Home What Works To boost admissions (and do the right thing), these hospitalists took on...

To boost admissions (and do the right thing), these hospitalists took on nursing home duties

February 2004

Published in the February 2004 issue of Today’s Hospitalist

Program: Stormont-Vail HealthCare Hospitalist Service Line

Hospitals served: Stormont-Vail Regional Health Center and eight nursing homes

Year founded: 1998 (with four hospitalists)

Staffing: Nine hospitalists work as part of the Cotton O’Neil Clinic, a 130-physician internal medicine multispeciality group, and are employed by Stormont-Vail HealthCare

Services: Inpatient care provided 24 hours a day/7 days a week. Hospitalists make 45 percent to 50 percent of all medical admissions to the medical center and serve as medical directors of eight local nursing homes

Average daily census: 100-120

One to two days each month, the nine hospitalists at Stormont-Vail HealthCare in Topeka, Kan., can be found in an unusual place. They are rounding in local nursing homes.

While the idea was controversial even within their own ranks, Stormont-Vail’s hospitalists agreed to take on nursing home work a year ago after the group’s chief medical officer came to them with the idea. Not only would the move help steer admissions to the group, he argued, but it would provide a great public service for the community.

“The hospitalists are the ones who were seeing these people anyway, since these patients are in and out of the hospital. I thought they might as well get to know them,” explains Kent Palmberg, MD, Stormont-Vail’s senior vice president and chief medical officer. (Dr. Palmberg was the internist who first organized the hospitalist service at Stormont-Vail eight years ago.)

“Most hospitalist programs continue to be hospital-contained, and I don’t know who else is trying to go out into the community like this,” he says. “But I see it as institutional medicine, a natural evolution of a hospitalist program.”

A growing need

Dr. Palmberg explains that the idea of putting hospitalists into nursing homes arose after he heard a steady stream of complaints from two sources.

Frustrated by the hassles of working as the medical directors of nursing homes, Stormont-Vail internists were leaving their posts. Nursing home administrators, in turn, were worried about what to do, and some were begging him for help.

“I had been a medical director of a nursing home for 17 years, so I was very aware of the pressures involved,” Dr. Palmberg recalls. “But I also had some sense of community responsibility. I think one of the most embarrassing things in America is the care we are providing to our nursing home residents. More and more doctors are saying they won’t go there.”

Dr. Palmberg says that he approached Stormont-Vail’s hospitalists. “I said I know this is not what you signed up for,” he recalls, “but this is the situation.”

He told the group’s physicians that if they agreed to take on the nursing home work, he would provide a full-time nurse practitioner to handle most of the day-to-day work, to field phone calls and to interact with patients’ families. The hospitalists would not have to squeeze nursing home work into their busy days on the wards. That work would instead be scheduled in advance for one or two days a month, when physicians would round at their assigned nursing home.

Today, each hospitalist is assigned to one or two nursing homes. The group currently covers eight nursing homes.

The nursing home responsibilities have required Stormont-Vail to add the equivalent of another full-time hospitalist to the roster, along with a dedicated nurse practitioner with special gerontology training.

A work in progress

The group voted to take on nursing home work only after much debate. And despite all of the planning, the assignment continues to be a “work in progress.”

Because three of the nine hospitalists “hate” the nursing home work, the group is now trying to figure out a way to give these colleagues some other responsibilities instead. (The group combines and equally distributes RVUs to help make sure that the physicians equally share the workload.)

Despite the changing nature of the work, Dr. Palmberg explains that picking up nursing home work has accomplished exactly what he had hoped.

For one, it has produced a steady stream of admissions, many of which previously had been heading to the competition. And as word gets out, Dr. Palmberg says he has been receiving calls from other nursing homes asking Stormont-Vail’s hospitalists to work at their facilities as well.

From a patient care perspective, he says that nursing home admissions are typically straightforward. Many patients present with acquired pneumonia, dehydration or sepsis from urinary tract infections.

“You really don’t end up with a lot of train wrecks out of nursing homes that become outliers for the hospital,” he explains. The hospitalists have also found that they can prevent some serious problems by helping the nursing homes care for their patients better.

The ground rules

When Dr. Palmberg muses about what has worked to make his hospitalists a well-respected, stable and growing service in the community, he points to a set of stringent rules he put in place “and has continually enforced with support from top administrators “from the very beginning.

At the core is a simple rule that hospitalist care must be “start to finish.” That, he explains, means that primary care physicians can’t call on a hospitalist to admit a patient at an inconvenient hour “the middle of the night or a Friday afternoon “and then come in when it’s more convenient and ask for the patient back. They also can’t admit one of their patients and then pass that individual off to a hospitalist because they don’t want to come in on a weekend.

“You have to enforce that rule,” he adds. “If hospitalists feel like housestaff for the attendings, they start to lose their sense of professionalism. If you look at hospitalist morale around the country, you find that it is related to whether physicians feel exploited or underappreciated. You have to protect their professionalism.”

When the issue has surfaced from time to time, he says, Stormont-Vail’s top leadership has gone to outpatient doctors and backed the hospitalists up. “Trying to find good hospitalists is everybody’s biggest challenge,” he says. “You don’t want to lose them.”