Published in the January 2008 issue of Today’s Hospitalist
Editor’s note:This is the third in a series of profiles on hospitalist groups that have launched new services. In this month’s issue, we highlight a hospitalist practice that has taken on preoperative evaluations.
GROUP: Gates Hospitalists LLC
LOCATION: Kansas City, Mo.
NEW SERVICE: Preop assessment of orthopedic patients
The decision by Gates Hospitalists LLC in Kansas City, Mo., to establish a preoperative evaluation service was driven by two mutual needs. On the one hand, orthopedic surgeons were looking for a level of efficiency in the operating room that often eluded them. At the same time, the hospitalists wanted to provide better perioperative continuity for patients.
The orthopedists found themselves having to cope with some delays in getting patients’ history and physicals. The solution they proposed ” that the hospitalists launch a preop evaluation service “would take care of that problem.
And the proposed service would also help solve what the hospitalist group’s founder, Lancer Gates, DO, sees as “a fundamental inherent flaw” in hospital medicine staffing: a daily encounter roster that varies little between weekdays and weekends.
Unless patient volume plummets on weekends by about 40%, he explains, hospitalist programs have to staff nearly the same number of hospitalists on the weekend as they do during the week. For the four physicians who were then part of Dr. Gates’ group, that meant working every other weekend “a surefire recipe for burnout.
“Hospitalists like to have weekends off, just like everyone else,” says Dr. Gates. “The only way to do that is to lower the number of encounters on the weekend, or increase them during the week and hire more hospitalists.”
Saving hospitalists’ sanity
The orthopedic group was struggling with a series of surgical delays. Their patients would be referred back to their family physicians for preop evaluations, but history and physicals still might not be available by the time of surgery.
Some orthopedic patients had trouble scheduling a preop appointment with a busy family physician, while other patients had their dictated history and physicals held up in office transcription. Or family physicians who practiced quite far from the hospital didn’t have privileges to do the history and physicals. The orthopedists, meanwhile, were losing slots in the operating room or facing delays, and in 2004, they called the hospitalists for help.
That’s when Dr. Gates had his “aha” moment. If the group took on the service, he realized, it would beef up its weekday service volume. That would make it possible for the group to hire more hospitalists and spread out weekend shifts among a bigger pool of physicians, freeing up more weekends for everyone.
Dr. Gates had been wrestling with the weekend scheduling problem since he founded the group in 2000, and he wasn’t any happier than his crew about working every other weekend. What proved to be a godsend for the orthopedic surgeons “having a history and physical on the patient’s chart in time for surgery “turned out to be a sanity-saver for the hospitalists.
Avoiding unpleasant surprises
“Increasing our Monday-to-Friday volume has allowed us to achieve 33% coverage on the weekends,” he explains. In 2007, the hospitalist group grew to five physicians. And “we have signed on a sixth physician to begin this coming April,” Dr. Gates adds, which will allow the group to share call one of every three weekends.
Establishing the preop service has produced other benefits, both clinical and logistic. Patients are evaluated well in advance of their procedure, typically 10 days to two weeks out. That’s reduced the number of unpleasant surprises that sometimes surfaced just before or after surgery.
One hospitalist found a dental abscess in a patient about to undergo hip surgery, Dr. Gates recalls, while another physician discovered that a patient scheduled for joint replacement had an MI two weeks earlier. One patient being evaluated turned out to be critically ill and was admitted on the spot, and Dr. Gates personally found a blood clot in a patient about to undergo knee arthroscopy.
How it works
Gates Hospitalists provides preop evaluations three days a week, from 8 a.m. to noon, at the two facilities that the group covers, Liberty Hospital and North Kansas City Hospital. The evaluations are scheduled through the hospitals’ pre-surgery clinics, and hospitalists can usually arrange any tests that patients need the same day.
Because the evaluations are standardized and thorough, the surgeons know that the patients “have been optimized” for the procedure, he says. “There have been times when we’ve called the surgeon and cancelled the procedure.” Anesthesiologists, he adds, have likewise been pleased with the service.
The group’s hospitalists have received some targeted training in performing evaluations. And this year, Dr. Gates plans to have each physician take a perioperative medicine “crash course.” Short intensive courses are offered by both the Mayo Clinic and the Cleveland Clinic.
When possible, individual hospitalists preoperatively evaluate the same patients who they’ll be following postoperatively. That provides for continuity of care internally, Dr. Gates explains. “We don’t reach 100%, but we’re close.” The group performs about 10 evaluations a week at Liberty Hospital and only a handful at the other facility, where the service started just last year.
The group bills for outpatient management services, and the associated revenue has boosted the group’s bottom line without causing claims hassles. “Payment hasn’t been an issue because the surgeons write a consult and a reason,” Dr. Gates explains. The main financial benefit to the group, he adds, is that the service has allowed it to increase overall staffing.
In fact, the arrangement is going so well that the group wants to expand it. “Ideally, I’d like this to be 30% to 40% of our practice, because we really make a difference medically,” says Dr. Gates, who adds that the service now accounts for 5% of the group’s business. “I don’t have numbers, but I’ve seen patients have a better perioperative experience.”
Politics and barriers
The service has been the subject of only a few minor turf issues, with some primary care physicians preferring to do an evaluation even when patients will be followed post-surgically by the hospitalists.
Otherwise, Dr. Gates says, the service has been well-received. Hospital administration has been very supportive, and the group has experienced little pushback from family physicians whose patients will undergo an inpatient procedure, rather than day surgery.
“We don’t get any resistance at all from the PCPs who are a long distance from here,” says Dr. Gates. “And we have a lot of patients who live more than two hours away.”
Bonnie Darves is a freelance writer specializing in health care. She is based in Chadds Ford, Pa.
Tips for starting a preop evaluation service
- Look for links to existing services. “Hospitalist groups have to diversify if they’re going to survive,” says Lancer Gates, DO, the founder of Gates Hospitalists LLC in Kansas City, Mo. “But when you look for a service to add, make sure you relate it to something you’re already doing in the hospital.” He says that doing preoperative evaluations is an excellent adjunct to surgical co-management arrangements that many hospitalist groups already have in place.
- Sort out referring physician relationships and preferences ahead of time. You should sort these out before the patient is scheduled for evaluation. “If the PCPs can do these evaluations more efficiently, or prefer to do them, they should,” says Dr. Gates.
- Keep primary care physicians in the loop. Even if the surgeon sends the patient to the service, communicating with the primary physician is in order. “We’re trying to do the best thing for the patient, the orthopedic surgeon and the family doc,” Dr. Gates says.