Published in the August 2007 issue of Today’s Hospitalist.
At first glance, Christine Myatt, MD, has a situation most hospitalists would try to avoid: She is on call for her own patients during the night.
But according to Dr. Myatt, the arrangement is no big deal. In fact, she says, one of the perks of her job is that most of the time, she is home throughout the night and can read her 9-year-old son a bedtime story.
“It allows my family to have some degree of sanity,” Dr. Myatt says of her call schedule. “Sometimes I have an emergency where I have to come back in, but that’s rare.”
How can a hospitalist be on call at night but rarely have to go to the hospital? In Dr. Myatt’s case, it’s because she is the lead physician at Houston’s Triumph Hospital at Town and Country, a long-term acute care hospital.
Her patients are seriously ill, but they’re generally stable, and Triumph has no emergency room, so no patients are admitted at night. Because the average length of stay hovers around 25 days, Dr. Myatt can write PRN orders for situations that are most likely to occur overnight. And with a physician always on-site at the facility, Dr. Myatt can get coverage, even when she’s on call.
When asked to explain the biggest difference between working at a long-term acute care hospital and the more common hospitalist option at a short-term acute hospital, Dr. Myatt puts it simply: “The difference is that you can sleep at night.”
Long-term acute care hospitals, also known as LTACs, are acute facilities that treat medically complex patients who have an average length of stay of at least 25 days. LTACs are the only hospitals in which the patient population is defined by length of stay, and payers like the Centers for Medicare and Medicaid Services (CMS) reimburse their care at much higher rates than traditional hospitals.
Although most of the nation’s 390 LTACs rely solely on community physicians, savvy CEOs are learning the advantages of hiring hospitalists to improve quality of care and operational efficiency. Many hospitalists, however, are either unaware “or misinformed “of job opportunities at LTACs.
“Physicians hear the long-term part, and they sort of miss the acute-care aspect,” says Deb Graves, RN, CEO of Regency Hospital of Minneapolis, which owns 21 LTAC hospitals around the country.
While LTACs are often confused with nursing homes or rehabilitation facilities, there’s a big difference. LTACs treat patients that might be classified as intensive care patients at short-term hospitals.
Respiratory conditions, psychoses and ventilator cases account for the highest proportion of admissions at most hospitals, according to a report issued by the CMS earlier this year. But patients with serious wounds, head trauma and a wide range of other medical conditions are also commonly referred.
LTAC patients are expected to survive “industry-wide, the mortality rate is about 30% “but the complexity of their medical problems is such that their length of stay will greatly exceed the four days that is typical at conventional hospitals.
Nearly half of all LTACs are so-called “hospitals within hospitals,” because they are hosted by a short-term hospital that leases a floor, wing or other space to the LTAC.
LTACs and hospitalists
Because of their unique nature, some LTACs are finding that working with hospitalists offers a perfect match. In 2004, Kindred Long Term Acute Care Hospital in Seattle contracted with TeamHealth, a hospitalist management firm, to move to a hospitalist model. The reasoning was simple: Community physicians were increasingly reluctant to round on patients, and there were plenty of hospitalists in the local job market.
“We were having a hard time finding physicians who were qualified to take care of patients who are this sick,” says Cheryl Payseno, RN, MPH, the hospital’s CEO.
Staffed with four hospitalists and one intensivist who pool their efforts to function as a multidisciplinary team, Kindred fully embraced the advantages of the hospitalist model.
“We have developed specific processes and are trying to standardize our work,” says William Boyan, MD, a pulmonologist at the Seattle hospital. “This cannot be done with a wide variety of providers coming in over their lunch hours.”
As in most venues in which hospitalists practice, consistency in patient care translates into better financial performance. Indeed, average length of stay at the 35-bed facility has dropped from 41 days to 27 days in the 2.5 years since the hospitalists came on board. The operating cost per admission has been cut by 29% over that same time period, and the hospital’s pharmacy costs per patient day are among the lowest of any Kindred facility nationwide.
While Kindred has been able to reduce variability in patient care, its hospitalists are helping it earn a reputation as a hotbed of research to identify the most effective treatment protocols for specific situations. “We are pioneers in that regard,” Dr. Boyan says. “And the first step to being able to do that work is that you have to be consistent.”
From an administrative viewpoint, “this has been a huge success,” Ms. Payseno says. “The underlying cause is the hospitalist who is managing these patients so much more effectively.”
An emerging model
Regency Hospital Company, which maintains an LTAC network across the country, first brought hospitalists into its LTACs in 2004, when it acquired a long-term hospital in Minneapolis. Since then, two other Regency LTACs have hired hospitalists.
Ms. Graves says the decision to use hospitalists reflected the facility’s status as a freestanding hospital and the fact that hospitalists are the predominant inpatient providers in the Minnesota market.
In Houston, another hospitalist hotbed, CEOs have similarly discovered the virtues of dedicated inpatient physicians. Dr. Myatt’s practice, which is affiliated with IPC-The Hospitalist Company, serves three LTACs, one of which saw its Press Gainey patient satisfaction scores jump from 70% to 98% after hospitalists came on board.
“Many of the hospitals are realizing that we are able to increase their reimbursements because our documentation is usually excellent,” Dr. Myatt says. “We’re actually in demand at more LTAC hospitals than we can cover in this region.”
But industry experts acknowledge that in most markets, that is not yet the norm. Ms. Payseno from Kindred, another national LTAC company, says the LTAC industry has been slow to embrace hospitalists because many hospitals rely on community physicians to make referrals into their hospital.
The right mindset for LTACs?
While overall salaries and workload for LTAC hospitalists are similar to those in short-term hospitals, LTAC employment is not for everyone.
“Because we are truly a freestanding hospital,” says Ms. Graves from Regency, “it really takes someone who has a comfort level with their skills. Our consultants come and they go, and you really need to feel that you can handle a crisis should one occur.”
While LTACs often require specific clinical skills, such as the ability to do central lines, long-term facilities also force hospitalists to develop communication skills akin to those of primary care physicians.
“People who are successful in an LTAC have to enjoy taking care of a patient through the long stay,” Dr. Myatt says. “They need to be able to talk to families about discharge planning and sometimes end-of-life hospice. You have a pretty intense relationship with the patient and the family.”
In other instances, LTACs can have difficulty getting specialists to round on their patients, something that can be frustrating or attractive, depending on the interests of the individual hospitalist.
“That can be an advantage for a more generalist physician who likes to do a little cardiology, a little nephrology, someone who has a more broad spectrum of training and likes that,” says Adam Singer, MD, president of IPC-The Hospitalist Company, which has contracts with more than 20 LTACs nationwide.
While the workload is comparable to that at a short-term hospital, the pace at an LTAC is different. At Regency in Minneapolis, hospitalists see about 15 patients in an eight-hour shift, or up to 20 if they work 12 hours. But because most patients have long stays, the disruption of admissions and discharges is much less time-consuming.
Ms. Graves says that her company looks for hospitalists who want the opportunity to spend enough time with a patient to see dramatic improvement in their health status.
“You get to see that patient come in on multiple drips, antibiotics, on the ventilator, unable to do anything for themselves,” she explains. “Then, hopefully, you’re also able to see that patient walk 100 feet with a walker, decannulated, on their way to rehab.”
That, she added, “is an amazing ‘sell’ for a certain type of physician who really wants to be a part of and manage that progression.”
Lola Butcher is a health care business writer who is based in Springfield, Mo.
LTAC growth: Any end in sight?
While the first long-term acute care (LTAC) facilities opened in the early 1980s, the model has boomed in the last decade, particularly in states like Texas and Florida, which have a large number of Medicare beneficiaries. But now there are questions about whether payers like the Centers for Medicare and Medicaid Services (CMS) are going to try to rein in that growth.
Concerned that patients are being inappropriately referred to LTACs because of the higher reimbursement those facilities receive, the CMS has begun introducing regulations that limit the proportion of patients that can be referred to a LTAC from a single short-term hospital.
The American Hospital Association (AHA) is fighting those CMS strategies to lower overall payments to LTACs. “There is a reason these hospitals have developed, and that is the care they provide is better than any other setting these patients could receive it,” says Don May, AHA’s vice president of policy. “This type of care needs to be facilitated, not squashed by the CMS.”
Although new LTACs are opening at a brisk pace, in part because of the aging population and increasing demand for their services, some LTACs have succumbed to the CMS’ referral rules. Mr. May points out, for instance, that the total number of LTACs in service actually decreased in 2006.
Nonetheless, he says he expects the LTACs to play an ever-increasing role in the health care continuum in the future.
“We will continue to see expansion of this across the country, regardless of where Medicare regulations go,” he says. “That’s going to happen because this has become the model of care that is the best for treating those patients.”