Very different hospitalist models deliver same outcomes’ benefits
Flexibility, cost savings are chief attractions
At Atlanta’s Crawford Long Hospital, a hospitalist program is staffed by recent medical school graduates and provided as an amenity for primary physicians. At Health Midwest Hospital System in Kansas City, MO, physicians with at least five years of hospital experience are carefully recruited as hospitalists to manage the care of a broad spectrum of patients on a full-time basis.
At Kaiser Permanente’s health care facilities in Santa Clara, CA, hospitalists include physicians who choose to do extra inpatient care, as opposed to extra outpatient clinic duty, during periods of peak hospital occupancy. Meanwhile, at Hershey (PA) Medical Center, a variation of the hospitalist model has been implemented to help the internal medicine staff maintain clinical skills in the fast-changing field of hospital-based medicine.
By all accounts, however medical facilities choose to implement it, the hospitalist model of inpatient care is growing. According to Robert M. Wachter, MD, of the Department of Medicine at the University of California-San Francisco, "Over the past two to three years, their [hospitalists] numbers have multiplied as the attention paid to their work has exploded." While the model has its critics, he notes, "few of them deny that the forces promoting the hospitalist model will ultimately lead to its expansion into a major — if not the major — system for inpatient care in the United States."1
And as you might expect, as the model spreads, it gets "tweaked" to suit the needs of the markets in which it takes hold. Healthcare Benchmarks asked members of several health care organizations to share their experiences using the hospitalist model, along with tips for making it work.
Within the General Internal Medicine Section at Hershey Medical Center, an academic health center that’s a unit of the Penn State/Geisinger Health System section, two physicians spend six months of the year caring exclusively for hospital patients. Meanwhile, a group of eight other physicians spends at least three months annually doing only inpatient care. There were several reasons behind this unit’s decision to adopt this variation of the hospitalist model of care, explains section chief Gregory M. Caputo, MD. But the primary one was "to improve the quality of care in the inpatient setting."
In the past, one-month hospital rotations once or twice per year have been considered the norm for internists, says Caputo. But these days, "If you are going to practice internal medicine in a hospital setting, we feel that it is important that you spend at least three months of the year doing nothing but hospital medicine. In the rapidly changing world of hospital-based medicine, we feel that having this minimum amount of time caring solely for hospital patients is essential to maintaining important clinical skills."
The hospitalist program at Hershey is voluntary, he says. "If a primary physician has a patient in his office that requires hospitalization, he has full freedom to admit that patient under his own care and not use the services of the hospital-based physician," Caputo adds.
When the hospitalist is used, though, "It is critical for the patient’s primary physician to be integrated, one way or another, into the decision- making process during hospitalization," he says. When handled successfully, "You get the benefits of the hospitalist, a person with very finely honed skills in hospital-based medicine, working on site and making decisions that help guide the patient through acute illness and the process of hospitalization," Caputo explains. Meanwhile, the hospitalist "maintains close contact with the patient’s personal physician during the course of hospitalization in order to insure continuity of care."
Based on his experience at Hershey, Caputo says that the hospitalist model of care works well. "It is not perfect, but it’s still evolving. There appears to be emerging data suggesting that the cost and efficiency of care may be positively impacted by hospital-based physicians," he adds. "But quite frankly, even though that is an important issue, it is certainly not the driving force in our movement toward that model."
Benefits for docs — and patients, payers?
At Crawford Long Hospital of Emory Univer-sity, a general acute-care hospital in Atlanta, the hospitalist model works as an amenity for area primary care physicians, according to COO Al Blackwelder. "We wanted to create something to set our hospital apart as being doctor-friendly’ in the marketplace as we competed for business."
Crawford Long’s hospitalist service is staffed by recent internal medicine graduates of Emory University’s School of Medicine. The service "allows physicians with hospitalized patients — rather than scramble to find someone to cover while they have to be away for some reason or another — to simply make a phone call to us and turn over the patient to the hospitalist service," he says. Alternatively, "If a patient has to be admitted from our emergency room at 2 a.m., their physician, rather than having to roll out of bed to come in and admit them, can call our hospitalist." From there, "the hospitalist admits the patient, does the history and the physical, puts the patient to bed with orders, and in the morning, turns the patient back over to the physician, later submitting a bill for the services rendered," Blackwelder explains.
While the Crawford Long program is an amenity for physicians, the hospital has generated some preliminary length of stay (LOS) data indicating some possible benefits for patients and payers. Between July 1997 and February 1998, nonrisk-adjusted raw data for a small sample of Crawford Long patients show that those admitted for heart failure and treated by all physicians had an average LOS of 5.1 days; those treated within the hospitalist service had an average LOS of 3.8 days. For gastroenteritis, the figures were 4.4 days and 2.6 days, respectively, and for chest pain, 2.3 and 1.4.
Take care in recruiting
Kaiser Permanente’s rollout of a hospitalist system at 16 hospitals in northern California is documented in a recent issue of the Annals of Internal Medicine (1999; 130:355-359). At the HMO’s Santa Clara Medical Center, "We are now in the process of trying to figure out if there are any differences in outcome measures on the facility level and, if so, why," says Diane Craig, MD, a hospital-based specialist who is assistant physician-in-chief at Santa Clara.
Craig says that one key to the success of a hospitalist program is the ability to staff flexibly. At Santa Clara Medical Center, the number of inpatients doubles during the winter months, she notes. To handle the load, this facility can call on a pool of physicians that normally work in two satellite outpatient clinics to work a rotation in the hospital, augmenting the hospitalists that normally staff the hospital’s medical department.
You have to be careful about the kind of physician you place in the role of the hospitalist, says Craig. "You have to watch out when you use pool [i.e., normally outside-the-hospital] physicians. Not knowing about all the alternatives you may have available to hospitalization," she says, "they are generally going to be pretty conservative and wind up admitting everybody."
It takes more than technical/professional skill to be a good hospitalist, adds Craig. "When you are recruiting, you want to get good physicians, but you also want physicians that can work as part of a team." Under a hospitalist system, "there are a lot of handoffs between physicians, so you have to get people that are able to work well with colleagues," she notes, "as well as with nurses, social workers, discharge planners, and everybody else in the hospital setting."
Hospitalists need to realize that they are involved "in what is really a team sport," says Craig, "that’s a lot different from working in the clinic, where you pretty much do your own thing." Additionally, aspiring hospitalists need to know what they are getting into. "We cover our service 24 hours a day/7 days a week, which means that more than half of the shifts are either during off hours or on weekends," she notes. "There are a lot of people that don’t want to do that."
In Kansas City, MO, Health Midwest Hospital System gets its hospitalists from San Antonio-based Hospital Inpatient Management Systems (HIMS). The hospitalist system at this hospital began in 1996, according to HIMS medical director Thomas Simmons, MD, who was a member of a local internist/family practice office at the time. "And after we all got familiar with it, we agreed that it was a better system of care," he notes.
At Health Midwest and several other smaller systems served by HIMS in the Kansas City area, average LOS has dropped by around 39% since 1996, according to HIMS statistics. Meanwhile, Simmons reports that one area hospital served by HIMS has recorded an average actual cost of hospitalization for patients admitted for congestive heart failure of $4,300 when care was handled by a hospitalist, compared with a $5,600 average actual cost for those handled by all other physicians.
The key to the success of a hospitalist program is selecting the right physicians, according to Simmons.
"The majority of physicians I have hired have had at least five years of experience in hospitals and outpatient work," he reports. "You also need someone that can handle a large volume of patients and situations simultaneously. At any one given time, [the hospitalist] may have three or four patients in the emergency room, all needing evaluation for admission. And the physician has to be able to handle that situation, while at the same time keeping the individual patients and their families happy."
Once hired, the hospitalist’s communication skills become crucial. "Communication is absolutely key — with the primary care physicians, the consultants, the patients, and their families," says Simmons.
When you are a hospitalist, "You are dealing with patients that are acutely ill, and in most cases, you haven’t even met them before. You have to establish almost instant rapport with these patients and their families and get them to trust that you are there to provide the best care available under difficult circumstances," he notes. "This takes a special kind of person, as well as someone who is good at picking out this kind of person."
[For more information, contact:
• Gregory M. Caputo, MD, Section Head of Internal Medicine, Hershey Medical Center/Penn State-Geisinger Health System, Section of GIM, UPC2, P.O. Box 850, Hershey, PA 17033. Telephone: (717) 531-8161.
• Al Blackwelder, COO, Crawford Long Hospital, 550 Peachtree St., Atlanta, GA 30065. Telephone: (404) 686-2449.
• Diane Craig, MD, Kaiser Permanente Medical Center, 900 Kiely Blvd., Santa Clara, CA 95051. E-mail: [email protected].
• Thomas Simmons, MD, Medical Director, Hospital Inpatient Management Systems, 6400 Prospect, Suite 446, Kansas City, MO 64132. Telephone: (816) 444-4646.]
Reference
1. Wachter RM. Foreword. The hospitalist movement in the United States. Ann Intern Med 1999; 130:337.
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