises when the “attending of record” during acute care and the “subacute” setting (e.g. long-term acute-care hospital) are two different hospitalists from the same group practice. The hospitalist receiving the patient in the transfer facility may decide to report subsequent hospital care (99231-99233), because the group has been providing ongoing care to this patient. In this scenario, the hospitalist group could be losing revenue if an admission service (99221-99223) was not reported.

 

An initial hospital care service (99221-99223) is permitted when the transfer is between:

• Different hospitals;
• Different facilities under common ownership which do not have merged records; or
• Between the acute-care hospital and a PPS (prospective payment system)-exempt unit within the same hospital when there are no merged records (e.g. Medicare Part A-covered inpatient care in psychiatric, rehabilitation, critical access, and long-term care hospitals).⁴

In all other transfer circumstances not meeting the elements noted above, the physician should bill only the appropriate level of subsequent hospital care (99231-99233) for the date of transfer.¹ Do not equate “merged records” to commonly accessible charts via an electronic medical record system or an electronic storage system. If the medical record for the patient’s acute stay is “closed” and the patient is given a separate medical record and registration for the stay in the transferred facility, consider the transfer stay as a separate admission.

Billing Two Services on Day of Transfer

Whether the transfer is classified as intrafacility or interfacility, an individual hospitalist or two separate hospitalists from the same group practice may provide the acute-care discharge and the transfer admission. A hospital discharge day management service (99238-99239) and an initial hospital care service (99221-99223) can only be reported if they do not occur on the same day.¹ Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician; if more than one evaluation and management (face to face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported.⁵

The Exception

CMS will allow a single hospitalist or two hospitalists from the same group practice to report a discharge day management service on the same day as an admission service. When they are billed by the same physician or group with the same date of service, contractors are instructed to pay the hospital discharge day management code (99238-99239) in addition to a nursing facility admission code (99304-99306).⁶

Conversely, if the patient is admitted to a hospital (99221-99223) following a nursing facility discharge (99315-99316) on the same date by the same physician/group, insurers will only reimburse the initial hospital care code. Payment for the initial hospital care service includes all work performed by the physician/group in all sites of service on that date.

---

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is faculty for SHM’s inpatient coding course.

References available online at the-hospitalist.org

Patient Transfers

Hospitalist billing depends on several factors. Know your role and avoid common mistakes Patient transfers can occur for many reasons: advanced technological services required, health insurance coverage, or a change in the level of care, to name a few. Patient care that is provided in the acute-care setting does not always terminate with discharge to home. Frequently, hospitalists are involved in patient transfers to another location to receive additional services: intrafacility (a different unit or related facility within the same physical plant) or interfacility (geographically separate facilities). The hospitalist must identify his or her role in the transfer and the patient’s new environment.

Physician billing in the transferred setting depends upon several factors:¹

• Shared or merged medical record;
• The attending of record in each setting;
• The requirements for care rendered by the hospitalist in each setting; and
• Service dates.

Intrafacility Initial Service

Let’s examine a common example: A hospitalist serves as the “attending of record” in an inpatient hospital where acute care is required for an 83-year-old female with hypertension and diabetes who sustained a left hip fracture. The hospitalist plans to discharge the patient to the rehabilitation unit. After transfer, the rehabilitation physician becomes the attending of record, and the hospitalist might be asked to provide ongoing care for the patient’s hypertension and diabetes.

What should the hospitalist report for the initial post-transfer service? The typical options to consider are:²

• Inpatient consultation (99251-99255);
• Initial hospital care (99221-99223); and
• Subsequent hospital care (99231-99233).

Report a consultation only if the rehab attending requests an opinion or advice for an unrelated, new condition instead of previously treated conditions, and the requesting physician’s intent is for opinion or advice on management options rather than the a priori intent for the hospitalist to assume the patient’s medical care. If these requirements are met, the hospitalist may report an inpatient consultation code (99251-99255). Alternatively, if the intent or need represents a continuity of medical care provided during the acute episode of care, report the most appropriate subsequent hospital care code (99231-99233) for the hospitalist’s initial rehab visit and all follow-up services.

Initial hospital care (99221-99223) codes can only be reported for Medicare beneficiaries in place of consultation codes (99251-99255), as Medicare ceased to reimburse consultation codes.³ Most other payors who do not recognize consultation services only allow one initial hospital care code per hospitalization, reserved for the attending of record.

Interfacility Initial Service

Hospitalist groups provide patient care and coverage in many different types of facilities. Confusion often arises when the “attending of record” during acute care and the “subacute” setting (e.g. long-term acute-care hospital) are two different hospitalists from the same group practice. The hospitalist receiving the patient in the transfer facility may decide to report subsequent hospital care (99231-99233), because the group has been providing ongoing care to this patient. In this scenario, the hospitalist group could be losing revenue if an admission service (99221-99223) was not reported.

 

An initial hospital care service (99221-99223) is permitted when the transfer is between:

• Different hospitals;
• Different facilities under common ownership which do not have merged records; or
• Between the acute-care hospital and a PPS (prospective payment system)-exempt unit within the same hospital when there are no merged records (e.g. Medicare Part A-covered inpatient care in psychiatric, rehabilitation, critical access, and long-term care hospitals).⁴

In all other transfer circumstances not meeting the elements noted above, the physician should bill only the appropriate level of subsequent hospital care (99231-99233) for the date of transfer.¹ Do not equate “merged records” to commonly accessible charts via an electronic medical record system or an electronic storage system. If the medical record for the patient’s acute stay is “closed” and the patient is given a separate medical record and registration for the stay in the transferred facility, consider the transfer stay as a separate admission.

Billing Two Services on Day of Transfer

Whether the transfer is classified as intrafacility or interfacility, an individual hospitalist or two separate hospitalists from the same group practice may provide the acute-care discharge and the transfer admission. A hospital discharge day management service (99238-99239) and an initial hospital care service (99221-99223) can only be reported if they do not occur on the same day.¹ Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician; if more than one evaluation and management (face to face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported.⁵

The Exception

CMS will allow a single hospitalist or two hospitalists from the same group practice to report a discharge day management service on the same day as an admission service. When they are billed by the same physician or group with the same date of service, contractors are instructed to pay the hospital discharge day management code (99238-99239) in addition to a nursing facility admission code (99304-99306).⁶

Conversely, if the patient is admitted to a hospital (99221-99223) following a nursing facility discharge (99315-99316) on the same date by the same physician/group, insurers will only reimburse the initial hospital care code. Payment for the initial hospital care service includes all work performed by the physician/group in all sites of service on that date.

---

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is faculty for SHM’s inpatient coding course.

References available online at the-hospitalist.org

Position Paper Did Not Address Family Practice Physicians in ICU

I just finished reading “The Critical-Care Debate” article in The Hospitalist’s October issue. I was quite interested in getting further follow-up and comments regarding family practice physicians’ role in critical care. Now that some hospitalist programs are utilized as “intensivists,” what are SHM and the Society of Critical Care Medicine’s (SCCM) opinions of family practitioners who are hospitalists acting in this manner? The TH article says that internal-medicine programs are insufficient for preparing internists; what are SHM and SCCM’s positions and opinions of family practice physicians being utilized as intensivists?

—Ray Nowaczyk, DO

Dr. Hospitalist responds:

Boy, and we thought this issue was politically charged before you asked that question. From my reading of the position paper (J Hosp Med. 2012;7:359-364) cited in the article, the role of family practice physicians is only alluded to, and not addressed except by its absence. The main thrust of the paper focuses specifically on physicians trained in internal medicine (IM) and how they could become “qualified” to provide ICU care. A few items stand out:

1. The baseline assumption is that these would be IM-trained physicians, not family practice physicians.
2. The requirements to entry wouldinclude: a) completion of IM residency; b) three years’ clinical practice as a hospitalist; and c) enrollment in the ABIM Focused Practice in Hospital Medicine Maintenance of Certification process, which, by definition, requires board certification in internal medicine.

Judging by the vocal backlash from the American College of Chest Physicians (ACCP), I imagine that even getting consensus on the points above required some fairly heavy lifting. Addressing the issue of family practitioners in HM likely was not a topic they felt could gain traction

You are absolutely correct, though, in that plenty of family practitioners practice full time as adult hospitalists (and are doing a fine job). As the paper notes, it is estimated that 6% to 8% of all hospitalists are familypractice- trained. Unfortunately, there is very little objective documentation that will allow them to demonstrate their clinical quality other than direct clinical practice or observation. There is no formal “bridge” to cross for a family practice physician wanting to receive certification in hospital medicine; this currently can only happen through ABIM.

At the same time, I do not believe that the absence of formal certification disqualifies any family practitioner from practicing quality medicine in the hospital. In fact, in my market, there are some fantastic family practice hospitalists who have been in practice in a busy, urban, Level I hospital for more than 10 years. They clearly have the clinical experience and skills that would vastly outweigh those of almost any new graduate of an internal-medicine program. Can they prove it? Not today.

I think it’s a similar discussion with IM-trained hospitalists providing ICU care. I have colleagues who actively seek to accept and care for ICU patients when it comes time for admissions, and these physicians spend much more time in direct patient care in the ICU than even some of our intensivists. Can they prove their skills? Not today. However, as noted in the Leapfrog data, at this point, only 4% of ICUs have 24/7 dedicated intensivists, so who are we kidding? We need hospitalists to provide competent ICU care. Whether we provide a pathway for objective recognition or not, it is still going to happen. It sure would be nice if it happened in a sensible way with input from the stakeholders—just as was suggested in the position paper.

 

Here’s a little anecdote: Many years ago, there was an ortho PA (we’ll call him Jimmy John) in our hospital, but when you called his pager number, which he also gave out routinely to patients, the message said, “You’ve reached the pager of Doctor John.” He was no doctor. Well, one of us finally asked him about it, and he replied, with a straight face: “Oh, I used to be a vet.” OK.

The point is, we all need to recognize our own skills and limitations and be able to communicate those same skills and limitations to others, especially to patients, honestly. Since honesty has its limits, then independent objective measurement is a useful adjunct. Just look at your office walls.

Position Paper Did Not Address Family Practice Physicians in ICU

I just finished reading “The Critical-Care Debate” article in The Hospitalist’s October issue. I was quite interested in getting further follow-up and comments regarding family practice physicians’ role in critical care. Now that some hospitalist programs are utilized as “intensivists,” what are SHM and the Society of Critical Care Medicine’s (SCCM) opinions of family practitioners who are hospitalists acting in this manner? The TH article says that internal-medicine programs are insufficient for preparing internists; what are SHM and SCCM’s positions and opinions of family practice physicians being utilized as intensivists?

—Ray Nowaczyk, DO

Dr. Hospitalist responds:

Boy, and we thought this issue was politically charged before you asked that question. From my reading of the position paper (J Hosp Med. 2012;7:359-364) cited in the article, the role of family practice physicians is only alluded to, and not addressed except by its absence. The main thrust of the paper focuses specifically on physicians trained in internal medicine (IM) and how they could become “qualified” to provide ICU care. A few items stand out:

1. The baseline assumption is that these would be IM-trained physicians, not family practice physicians.
2. The requirements to entry wouldinclude: a) completion of IM residency; b) three years’ clinical practice as a hospitalist; and c) enrollment in the ABIM Focused Practice in Hospital Medicine Maintenance of Certification process, which, by definition, requires board certification in internal medicine.

Judging by the vocal backlash from the American College of Chest Physicians (ACCP), I imagine that even getting consensus on the points above required some fairly heavy lifting. Addressing the issue of family practitioners in HM likely was not a topic they felt could gain traction

You are absolutely correct, though, in that plenty of family practitioners practice full time as adult hospitalists (and are doing a fine job). As the paper notes, it is estimated that 6% to 8% of all hospitalists are familypractice- trained. Unfortunately, there is very little objective documentation that will allow them to demonstrate their clinical quality other than direct clinical practice or observation. There is no formal “bridge” to cross for a family practice physician wanting to receive certification in hospital medicine; this currently can only happen through ABIM.

At the same time, I do not believe that the absence of formal certification disqualifies any family practitioner from practicing quality medicine in the hospital. In fact, in my market, there are some fantastic family practice hospitalists who have been in practice in a busy, urban, Level I hospital for more than 10 years. They clearly have the clinical experience and skills that would vastly outweigh those of almost any new graduate of an internal-medicine program. Can they prove it? Not today.

I think it’s a similar discussion with IM-trained hospitalists providing ICU care. I have colleagues who actively seek to accept and care for ICU patients when it comes time for admissions, and these physicians spend much more time in direct patient care in the ICU than even some of our intensivists. Can they prove their skills? Not today. However, as noted in the Leapfrog data, at this point, only 4% of ICUs have 24/7 dedicated intensivists, so who are we kidding? We need hospitalists to provide competent ICU care. Whether we provide a pathway for objective recognition or not, it is still going to happen. It sure would be nice if it happened in a sensible way with input from the stakeholders—just as was suggested in the position paper.

 

Here’s a little anecdote: Many years ago, there was an ortho PA (we’ll call him Jimmy John) in our hospital, but when you called his pager number, which he also gave out routinely to patients, the message said, “You’ve reached the pager of Doctor John.” He was no doctor. Well, one of us finally asked him about it, and he replied, with a straight face: “Oh, I used to be a vet.” OK.

The point is, we all need to recognize our own skills and limitations and be able to communicate those same skills and limitations to others, especially to patients, honestly. Since honesty has its limits, then independent objective measurement is a useful adjunct. Just look at your office walls.

Position Paper Did Not Address Family Practice Physicians in ICU

I just finished reading “The Critical-Care Debate” article in The Hospitalist’s October issue. I was quite interested in getting further follow-up and comments regarding family practice physicians’ role in critical care. Now that some hospitalist programs are utilized as “intensivists,” what are SHM and the Society of Critical Care Medicine’s (SCCM) opinions of family practitioners who are hospitalists acting in this manner? The TH article says that internal-medicine programs are insufficient for preparing internists; what are SHM and SCCM’s positions and opinions of family practice physicians being utilized as intensivists?

—Ray Nowaczyk, DO

Dr. Hospitalist responds:

Boy, and we thought this issue was politically charged before you asked that question. From my reading of the position paper (J Hosp Med. 2012;7:359-364) cited in the article, the role of family practice physicians is only alluded to, and not addressed except by its absence. The main thrust of the paper focuses specifically on physicians trained in internal medicine (IM) and how they could become “qualified” to provide ICU care. A few items stand out:

1. The baseline assumption is that these would be IM-trained physicians, not family practice physicians.
2. The requirements to entry wouldinclude: a) completion of IM residency; b) three years’ clinical practice as a hospitalist; and c) enrollment in the ABIM Focused Practice in Hospital Medicine Maintenance of Certification process, which, by definition, requires board certification in internal medicine.

Judging by the vocal backlash from the American College of Chest Physicians (ACCP), I imagine that even getting consensus on the points above required some fairly heavy lifting. Addressing the issue of family practitioners in HM likely was not a topic they felt could gain traction

You are absolutely correct, though, in that plenty of family practitioners practice full time as adult hospitalists (and are doing a fine job). As the paper notes, it is estimated that 6% to 8% of all hospitalists are familypractice- trained. Unfortunately, there is very little objective documentation that will allow them to demonstrate their clinical quality other than direct clinical practice or observation. There is no formal “bridge” to cross for a family practice physician wanting to receive certification in hospital medicine; this currently can only happen through ABIM.

At the same time, I do not believe that the absence of formal certification disqualifies any family practitioner from practicing quality medicine in the hospital. In fact, in my market, there are some fantastic family practice hospitalists who have been in practice in a busy, urban, Level I hospital for more than 10 years. They clearly have the clinical experience and skills that would vastly outweigh those of almost any new graduate of an internal-medicine program. Can they prove it? Not today.

I think it’s a similar discussion with IM-trained hospitalists providing ICU care. I have colleagues who actively seek to accept and care for ICU patients when it comes time for admissions, and these physicians spend much more time in direct patient care in the ICU than even some of our intensivists. Can they prove their skills? Not today. However, as noted in the Leapfrog data, at this point, only 4% of ICUs have 24/7 dedicated intensivists, so who are we kidding? We need hospitalists to provide competent ICU care. Whether we provide a pathway for objective recognition or not, it is still going to happen. It sure would be nice if it happened in a sensible way with input from the stakeholders—just as was suggested in the position paper.

 

Here’s a little anecdote: Many years ago, there was an ortho PA (we’ll call him Jimmy John) in our hospital, but when you called his pager number, which he also gave out routinely to patients, the message said, “You’ve reached the pager of Doctor John.” He was no doctor. Well, one of us finally asked him about it, and he replied, with a straight face: “Oh, I used to be a vet.” OK.

The point is, we all need to recognize our own skills and limitations and be able to communicate those same skills and limitations to others, especially to patients, honestly. Since honesty has its limits, then independent objective measurement is a useful adjunct. Just look at your office walls.

Electronic decision support significantly improves VTE prophylaxis and hospital-acquired VTE rates, according to a new study in the Journal of Hospital Medicine.

The report, "Improving Hospital Venous Thromboembolism Prophylaxis With Electronic Decision Report," saw overall medical service prophylaxis rise to 82.1% from 61.9% (P<0.001) and pharmacologic VTE prophylaxis increase to 74.5% from 59% (P<0.001).

"Healthcare leaders talk about information technology (IT) as a means toward effecting improvements in quality and patient safety and, most of the time, they view that and discuss that in terms of the actual IT system being implemented," says lead author Rohit Bhalla, MD, MPH, associate professor of clinical medicine at Albert Einstein College of Medicine in New York City. "What our intervention really got to was once you've implemented an IT system ... how can it be modified, vis-à-vis decision support, so that it provides an even better result than you get with the product that comes out of the box."

Tailoring a health IT system to improve outcomes requires interdisciplinary work that includes quality officers, physicians, IT staff, and programmers. Hospitalist and fellow author Jason Adelman, MD, MS, patient safety officer at Montefiore Medical Center in the Bronx, N.Y., where the study was conducted, says that the research can help generate future buy-in from physicians who don't value electronic decision support tools.

It can "ease the swallowing of the bitter pill to know that it really makes a difference," Dr. Adelman says. "Don't be up in arms when you're forced to do something a little bit extra, because it really works."

 

Visit our website for more information about health information technology.

 

Electronic decision support significantly improves VTE prophylaxis and hospital-acquired VTE rates, according to a new study in the Journal of Hospital Medicine.

The report, "Improving Hospital Venous Thromboembolism Prophylaxis With Electronic Decision Report," saw overall medical service prophylaxis rise to 82.1% from 61.9% (P<0.001) and pharmacologic VTE prophylaxis increase to 74.5% from 59% (P<0.001).

"Healthcare leaders talk about information technology (IT) as a means toward effecting improvements in quality and patient safety and, most of the time, they view that and discuss that in terms of the actual IT system being implemented," says lead author Rohit Bhalla, MD, MPH, associate professor of clinical medicine at Albert Einstein College of Medicine in New York City. "What our intervention really got to was once you've implemented an IT system ... how can it be modified, vis-à-vis decision support, so that it provides an even better result than you get with the product that comes out of the box."

Tailoring a health IT system to improve outcomes requires interdisciplinary work that includes quality officers, physicians, IT staff, and programmers. Hospitalist and fellow author Jason Adelman, MD, MS, patient safety officer at Montefiore Medical Center in the Bronx, N.Y., where the study was conducted, says that the research can help generate future buy-in from physicians who don't value electronic decision support tools.

It can "ease the swallowing of the bitter pill to know that it really makes a difference," Dr. Adelman says. "Don't be up in arms when you're forced to do something a little bit extra, because it really works."

 

Visit our website for more information about health information technology.

 

Electronic decision support significantly improves VTE prophylaxis and hospital-acquired VTE rates, according to a new study in the Journal of Hospital Medicine.

The report, "Improving Hospital Venous Thromboembolism Prophylaxis With Electronic Decision Report," saw overall medical service prophylaxis rise to 82.1% from 61.9% (P<0.001) and pharmacologic VTE prophylaxis increase to 74.5% from 59% (P<0.001).

"Healthcare leaders talk about information technology (IT) as a means toward effecting improvements in quality and patient safety and, most of the time, they view that and discuss that in terms of the actual IT system being implemented," says lead author Rohit Bhalla, MD, MPH, associate professor of clinical medicine at Albert Einstein College of Medicine in New York City. "What our intervention really got to was once you've implemented an IT system ... how can it be modified, vis-à-vis decision support, so that it provides an even better result than you get with the product that comes out of the box."

Tailoring a health IT system to improve outcomes requires interdisciplinary work that includes quality officers, physicians, IT staff, and programmers. Hospitalist and fellow author Jason Adelman, MD, MS, patient safety officer at Montefiore Medical Center in the Bronx, N.Y., where the study was conducted, says that the research can help generate future buy-in from physicians who don't value electronic decision support tools.

It can "ease the swallowing of the bitter pill to know that it really makes a difference," Dr. Adelman says. "Don't be up in arms when you're forced to do something a little bit extra, because it really works."

 

Visit our website for more information about health information technology.

 

University of Minnesota hospitalist Karyn Baum, MD, MSEd, directs one of six regional training centers for Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), an evidence-based, multimedia curriculum, tool set, and system for healthcare organizations to improve their teamwork.

Using the TeamSTEPPS approach, Dr. Baum collaborated with hospitalist Albertine Beard, MD, and the charge nurse on a 28-bed medical unit at the Minneapolis VA Medical Center to present a half-day training session for all VA staff, including four hospitalists. The seminar mixed didactics, discussions, and simulations, similar to traditional role-playing techniques but using a high-fidelity manikin that talks and displays vital signs.

"Teamwork is a set of knowledge, skills, and attitudes that lead to the creation of a culture where it’s about us as a team, not about who is highest in the hierarchy," Dr. Baum says. Hospitalists want to be leaders, "but we have a responsibility to be intentional leaders, learning the skills and modeling them," she adds.

Improved teamwork benefits patients through more effective communication and reduction in medical errors, Dr. Baum says, "but it also helps to create a healthy environment in which to work, where we all have each other’s backs."

TeamSTEPPS, developed jointly by the federal Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense, has reached 25% to 30% of U.S. hospitals by annually training about 700 masters. The masters then go back to their institutions and share the techniques.

 

Read more about why improving teamwork is good for your patients.

 

University of Minnesota hospitalist Karyn Baum, MD, MSEd, directs one of six regional training centers for Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), an evidence-based, multimedia curriculum, tool set, and system for healthcare organizations to improve their teamwork.

Using the TeamSTEPPS approach, Dr. Baum collaborated with hospitalist Albertine Beard, MD, and the charge nurse on a 28-bed medical unit at the Minneapolis VA Medical Center to present a half-day training session for all VA staff, including four hospitalists. The seminar mixed didactics, discussions, and simulations, similar to traditional role-playing techniques but using a high-fidelity manikin that talks and displays vital signs.

"Teamwork is a set of knowledge, skills, and attitudes that lead to the creation of a culture where it’s about us as a team, not about who is highest in the hierarchy," Dr. Baum says. Hospitalists want to be leaders, "but we have a responsibility to be intentional leaders, learning the skills and modeling them," she adds.

Improved teamwork benefits patients through more effective communication and reduction in medical errors, Dr. Baum says, "but it also helps to create a healthy environment in which to work, where we all have each other’s backs."

TeamSTEPPS, developed jointly by the federal Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense, has reached 25% to 30% of U.S. hospitals by annually training about 700 masters. The masters then go back to their institutions and share the techniques.

 

Read more about why improving teamwork is good for your patients.

 

University of Minnesota hospitalist Karyn Baum, MD, MSEd, directs one of six regional training centers for Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), an evidence-based, multimedia curriculum, tool set, and system for healthcare organizations to improve their teamwork.

Using the TeamSTEPPS approach, Dr. Baum collaborated with hospitalist Albertine Beard, MD, and the charge nurse on a 28-bed medical unit at the Minneapolis VA Medical Center to present a half-day training session for all VA staff, including four hospitalists. The seminar mixed didactics, discussions, and simulations, similar to traditional role-playing techniques but using a high-fidelity manikin that talks and displays vital signs.

"Teamwork is a set of knowledge, skills, and attitudes that lead to the creation of a culture where it’s about us as a team, not about who is highest in the hierarchy," Dr. Baum says. Hospitalists want to be leaders, "but we have a responsibility to be intentional leaders, learning the skills and modeling them," she adds.

Improved teamwork benefits patients through more effective communication and reduction in medical errors, Dr. Baum says, "but it also helps to create a healthy environment in which to work, where we all have each other’s backs."

TeamSTEPPS, developed jointly by the federal Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense, has reached 25% to 30% of U.S. hospitals by annually training about 700 masters. The masters then go back to their institutions and share the techniques.

 

Read more about why improving teamwork is good for your patients.

 

Need another reason to hone your skills in treating people with kidney disease?

Take a look at a study out of the University of Washington: Kidney disease, researchers there found, is the diagnosis associated with the highest rate of readmission to the hospital and the emergency room and hospital mortality—controlling for cardiovascular disease, infection, sepsis, encephalopathy and “all the usual suspects associated with readmission,” says Katherine Tuttle, MD, clinical professor of medicine in the University of Washington Division of Nephrology.

The study, which included 676,000 hospitalized patients in Washington state in 2006 through 2008, was done in collaboration with Washington State University and Spokane-based Providence Sacred Heart Medical Center. Researchers found that the highest risk was found in patients on dialysis, but even in early stages of chronic kidney disease there was a significantly increased risk of readmissions and death, Dr. Tuttle said.¹

The reasons are not known.

“One reason we think is really important is this issue of medication management,” Dr. Tuttle says.

Researchers then did a pilot study showing that, at the time of discharge, if a pharmacist visited within the first week, the rates of readmission were reduced by 50 percent. “The goal of that visit was basically do what probably should have been done through the hospital, which is adjust drug doses properly for kidney function and address drug interaction,” Dr. Tuttle says.

The research team is working on a large study funded by the National Institutes of Health to validate those findings and look at a broader population of patients. This is more evidence pointing to the importance of handoffs, she says.

"These transitions in care are dangerous situations,” Dr. Tuttle says. “But they’re also opportunities for improvement. And I think anything we can do to enhance education management is likely to be very beneficial in people with chronic kidney disease.”

Hospitalists have "serious work to do in improving continuity in care, and handoffs in general,” she adds.

“So much of what they do in the hospital is influenced by kidney function, whether it’s the drugs they give or the diagnostic tests that they want to do,” she says. “I’m not being critical at all. It’s a new area, relatively speaking, and there are lots of opportunities for improvement in the system.”

Tom Collins is a freelance writer in South Florida.

Reference

1. Risks of subsequent hospitalization and death in patients with kidney disease. Clin J Am Soc Nephrol. 2012;7(3):409-416.

Need another reason to hone your skills in treating people with kidney disease?

Take a look at a study out of the University of Washington: Kidney disease, researchers there found, is the diagnosis associated with the highest rate of readmission to the hospital and the emergency room and hospital mortality—controlling for cardiovascular disease, infection, sepsis, encephalopathy and “all the usual suspects associated with readmission,” says Katherine Tuttle, MD, clinical professor of medicine in the University of Washington Division of Nephrology.

The study, which included 676,000 hospitalized patients in Washington state in 2006 through 2008, was done in collaboration with Washington State University and Spokane-based Providence Sacred Heart Medical Center. Researchers found that the highest risk was found in patients on dialysis, but even in early stages of chronic kidney disease there was a significantly increased risk of readmissions and death, Dr. Tuttle said.¹

The reasons are not known.

“One reason we think is really important is this issue of medication management,” Dr. Tuttle says.

Researchers then did a pilot study showing that, at the time of discharge, if a pharmacist visited within the first week, the rates of readmission were reduced by 50 percent. “The goal of that visit was basically do what probably should have been done through the hospital, which is adjust drug doses properly for kidney function and address drug interaction,” Dr. Tuttle says.

The research team is working on a large study funded by the National Institutes of Health to validate those findings and look at a broader population of patients. This is more evidence pointing to the importance of handoffs, she says.

"These transitions in care are dangerous situations,” Dr. Tuttle says. “But they’re also opportunities for improvement. And I think anything we can do to enhance education management is likely to be very beneficial in people with chronic kidney disease.”

Hospitalists have "serious work to do in improving continuity in care, and handoffs in general,” she adds.

“So much of what they do in the hospital is influenced by kidney function, whether it’s the drugs they give or the diagnostic tests that they want to do,” she says. “I’m not being critical at all. It’s a new area, relatively speaking, and there are lots of opportunities for improvement in the system.”

Tom Collins is a freelance writer in South Florida.

Reference

1. Risks of subsequent hospitalization and death in patients with kidney disease. Clin J Am Soc Nephrol. 2012;7(3):409-416.

Need another reason to hone your skills in treating people with kidney disease?

Take a look at a study out of the University of Washington: Kidney disease, researchers there found, is the diagnosis associated with the highest rate of readmission to the hospital and the emergency room and hospital mortality—controlling for cardiovascular disease, infection, sepsis, encephalopathy and “all the usual suspects associated with readmission,” says Katherine Tuttle, MD, clinical professor of medicine in the University of Washington Division of Nephrology.

The study, which included 676,000 hospitalized patients in Washington state in 2006 through 2008, was done in collaboration with Washington State University and Spokane-based Providence Sacred Heart Medical Center. Researchers found that the highest risk was found in patients on dialysis, but even in early stages of chronic kidney disease there was a significantly increased risk of readmissions and death, Dr. Tuttle said.¹

The reasons are not known.

“One reason we think is really important is this issue of medication management,” Dr. Tuttle says.

Researchers then did a pilot study showing that, at the time of discharge, if a pharmacist visited within the first week, the rates of readmission were reduced by 50 percent. “The goal of that visit was basically do what probably should have been done through the hospital, which is adjust drug doses properly for kidney function and address drug interaction,” Dr. Tuttle says.

The research team is working on a large study funded by the National Institutes of Health to validate those findings and look at a broader population of patients. This is more evidence pointing to the importance of handoffs, she says.

"These transitions in care are dangerous situations,” Dr. Tuttle says. “But they’re also opportunities for improvement. And I think anything we can do to enhance education management is likely to be very beneficial in people with chronic kidney disease.”

Hospitalists have "serious work to do in improving continuity in care, and handoffs in general,” she adds.

“So much of what they do in the hospital is influenced by kidney function, whether it’s the drugs they give or the diagnostic tests that they want to do,” she says. “I’m not being critical at all. It’s a new area, relatively speaking, and there are lots of opportunities for improvement in the system.”

Tom Collins is a freelance writer in South Florida.

Reference

1. Risks of subsequent hospitalization and death in patients with kidney disease. Clin J Am Soc Nephrol. 2012;7(3):409-416.

Two recent studies have reached the same surprising conclusion: Adherence to national quality and performance guidelines does not translate into reduced readmissions rates.

Sula Mazimba, MD, MPH, and colleagues at Kettering Medical Center in Kettering, Ohio, focused on congestive heart failure (CHF) patients, documenting compliance with four core CHF performance measures at discharge and subsequent 30-day readmissions. Only one measure-assessment of left ventricular function-had a significant association with readmissions.

A second study published the same month looked at a wider range of diagnoses in a Medicare population at more than 2,000 hospitals nationwide. That study reached similar conclusions about the disconnect between hospitals that followed Hospital Compare process quality measures and their readmission rates.

Dr. Mazimba says hospitalists and other physicians involved in quality improvement (QI) should be more involved in defining quality measures that reflect quality of care for their patients.

“We should be looking for parameters that have a higher yield for outcomes, such as preventing readmissions,” he says, encouraging better symptom management before the CHF patient is hospitalized and enhanced coordination of care after discharge.

Alpesh Amin, MD, MBA, SFHM, professor and chair of the department of medicine and executive director of the hospitalist program at the University of California at Irvine, says the findings are important, but he adds that the core quality measures studied were never designed to address readmissions.

“The challenge is to find a way to connect the dots between the core measures and readmissions,” he says.

Learn more about the four "core" heart failure quality measures for hospitals by visiting the Resource Rooms on the SHM website, or check out this 80-page implementation guide, “Improving Heart Failure Care for Hospitalized Patients [PDF],” also available on SHM’s website.

Read The Hospitalist columnist Win Whitcomb’s take on readmissions penalty programs.

 

Two recent studies have reached the same surprising conclusion: Adherence to national quality and performance guidelines does not translate into reduced readmissions rates.

Sula Mazimba, MD, MPH, and colleagues at Kettering Medical Center in Kettering, Ohio, focused on congestive heart failure (CHF) patients, documenting compliance with four core CHF performance measures at discharge and subsequent 30-day readmissions. Only one measure-assessment of left ventricular function-had a significant association with readmissions.

A second study published the same month looked at a wider range of diagnoses in a Medicare population at more than 2,000 hospitals nationwide. That study reached similar conclusions about the disconnect between hospitals that followed Hospital Compare process quality measures and their readmission rates.

Dr. Mazimba says hospitalists and other physicians involved in quality improvement (QI) should be more involved in defining quality measures that reflect quality of care for their patients.

“We should be looking for parameters that have a higher yield for outcomes, such as preventing readmissions,” he says, encouraging better symptom management before the CHF patient is hospitalized and enhanced coordination of care after discharge.

Alpesh Amin, MD, MBA, SFHM, professor and chair of the department of medicine and executive director of the hospitalist program at the University of California at Irvine, says the findings are important, but he adds that the core quality measures studied were never designed to address readmissions.

“The challenge is to find a way to connect the dots between the core measures and readmissions,” he says.

Learn more about the four "core" heart failure quality measures for hospitals by visiting the Resource Rooms on the SHM website, or check out this 80-page implementation guide, “Improving Heart Failure Care for Hospitalized Patients [PDF],” also available on SHM’s website.

Read The Hospitalist columnist Win Whitcomb’s take on readmissions penalty programs.

 

Two recent studies have reached the same surprising conclusion: Adherence to national quality and performance guidelines does not translate into reduced readmissions rates.

Sula Mazimba, MD, MPH, and colleagues at Kettering Medical Center in Kettering, Ohio, focused on congestive heart failure (CHF) patients, documenting compliance with four core CHF performance measures at discharge and subsequent 30-day readmissions. Only one measure-assessment of left ventricular function-had a significant association with readmissions.

A second study published the same month looked at a wider range of diagnoses in a Medicare population at more than 2,000 hospitals nationwide. That study reached similar conclusions about the disconnect between hospitals that followed Hospital Compare process quality measures and their readmission rates.

Dr. Mazimba says hospitalists and other physicians involved in quality improvement (QI) should be more involved in defining quality measures that reflect quality of care for their patients.

“We should be looking for parameters that have a higher yield for outcomes, such as preventing readmissions,” he says, encouraging better symptom management before the CHF patient is hospitalized and enhanced coordination of care after discharge.

Alpesh Amin, MD, MBA, SFHM, professor and chair of the department of medicine and executive director of the hospitalist program at the University of California at Irvine, says the findings are important, but he adds that the core quality measures studied were never designed to address readmissions.

“The challenge is to find a way to connect the dots between the core measures and readmissions,” he says.

Learn more about the four "core" heart failure quality measures for hospitals by visiting the Resource Rooms on the SHM website, or check out this 80-page implementation guide, “Improving Heart Failure Care for Hospitalized Patients [PDF],” also available on SHM’s website.

Read The Hospitalist columnist Win Whitcomb’s take on readmissions penalty programs.

 

Applying the HM model to specialties that can dedicate themselves to managing inpatients could improve care efficiency, says the coauthor of a new report from the American Hospital Association's (AHA) Physician Leadership Forum.

The 20-page report, "Creating the Hospital of the Future: The Implications for Hospital-Focused Physician Practice [PDF]," codified a daylong summit of hospitalist leaders and hospital administrators following the annual Health Forum/AHA Leadership Summit last July in San Francisco. SHM helped organize the meeting, which focused on the growing role and importance of "hyphenated hospitalists."

"With the hospitalist movement, it's critical that there is coordination between the inpatient and the outpatient world … but also inpatient-wise, there should be some coordination of services between the various specialties that are dedicated to the hospital," says John Combes, MD, AHA senior vice president. "We have an opportunity here, as more and more subspecialties develop hospital-based and hospital-focused practices, to construct it right."

Dr. Combes says the model is not applicable to all specialties, but early adoption by fields including OBGYN, orthopedics, neurology, and surgery is a good sign. Hospitalist could look at forming large, multispecialty groups to bring all hospital-focused programs under one proverbial roof. "So there's not only coordination at the hospital level, but also at the group level," he adds.

The continued growth of specialty hospitalists might hinge on whether research shows that the approach improves patient outcomes.

"The jury is out on that right now," Dr. Combes says. "As hospitalists get better at defining what their role is within the inpatient setting—particularly around care coordination, care improvement, efficiency, reduction of unnecessary procedures and testing—we'll be able to document more value."

 

Visit our website for more information about hospital-based medical practices.

 

Applying the HM model to specialties that can dedicate themselves to managing inpatients could improve care efficiency, says the coauthor of a new report from the American Hospital Association's (AHA) Physician Leadership Forum.

The 20-page report, "Creating the Hospital of the Future: The Implications for Hospital-Focused Physician Practice [PDF]," codified a daylong summit of hospitalist leaders and hospital administrators following the annual Health Forum/AHA Leadership Summit last July in San Francisco. SHM helped organize the meeting, which focused on the growing role and importance of "hyphenated hospitalists."

"With the hospitalist movement, it's critical that there is coordination between the inpatient and the outpatient world … but also inpatient-wise, there should be some coordination of services between the various specialties that are dedicated to the hospital," says John Combes, MD, AHA senior vice president. "We have an opportunity here, as more and more subspecialties develop hospital-based and hospital-focused practices, to construct it right."

Dr. Combes says the model is not applicable to all specialties, but early adoption by fields including OBGYN, orthopedics, neurology, and surgery is a good sign. Hospitalist could look at forming large, multispecialty groups to bring all hospital-focused programs under one proverbial roof. "So there's not only coordination at the hospital level, but also at the group level," he adds.

The continued growth of specialty hospitalists might hinge on whether research shows that the approach improves patient outcomes.

"The jury is out on that right now," Dr. Combes says. "As hospitalists get better at defining what their role is within the inpatient setting—particularly around care coordination, care improvement, efficiency, reduction of unnecessary procedures and testing—we'll be able to document more value."

 

Visit our website for more information about hospital-based medical practices.

 

Applying the HM model to specialties that can dedicate themselves to managing inpatients could improve care efficiency, says the coauthor of a new report from the American Hospital Association's (AHA) Physician Leadership Forum.

The 20-page report, "Creating the Hospital of the Future: The Implications for Hospital-Focused Physician Practice [PDF]," codified a daylong summit of hospitalist leaders and hospital administrators following the annual Health Forum/AHA Leadership Summit last July in San Francisco. SHM helped organize the meeting, which focused on the growing role and importance of "hyphenated hospitalists."

"With the hospitalist movement, it's critical that there is coordination between the inpatient and the outpatient world … but also inpatient-wise, there should be some coordination of services between the various specialties that are dedicated to the hospital," says John Combes, MD, AHA senior vice president. "We have an opportunity here, as more and more subspecialties develop hospital-based and hospital-focused practices, to construct it right."

Dr. Combes says the model is not applicable to all specialties, but early adoption by fields including OBGYN, orthopedics, neurology, and surgery is a good sign. Hospitalist could look at forming large, multispecialty groups to bring all hospital-focused programs under one proverbial roof. "So there's not only coordination at the hospital level, but also at the group level," he adds.

The continued growth of specialty hospitalists might hinge on whether research shows that the approach improves patient outcomes.

"The jury is out on that right now," Dr. Combes says. "As hospitalists get better at defining what their role is within the inpatient setting—particularly around care coordination, care improvement, efficiency, reduction of unnecessary procedures and testing—we'll be able to document more value."

 

Visit our website for more information about hospital-based medical practices.

 

There are 10 industry-changing recommendations in the recent Institute of Medicine (IOM) report “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.” Suggestions include reforming payment, adopting digital infrastructure, and improving the continuity of care. And to Brent James, MD, all of those recommendations are areas in which hospitalists can help lead healthcare from fee-for-service to an organized-care model.

Dr. James, executive director of the Institute for Health Care Delivery Research and chief quality officer at Intermountain Healthcare in Salt Lake City, says hospitalists can be linchpins to that hoped-for sea change because the specialty’s growth the past 15 years shows that physicians taking a collaborative, evidence-based approach to patient care can improve outcomes and lower costs.

“In some sense, the hospitalist movement triggered [the move to organized care],” says Dr. James, one of the IOM report’s authors. “You started to have teams caring for inpatients in a coordinated way. Pieces started to kind of fall into place underneath it. So I regard this as … [hospitalists] coming into their own, their vision of the future starting to really take hold.”

The report estimates the national cost of unnecessary or wasteful healthcare at $750 billion per year. Published in September, the report was crafted by a nationwide committee of healthcare leaders, including hospitalist and medical researcher David Meltzer, MD, PhD, chief of University of Chicago’s Division of Hospital Medicine and director of the Center for Health and Social Sciences in Chicago.

Dr. Meltzer says that for a relatively young specialty, hospitalists have been “remarkably forward-looking.” The specialty, in his view, has embraced teamwork, digital infrastructure, and quality initiatives. As the U.S. healthcare system evolves, he notes, HM leaders need to keep that mentality. Hospitalists are confronted daily with a combination of sicker patients and more treatment options, and making the right decisions is paramount to a “learning healthcare system,” Dr. Meltzer adds.

“As the database of options grows, decision-making becomes more difficult,” he says. “We have an important role to play in how to think about trying to control costs.”

Gary Kaplan, MD, FACP, FACMPE, FACPE, chairman and chief executive officer of Virginia Mason Health System in Seattle, agrees that HM’s priorities dovetail nicely with reform efforts. He hopes the IOM report’s findings will serve as a springboard for hospitalists to further spearhead improvements.

In particular, Dr. Kaplan notes that healthcare delivery organizations should develop, implement, and fine-tune their “systems, engineering tools, and process-improvement methods.” Such changes would help “eliminate inefficiencies, remove unnecessary burdens on clinicians and staff, enhance patient experience, and improve patient health outcomes,” he says.

“The hospitalists and the care teams with which the hospitalist connects are very critical to streamlining operations,” Dr. Kaplan adds.

Dr. James, who has long championed process improvement as the key to improved clinical outcomes, says that extending the hospitalist model throughout healthcare can only have good results. He preaches the implementation of standardized protocols and sees hospitalists as natural torchbearers for the cause.

 

“When you start to focus on process—our old jargon for it was ‘continuum of care’—it forces you to patient-centered care,” he says. “Instead of building your care around the physicians, or around the hospital, or around the technology, you build the care around the patient.”

Dr. James has heard physicians say protocols are too rigid and do not improve patient care. He disagrees—vehemently.

“It’s not just that we allow, or even that we encourage, we demand that you modify [the protocol] for individual patient needs,” he says. “What I have is a standard process of care. That means that you don’t have to bird-dog every little step. I take my most important resource—a trained, expert mind—and focus it on that relatively small set of problems that need to be modified. We’ve found that it massively improves patient outcomes.”

Many of the IOM report’s complaints about unnecessary testing, poor communication, and inefficient care delivery connect with the quality, patient-safety, and practice-management improvements HM groups already push, Dr. Kaplan adds. To advance healthcare delivery’s evolution, hospitalists should view the task of reform as an opportunity, not a challenge.

“There are very powerful opportunities for the hospitalist now to have great impact,” he says. “To not just be the passive participants in a broken and dysfunctional system, but in many ways, [to be] one of the architects of an improved care system going forward.”

Richard Quinn is a freelance writer in New Jersey.

There are 10 industry-changing recommendations in the recent Institute of Medicine (IOM) report “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.” Suggestions include reforming payment, adopting digital infrastructure, and improving the continuity of care. And to Brent James, MD, all of those recommendations are areas in which hospitalists can help lead healthcare from fee-for-service to an organized-care model.

Dr. James, executive director of the Institute for Health Care Delivery Research and chief quality officer at Intermountain Healthcare in Salt Lake City, says hospitalists can be linchpins to that hoped-for sea change because the specialty’s growth the past 15 years shows that physicians taking a collaborative, evidence-based approach to patient care can improve outcomes and lower costs.

“In some sense, the hospitalist movement triggered [the move to organized care],” says Dr. James, one of the IOM report’s authors. “You started to have teams caring for inpatients in a coordinated way. Pieces started to kind of fall into place underneath it. So I regard this as … [hospitalists] coming into their own, their vision of the future starting to really take hold.”

The report estimates the national cost of unnecessary or wasteful healthcare at $750 billion per year. Published in September, the report was crafted by a nationwide committee of healthcare leaders, including hospitalist and medical researcher David Meltzer, MD, PhD, chief of University of Chicago’s Division of Hospital Medicine and director of the Center for Health and Social Sciences in Chicago.

Dr. Meltzer says that for a relatively young specialty, hospitalists have been “remarkably forward-looking.” The specialty, in his view, has embraced teamwork, digital infrastructure, and quality initiatives. As the U.S. healthcare system evolves, he notes, HM leaders need to keep that mentality. Hospitalists are confronted daily with a combination of sicker patients and more treatment options, and making the right decisions is paramount to a “learning healthcare system,” Dr. Meltzer adds.

“As the database of options grows, decision-making becomes more difficult,” he says. “We have an important role to play in how to think about trying to control costs.”

Gary Kaplan, MD, FACP, FACMPE, FACPE, chairman and chief executive officer of Virginia Mason Health System in Seattle, agrees that HM’s priorities dovetail nicely with reform efforts. He hopes the IOM report’s findings will serve as a springboard for hospitalists to further spearhead improvements.

In particular, Dr. Kaplan notes that healthcare delivery organizations should develop, implement, and fine-tune their “systems, engineering tools, and process-improvement methods.” Such changes would help “eliminate inefficiencies, remove unnecessary burdens on clinicians and staff, enhance patient experience, and improve patient health outcomes,” he says.

“The hospitalists and the care teams with which the hospitalist connects are very critical to streamlining operations,” Dr. Kaplan adds.

Dr. James, who has long championed process improvement as the key to improved clinical outcomes, says that extending the hospitalist model throughout healthcare can only have good results. He preaches the implementation of standardized protocols and sees hospitalists as natural torchbearers for the cause.

 

“When you start to focus on process—our old jargon for it was ‘continuum of care’—it forces you to patient-centered care,” he says. “Instead of building your care around the physicians, or around the hospital, or around the technology, you build the care around the patient.”

Dr. James has heard physicians say protocols are too rigid and do not improve patient care. He disagrees—vehemently.

“It’s not just that we allow, or even that we encourage, we demand that you modify [the protocol] for individual patient needs,” he says. “What I have is a standard process of care. That means that you don’t have to bird-dog every little step. I take my most important resource—a trained, expert mind—and focus it on that relatively small set of problems that need to be modified. We’ve found that it massively improves patient outcomes.”

Many of the IOM report’s complaints about unnecessary testing, poor communication, and inefficient care delivery connect with the quality, patient-safety, and practice-management improvements HM groups already push, Dr. Kaplan adds. To advance healthcare delivery’s evolution, hospitalists should view the task of reform as an opportunity, not a challenge.

“There are very powerful opportunities for the hospitalist now to have great impact,” he says. “To not just be the passive participants in a broken and dysfunctional system, but in many ways, [to be] one of the architects of an improved care system going forward.”

Richard Quinn is a freelance writer in New Jersey.

There are 10 industry-changing recommendations in the recent Institute of Medicine (IOM) report “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.” Suggestions include reforming payment, adopting digital infrastructure, and improving the continuity of care. And to Brent James, MD, all of those recommendations are areas in which hospitalists can help lead healthcare from fee-for-service to an organized-care model.

Dr. James, executive director of the Institute for Health Care Delivery Research and chief quality officer at Intermountain Healthcare in Salt Lake City, says hospitalists can be linchpins to that hoped-for sea change because the specialty’s growth the past 15 years shows that physicians taking a collaborative, evidence-based approach to patient care can improve outcomes and lower costs.

“In some sense, the hospitalist movement triggered [the move to organized care],” says Dr. James, one of the IOM report’s authors. “You started to have teams caring for inpatients in a coordinated way. Pieces started to kind of fall into place underneath it. So I regard this as … [hospitalists] coming into their own, their vision of the future starting to really take hold.”

The report estimates the national cost of unnecessary or wasteful healthcare at $750 billion per year. Published in September, the report was crafted by a nationwide committee of healthcare leaders, including hospitalist and medical researcher David Meltzer, MD, PhD, chief of University of Chicago’s Division of Hospital Medicine and director of the Center for Health and Social Sciences in Chicago.

Dr. Meltzer says that for a relatively young specialty, hospitalists have been “remarkably forward-looking.” The specialty, in his view, has embraced teamwork, digital infrastructure, and quality initiatives. As the U.S. healthcare system evolves, he notes, HM leaders need to keep that mentality. Hospitalists are confronted daily with a combination of sicker patients and more treatment options, and making the right decisions is paramount to a “learning healthcare system,” Dr. Meltzer adds.

“As the database of options grows, decision-making becomes more difficult,” he says. “We have an important role to play in how to think about trying to control costs.”

Gary Kaplan, MD, FACP, FACMPE, FACPE, chairman and chief executive officer of Virginia Mason Health System in Seattle, agrees that HM’s priorities dovetail nicely with reform efforts. He hopes the IOM report’s findings will serve as a springboard for hospitalists to further spearhead improvements.

In particular, Dr. Kaplan notes that healthcare delivery organizations should develop, implement, and fine-tune their “systems, engineering tools, and process-improvement methods.” Such changes would help “eliminate inefficiencies, remove unnecessary burdens on clinicians and staff, enhance patient experience, and improve patient health outcomes,” he says.

“The hospitalists and the care teams with which the hospitalist connects are very critical to streamlining operations,” Dr. Kaplan adds.

Dr. James, who has long championed process improvement as the key to improved clinical outcomes, says that extending the hospitalist model throughout healthcare can only have good results. He preaches the implementation of standardized protocols and sees hospitalists as natural torchbearers for the cause.

 

“When you start to focus on process—our old jargon for it was ‘continuum of care’—it forces you to patient-centered care,” he says. “Instead of building your care around the physicians, or around the hospital, or around the technology, you build the care around the patient.”

Dr. James has heard physicians say protocols are too rigid and do not improve patient care. He disagrees—vehemently.

“It’s not just that we allow, or even that we encourage, we demand that you modify [the protocol] for individual patient needs,” he says. “What I have is a standard process of care. That means that you don’t have to bird-dog every little step. I take my most important resource—a trained, expert mind—and focus it on that relatively small set of problems that need to be modified. We’ve found that it massively improves patient outcomes.”

Many of the IOM report’s complaints about unnecessary testing, poor communication, and inefficient care delivery connect with the quality, patient-safety, and practice-management improvements HM groups already push, Dr. Kaplan adds. To advance healthcare delivery’s evolution, hospitalists should view the task of reform as an opportunity, not a challenge.

“There are very powerful opportunities for the hospitalist now to have great impact,” he says. “To not just be the passive participants in a broken and dysfunctional system, but in many ways, [to be] one of the architects of an improved care system going forward.”

Richard Quinn is a freelance writer in New Jersey.

A multidisciplinary pain-management research group at Mount Sinai School of Medicine in New York City has been evaluating numerical pain-rating scales, independent predictors of severe pain, their association with patient satisfaction rates, and improved inpatient pain outcomes resulting from targeted interventions with physicians. However, they found that while overall pain scores on medicine floors were lower than for surgical patients, they were also less responsive to the targeted interventions.

The group is piloting a program to promote pain champions in its department of medicine and encourage hospitalists to partner with nurses in focusing on pain assessment and treatment.

David L. Reich, MD, an anesthesiologist at Mount Sinai who leads the pain group, and colleagues recently published results from their research in the American Journal of Medical Quality.¹ Pain increasingly will be an issue for hospitals and hospitalists, he says, with two pain-related questions now included on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey that is part of the government’s value-based purchasing initiative.

“It is our belief that unrelieved pain is an overall driver of other patient-reported metrics,” Dr. Reich says.

Andrew Dunn, MD, SFHM, head of the hospitalist service at Mount Sinai, acknowledges that medicine floors have been less successful at improving pain management, in part because the patient population is so much more heterogeneous.

“One thing that did not work was to have the pain team join medical rounds. That’s just not systematic or robust enough,” Dr. Dunn says. “We have piloted a program where patients’ pain scores are now delivered twice a day in reports to nurse managers and floor medical directors.”

Consecutive reports of pain scores of 5 or more (on a scale of 0 to 10) trigger consideration of a consultation with either the anesthesiology pain-management service or palliative-care service.

Reference

1. Reich DL, Porter C, Levin MA, et al. Data-driven interdisciplinary interventions to improve inpatient pain management. Am J Med Q. 2012 Sept 25 [Epub ahead of print].

A multidisciplinary pain-management research group at Mount Sinai School of Medicine in New York City has been evaluating numerical pain-rating scales, independent predictors of severe pain, their association with patient satisfaction rates, and improved inpatient pain outcomes resulting from targeted interventions with physicians. However, they found that while overall pain scores on medicine floors were lower than for surgical patients, they were also less responsive to the targeted interventions.

The group is piloting a program to promote pain champions in its department of medicine and encourage hospitalists to partner with nurses in focusing on pain assessment and treatment.

David L. Reich, MD, an anesthesiologist at Mount Sinai who leads the pain group, and colleagues recently published results from their research in the American Journal of Medical Quality.¹ Pain increasingly will be an issue for hospitals and hospitalists, he says, with two pain-related questions now included on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey that is part of the government’s value-based purchasing initiative.

“It is our belief that unrelieved pain is an overall driver of other patient-reported metrics,” Dr. Reich says.

Andrew Dunn, MD, SFHM, head of the hospitalist service at Mount Sinai, acknowledges that medicine floors have been less successful at improving pain management, in part because the patient population is so much more heterogeneous.

“One thing that did not work was to have the pain team join medical rounds. That’s just not systematic or robust enough,” Dr. Dunn says. “We have piloted a program where patients’ pain scores are now delivered twice a day in reports to nurse managers and floor medical directors.”

Consecutive reports of pain scores of 5 or more (on a scale of 0 to 10) trigger consideration of a consultation with either the anesthesiology pain-management service or palliative-care service.

Reference

1. Reich DL, Porter C, Levin MA, et al. Data-driven interdisciplinary interventions to improve inpatient pain management. Am J Med Q. 2012 Sept 25 [Epub ahead of print].

A multidisciplinary pain-management research group at Mount Sinai School of Medicine in New York City has been evaluating numerical pain-rating scales, independent predictors of severe pain, their association with patient satisfaction rates, and improved inpatient pain outcomes resulting from targeted interventions with physicians. However, they found that while overall pain scores on medicine floors were lower than for surgical patients, they were also less responsive to the targeted interventions.

The group is piloting a program to promote pain champions in its department of medicine and encourage hospitalists to partner with nurses in focusing on pain assessment and treatment.

David L. Reich, MD, an anesthesiologist at Mount Sinai who leads the pain group, and colleagues recently published results from their research in the American Journal of Medical Quality.¹ Pain increasingly will be an issue for hospitals and hospitalists, he says, with two pain-related questions now included on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey that is part of the government’s value-based purchasing initiative.

“It is our belief that unrelieved pain is an overall driver of other patient-reported metrics,” Dr. Reich says.

Andrew Dunn, MD, SFHM, head of the hospitalist service at Mount Sinai, acknowledges that medicine floors have been less successful at improving pain management, in part because the patient population is so much more heterogeneous.

“One thing that did not work was to have the pain team join medical rounds. That’s just not systematic or robust enough,” Dr. Dunn says. “We have piloted a program where patients’ pain scores are now delivered twice a day in reports to nurse managers and floor medical directors.”

Consecutive reports of pain scores of 5 or more (on a scale of 0 to 10) trigger consideration of a consultation with either the anesthesiology pain-management service or palliative-care service.

Reference

1. Reich DL, Porter C, Levin MA, et al. Data-driven interdisciplinary interventions to improve inpatient pain management. Am J Med Q. 2012 Sept 25 [Epub ahead of print].