Published in the April 2011 issue of Today’s Hospitalist
Ask Lauren Doctoroff, MD, how she and several other hospitalists at Beth Israel Deaconess Medical Center in Boston felt two years ago when they agreed to help staff a post-discharge clinic part-time, and she sums it up with one word: worried.
“We were leery of crossing the line between inpatient and outpatient,” Dr. Doctoroff says, “and of stepping on the toes of primary care providers. With hospitalists leaving the hospital setting, we wanted to be very careful to draw the line and not position ourselves as a primary care clinic.”
She notes that while the hospitalists at Beth Israel Deaconess kicked around the idea of starting a post-discharge clinic for years, concerns about turf issues and mission creep had always killed the idea. But with a surge of newly insured patients in the wake of health care reform in Massachusetts and a growing number of at-risk patients not getting timely follow-up, the hospitalists felt their hand was finally being forced.
A year or so ago, it would have been easy to chalk up Dr. Doctoroff’s experience as particular to the state of health care in Massachusetts. But as health care continues to evolve, in part because of national health care reform, many hospitals and hospitalists may soon find themselves making similar plans to provide post-discharge care.
Even if hospitalists decide to embrace post-discharge care, it will be far from a done deal. Some experts wonder if having hospitalists leave the acute care setting is little more than a band-aid that masks fundamental access problems in American medicine. The notion that hospitalists will follow patients into the outpatient setting for even a short time has some primary care physicians howling in protest.
But a growing number of hospitalists are looking at post-discharge care not just as a stopgap measure, but as a serious solution to prevent unnecessary readmissions and control costs. Some also believe that it could become a major opportunity for the specialty.
Drawing the line
Dr. Doctoroff says that in the two years since her group started the post-discharge clinic, her colleagues’ concerns about invading primary care turf have not been realized. But that’s in part because the group designed a post-discharge clinic with strict parameters.
Clinic visits with hospitalists are available only for patients who are seen by the doctors in the faculty practice and who can’t get a follow-up appointment with their primary care physician within a week or 10 days. And it’s rare, she says, for any of those patients to see a hospitalist in the clinic more than once before being handed back to their outpatient doctor.
Even more importantly, the hospitalists steer clear in clinic visits of anything that smacks of primary care. “We’ve designed a visit that is very focused on the hospitalization: medication reconciliation, outstanding tests and follow-up on things that need to be done,” Dr. Doctoroff says. “It’s the same responsibilities we have as hospitalists, but we’re just taking them a little bit further.”
Dr. Doctoroff says that she sees both the pros and the cons of having hospitalists briefly leaving the wards to see patients. (She’s one of four hospitalists staffing the clinic part-time.) The downside is that patients lose some continuity of care with their primary care physician, even if it’s only temporary. On the plus side, she says, “Patients benefit in terms of us bringing our inpatient expertise to the outpatient setting.”
And the fact that hospitalists don’t have a long history with patients can make for more targeted clinic visits. “When patients see their primary care doctor after they’ve left the hospital, they may go back to complaining about the same things they complained about before their admission,” Dr. Doctoroff points out. “It’s easier for us to say, ‘I know you have chronic back pain, but what we’re here to talk about is X.’ Because patients don’t know us, it can be easier to focus the clinic visit.”
In San Francisco, hospitalist Sumana Kesh, MD, is one of four hospitalists with the University of California, San Francisco (UCSF), who help staff a post-discharge clinic part time. The patients she sees are also all insured, but they either don’t have primary care physicians or can’t see them soon after discharge.
Dr. Kesh is convinced that the high-risk patients she treats post-discharge benefit from seeing a hospitalist outside the hospital. For one, she says, she’s much faster at accessing patients’ discharge information through the electronic medical record than her primary care colleagues.
“I know what to look for,” she says, “so the appointment is quicker.”
But Dr. Kesh admits that the post-discharge care now in place is far from her original idea of a stand- alone clinic. Right now, the post-acute patients she sees are being shoehorned into UCSF’s urgent care clinic where some are seen by the primary care physicians who staff the clinic.
Sharing a clinic with primary care physicians has its drawbacks. The physicians on either side of that divide belong to different departments, for instance, with different leadership. While the two physician groups aren’t at odds with one another, Dr. Kesh says, they do have to share limited resources.
It’s that lack of resources that’s stopping the hospital medicine group from reaching more post-discharge patients. While uninsured patients are in great need of post-discharge care, Dr. Kesh points out, the hospital system can’t provide that funding.
She plans to apply for city and county grants to expand the clinic’s scope of care, but she lacks the staff to navigate the paperwork. And while she’s acting as director of the post-discharge clinic, she has no dedicated time to administer it “so she simply tacks that administration on to her full-time hospitalist work. “If I could buy out my time,” she says, “I could do more with this.”
A better business case?
If academic centers like UCSF have a hard time mustering funds for post-discharge care, even for insured patients, individual hospitals are even more hard-pressed. Robert Holloway, MD, co-founder, CEO and CMO of IN Compass Health, a hospitalist management company in Alpharetta, Ga., helped establish a post-discharge clinic at an inner-city Atlanta hospital in 1997 where IN Compass was managing a hospitalist program. The clinic was designed to provide post-discharge care to uninsured and Medicaid patients.
“It was doomed,” Dr. Holloway says, adding that the hospitalists maintained the clinic for several years before the hospital transitioned it to a Coumadin clinic. “It just financially didn’t make sense.” That “doomed” business case may now be changing, in large part because Medicare is planning to start penalizing hospitals with higher than expected readmission rates in 2013.
“That’s probably going to be a push in the future, and we’ve kicked the idea around in different places,” Dr. Holloway notes. IN Compass has thought about establishing post-discharge clinics for patients with heart failure in its hospitalist programs in Florida that treat a high number of Medicare patients.
But even if the dollars do start adding up, post-discharge clinics may be appropriate only in certain settings. “If you have patients with special needs like Coumadin or a high indigent population or not good primary care coverage in the community, it might make sense,” Dr. Holloway says. “But one-size-fits-all just doesn’t work.”
Finding the right volume
It was the lack of primary care coverage that led the hospitalists with the University of New Mexico Health Sciences Center in Albuquerque to push for a post-discharge clinic in 2007. According to Kendall Rogers, MD, chief of hospital medicine, the concept was “a hard sell” to the administration.
But in Albuquerque, even some patients with primary care physicians weren’t able to get follow-up for months after discharge, Dr. Rogers says. “We also had many patients who didn’t have primary care physicians, and we had no options for them.”
After four years, the clinic is still not, as Dr. Rogers dryly puts it, “an effective cost center.” Yet the hospital has seen enough clinical benefit from it to expand the clinic from three half days a week to full time. The clinic now accepts not only those patients who the hospitalists have identified as being at high risk for readmission, but high-risk patients from the medical ICU, some cardiology patients and even some patients who’ve been seen in the ED.
“We’ve discussed the possibility of doing preop evaluations through the discharge clinic as well,” Dr. Rogers says. “That way, we’d catch some of the same population both before admission and after discharge.”
Finding “discharge failures”
Dr. Rogers points out that the hospitalists don’t staff the post-discharge clinic. Instead, it’s run by a nurse practitioner who’s part of the hospital medicine department. (See “Keeping post-discharge care within hospital medicine,” below.)
But like other physicians interviewed for this article, Dr. Rogers says that getting feedback from someone staffing a post-discharge clinic has been incredibly illuminating for the hospitalist group.
“A big reason to keep this within the hospital medicine section is because it helps us identify failures in our discharge process,” he says. The NP who runs the clinic, he explains, keeps an Excel spreadsheet to document “discharge failures.” The list includes medications that don’t match, patients who don’t know their discharge diagnosis, patients who aren’t aware of their follow-up appointments, and patients with misconceptions that stop them from filling prescriptions.
“We want to capture all of that to improve those processes,” says Dr. Rogers. “The discharge clinic serves as our canary in the mine.”
Some of that feedback has changed the way hospitalists approach discharges. The physicians now realize, for instance, how frequently “many of our patients cherry pick their medications,” Dr. Rogers explains. “They get only a few out of the 10 that we sent them home on.” That’s led the hospitalists to “stress to patients which medications we feel they absolutely need to get if they’re only going to get a few.”
Dr. Rogers appreciates the fact that his hospital is at least “willing to sit at the table and talk about post-discharge care, now that readmissions are hitting the main stage.”
But as far as he’s concerned, a post-discharge clinic “is never a long-term solution,” he says. “It’s only a band-aid for the larger, systemic issue of access that currently doesn’t exist, so we definitely hope to be put out of business.”
Making it work
In southern California, multispecialty groups and IPAs have for years accepted financial risk for patients “a business model that more physicians around the country may be exposed to through accountable care organizations and, possibly, the use of bundled payments. Many of those physicians now see post-discharge care as a good clinical and business opportunity.
For nearly two years, the hospitalists with Health- Care Partners, a physician-owned multispecialty group that has more than 80 hospitalists serving in more than 15 facilities, have helped maintain five post-discharge clinics. Each clinic sees patients covered by the multispecialty group.
The clinics are not a just stopgap measure, but an integral part of the group’s strategy to provide effective transitional care, according to Tyler Jung, MD, the hospitalist group’s medical director.
He notes that in accepting global risk, the multispecialty group has made post-discharge care a priority in other ways as well. It maintains a team of providers, for instance, who visit the sickest, most frail patients at home, and it gives patients enrolled in the post-discharge program around-the-clock access to care even when the clinics are closed.
The goal, he points out, is to not only cut readmissions, Dr. Jung says, but “help reduce ED visits”.
The role of transitional care
Dr. Jung adds that in his group’s transitional care model, the post-discharge team may hang onto some patients for a while instead of automatically returning them to primary care after only a visit or two. The transitional care team also takes on patients who have particularly challenging chronic conditions, not just high-risk patients coming out of the hospital.
Some patients may be seen by transitional team members for a matter of months, a fact that could cause concern among the multispecialty group’s affiliated primary care physicians. “This is now a kind of clinic vs. clinic situation where primary care physicians could have some very small loss of income,” he says. “We reconciled that and made them whole with stipends for these patients.”
While the post-discharge clinics and the homecare program have made progress toward reducing unnecessary readmissions, Dr. Jung says that both are still works in progress. The group continues to tinker with its definition of who’s at high risk for readmissions, and it’s working out the optimal roles and responsibilities for different team members.
“Because this is such a new field,” he adds, “we have to figure out what interventions within these clinics or the home-care setting actually make a difference. We need to be strategic and figure out what’s valuable because just doing more primary care and giving physicians more time to do a longer exam doesn’t work.”
Finally, there’s another big challenge: finding hospitalists interested in providing transitional care. While some older hospitalists find the work a welcome change of pace, Dr. Jung says that most hospitalists would rather do acute care exclusively.
But if the type of business model that his group is used to “taking global risk for patients “becomes more of the norm, that’s a challenge that hospitalists everywhere may have to face, Dr. Jung says.
“As the goals of care change over time, everybody is going to have to reinvent themselves, and I think hospitalists should gravitate toward these positions,” Dr. Jung says. “If the model shows that these patients are better cared for by hospitalists than by outpatient physicians or geriatricians, then I think transitional care will be part of our job.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
WHILE MANY POST-DISCHARGE CLINICS are staffed by hospitalists with an interest in transitional care, the unit run by the hospitalist group of the University of New Mexico Health Sciences Center in Albuquerque is staffed full-time by a nurse practitioner.
According to Kendall Rogers, MD, chief of hospital medicine, the group has been fortunate to find a nurse practitioner who not only had inpatient experience but who has also done primary care.
A hospitalist does provide oversight for the NP, and while the midlevel works exclusively in the post-discharge clinic, she’s a member of the hospital medicine department and attends all hospital medicine meetings. It was, Dr. Rogers adds, very important to have the person staffing the post-discharge clinic be part of the hospitalists’ home team.
That’s because through her clinic work, the NP sees what hospitalists aren’t doing right in terms of discharge planning and education. “We wanted her to be a part of our group so that it’s not an adversarial situation when she’s giving us feedback about what goes wrong,” says Dr. Rogers.
To help focus post-discharge visits even more, Dr. Rogers says that the goal is for the NP staffing the clinic to at least visit patients being referred to the clinic while they’re still in the hospital. (In practice, he says, the NP probably meets half the clinic patients at the bedside before discharge.)
That helps get the NP up to speed on patient problems. Perhaps even more importantly, it also cuts down on one of the biggest problems plaguing post-discharge clinics: no-shows.
The no-show rate for people being referred to the post-discharge clinic is running about 36%, he notes, which is higher than primary care practices in his system suffer. (The rate of no shows for post-discharge care provided by the hospitalists at the University of California, San Francisco, is even higher: 50%.)
“We definitely know that the patients that the NP sees in the hospital have a much higher show rate than the ones she doesn’t meet in person,” Dr. Rogers points out. “That’s one reason we want her to meet them in the hospital.”
A new type of medical home
SINCE IT WAS FOUNDED IN 1995, Intercede Health “a physician-owned medical management company with six hospitalist programs in Texas and Virginia “has fielded requests from hospitals to establish post-discharge clinics for indigent patients who had no primary care follow-up.
“But we couldn’t make it from a business standpoint,” says Philip Sanger, MD, the company’s founder, “so we never moved into that model.”
What the company has had success with is maintaining transitional care clinics for insurers that include the U.S. Family Health Plan for military members and their families, Medicare Advantage plans and managed Medicaid plans. Intercede Health established its first transitional care clinic in 1997 and now runs six clinic sites, all in the Houston area.
So what does transitional care look like when done by payers who save money keeping patients out of hospitals? For one, the patients seen by Intercede Health’s transitional care team aren’t exclusively those who’ve just been discharged. Some, for instance, are patients at the end of life. Others are patients who’ve had several stable conditions for years but are now getting older and finding some medical problems becoming more acute.
“There is no one-size-fits-all,” points out Amy Kaszak, the company’s president of transitional care clinics. Patients who need only post-discharge support will be seen in the clinics for perhaps three months. “Patients transitioning with their families to an end-of-life situation will generally use three to six months of visits,” Ms. Kaszak says. Other patients who have more complex chronic needs than primary care physicians can treat may be seen for up to nine months.
According to Dr. Sanger, who says he coined the phrase “extensivist” to describe the type of physician working in transitional care, hospitalists make a perfect fit. They are used to managing very acute medical conditions without calling in a slew of specialists. “We also look for doctors who are very used to having appropriate end-of-life discussions,” Dr. Sanger adds.
Now that Medicare’s readmission penalty is looming, says Intercede Health CEO Gray Miller, many more hospitals are calling, interested in getting a transitional care clinic off the ground.
The challenge, Mr. Miller says, is figuring out how to manage the downside risk. “I worry about those things that aren’t in our control,” he says, which include how many case managers and social workers a hospital system would be willing to devote to transitional care. Patient transportation can be another challenge that can derail a clinic, and Mr. Miller says that his company has had to work with its insurer partners to convince them to cover patients’ transportation costs and copays.
As for the future of transitional care, Mr. Miller says he sees it evolving into several tiers of “medical homes.” Primary care practices, for example, would be the medical home for patients at low and moderate risk.
But in addition to having clinics provide short-term support for some patients post-discharge, “we see transitional care clinics evolving into specialty homes for the highest- risk patients,” Mr. Miller points out. “The high-end-acuity patient home, where you take that minority of patients who carry the majority of costs, is where the rubber has to hit the road.”