Communication, Best Practices are Key to Hospitalist Programs
April 1, 2000 7 minutes read
Communication, Best Practices are Key to Hospitalist Programs
Collaboration with primary care physicians critical
There’s no magic involved in building a successful hospitalist program, just some key fundamentals, says Ronald A. Greeno, MD, a co-founder and vice president of network development for Cogent Medical Care, Laguna Hills, CA.
Those include voluntary participation, clearly delineated responsibilities, and complete, open communications between hospitalists and primary care physicians (PCPs), he says. Greeno is obviously an advocate of hospitalist systems and maintains that "a well-designed and administered hospitalist plan is simply a better model of care." He emphasizes that a well-structured program is never mandatory, but allows the PCPs the option of turning their patients over to the hospitalist program. And when PCPs decide to turn their in-hospital work over to one of Cogent’s hospitalist programs, everything that’s going to happen regarding patient care has already been clearly spelled out and agreed to by all parties. This includes not only in-hospital patient management but all the process issues that surround a patient’s hospitalization as well.
Greeno adds that in a good hospitalist program, the PCP has clear expectations of the hospitalist team for both the patient’s clinical management and the process issues that surround hospitalization. "The only way to do this is for the participating physicians to agree on what the expectations will be, educate everyone as to what the expectations are, then put a system in place that allows tracking to see if they were met. "That’s what we’ve done to standardize care across a network of hospitalist physicians," Greeno says. "What is a true hospitalist practice? There is no uniform set of standards," says Greeno. "Right now, any generalist or medical subspecializing physician can say I’m a hospitalist and if you want me to take care of your patients in the hospital, I’ll do that.’"
He adds that some programs merely change the staffing model by sending the patient to a small group of doctors in the hospital. "At Cogent," Greeno says, "we decided it isn’t sufficient just to change who takes care of patients in the hospital. We improved the model to create a higher level of patient care and put the systems in place that ensure it."
Data equals best practice standards
Cogent hospitalist programs use data management to elevate the standard of care for hospitalized patients by consistently applying evidence-based medicine, Greeno says. He notes that best practice standards are supported by medical literature and have been agreed to by a large number of physicians across a wide geography. Yet even though certain things have now been identified as best medical practices, many times those practices are not implemented.
For example, best practices now call for putting most patients with congestive heart failure on an ACE inhibitor. "The evidence is clear from the medical literature, and it has been there for years," Greeno says. "Yet if you look at any population of patients in the country, up to 70% of them are not on these medications."
Clearly, hospitalists can’t do anything about patients who have heart failure who don’t end up in the hospital. But all patients with heart failure who come into a Cogent-run program are evaluated for taking an ACE inhibitor prior to their release, he says.
"Our data collection system allows us to measure how well we are meeting best practice standards," Greeno says. "We track results and feed that information back to the physicians so that they can see if they need to make improvements."
He notes that outcomes data are becoming more important as time goes on. "The government is going to expect it, our peers are going to expect it, and physician groups that are able to demonstrate their outcomes will be way ahead of groups that can’t."
Communication should be constant
Constant communication between the hospitalist team and the PCP, both during the hospitalization and when the patient transfers back to the outpatient arena, is central to success, Greeno says.
Cogent-trained hospitalists initially obtain a newly admitted patient’s medical history to complete their own database. Any key event that occurs for that patient during hospitalization is immediately relayed to the PCP.
"We have a list of mandatory status changes we require our hospitalist team to report to the primary care physician, ranging from change in code status to death," says Greeno. "We also document those changes in our data system so that we know when that communication happened."
These hospitalists fax a database-format discharge letter to the PCP that includes information on diagnosis, procedures, consultants, medications, suggested follow-up, and home health care. The PCP then has a hard copy in hand for the patient’s next appointment. The same information is entered into the hospitalist team’s database in case the patient is readmitted or admitted to another hospital in the same city.
Cogent also uses a Web-based database accessible to any hospitalist physician with security clearance.
"Many times patients are admitted to a second hospital, where they have no medical records," Greeno says. "What we are doing is tying the patient’s medical information to the patient rather than an institution and making it readily available to the people who need to make rapid clinical decisions should the patient be admitted to a hospital again."
Patient discharge information is also available to the personnel at Cogent’s call centers, who contact patients after they go home and review their discharge information with them to make sure their discharge plans are being implemented. Did they pick up their medications? Do they know how to take them? Do they have a way to get to their follow-up appointment? Did their oxygen and home health care provider arrive?
If a patient answers "no" to any of these, a nurse trained as clinical care coordinator by Cogent handles the problem. "Without this follow-up, you’d never know about these things until the patient was readmitted, Greeno says. "All of this is driven by a two-minute dictation the hospitalist makes at the time of discharge. The database entries, follow-up phone call, patient satisfaction survey all flow from a single process put in place by the hospitalist."
Data management saves time and money
Greeno, who is triple-boarded in internal medicine, pulmonary, and critical care, also co-directs the critical care unit at Good Samaritan Hospital in Los Angeles. He observes that many hospitals waste huge amounts of their time and money resources because personnel don’t know the right way to do things and are not available when decisions need to be made. "For example," he says, "a patient is admitted to one hospital and gets an MRI. A week later, the same patient is admitted to a second hospital and gets a second MRI because nobody knew about the first one."
He points out that sometimes a patient can remain in a hospital for days with little being done because his or her PCP needs to see 30 patients per day in the office and isn’t available to follow up on hospital tests. "When we started this organization," Greeno says, "we saw that the number of health care resources was about to be limited. Now, medical-care providers in this country are almost in a position where it’s necessary to ration health care, yet 30-40% of the dollars spent on hospitalized patients is wasted because no one was focusing on the patient’s in-hospital care."
Cogent was started by groups of physicians who wanted to be hospitalists but wanted access to infrastructure in order to deliver a better program. "We couldn’t do it as individual groups, so we got together as a larger group to create that infrastructure," Greeno says. "Then other groups became interested in having us help them."
The company has built its standard operating model by installing information systems that gather performance data, evaluating those data, and putting systems into place that increase reliability of communications with PCPs.
The company’s customers are organizations with a group of patients for whom they are at risk who contract with Cogent to build and manage a hospitalist system.
This is how Cogent puts a hospitalist program in place:
• Finds physicians within the community who want to be in the hospitalist business for a particular patient population. "We don’t employ physicians or buy physician practices," Greeno says. "We use physicians who are already practicing in those hospitals."
• Contracts with those physicians who want to use Cogent’s model to bring them the population of patients they desire. Those physicians are independent contractors with Cogent, taking care of those patients in that hospital.
• Hires and trains the nurses who coordinate clinical care.
• Puts in information systems and operations people. "We have people who stay in that market who make sure that the operation continues to run smoothly. You can’t just set these things up and expect them to run smoothly," Greeno says.
Cogent’s hospitalist program implementation takes about a 120 days before the first patients are seen. The model is designed to make doctors more efficient and to put processes and people in place to support them.
The company has put hospitalist programs in about 55 hospitals in nine states. Growth has been rapid. Cogent’s first program began in October 1997.
"What you are saying by virtue of using a hospitalist model is that you can do a better job of taking care of patients," Greeno says. "Unless you are prepared to demonstrate that, you shouldn’t be saying it."
Source
1. Ronald A. Greeno, MD, 23282 Mill Creek Road, Suite 300, Laguna Hills, CA 92653. Telephone: (949) 699-6003. Fax: (213) 977-0544.
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