Published in the December 2003 issue of Today’s Hospitalist
Program: Northeast Inpatient Medical Service
Location: Bangor, Maine (affiliated with and owned by 100-bed St. Joseph Hospital)
Year founded: 1996
Staffing: 10 full-time dedicated hospitalists; four mid-level providers
Services: Inpatient care; referral base includes 75 local primary care physicians, multiple specialists and subspecialists, and a number of physicians from 11 hospitals in rural Maine
Average daily census: 45-55
When Kenneth Simone, DO, decided to establish Northeast Inpatient Medical Service in 1996, he knew that end-to-end communication would be crucial not only in ensuring good care, but also in securing the trust of the referring-physician community. That’s why when it came time to develop a model for the hospitalist group in Bangor, Maine, Dr. Simone made timely communication one of his chief objectives.
“From day one,” he says, “we felt that to be successful, we had to communicate as the patients were coming in to the hospital, during their stay and as they were leaving, from PCP to hospitalist and hospitalist back to the PCP.”
While that may sound simple enough, every hospitalist knows that the logistics of such a system can be daunting. Ensuring that admitting hospitalists have all the patient data they need before they evaluate the patient “and that referring physicians have a detailed discharge summary in hand soon after their patients leave the hospital “is no small task.
Dr. Simone started with his own wish list, based in part on his experience as a private-practice family physician. Then, with a little help from administrators at nearby St. Joseph Hospital, he began to build a communication system that would achieve several objectives.
The system that emerged includes the following components:
- Comprehensive patient data before admission. Referring physicians are required, as a condition of participation, to give hospitalists information on six areas: past medical and surgical history (problem list); known allergies; next-of-kin contact information; DNR wishes/status; current medications; and a summary of the presenting problem and recent medical history, including tests and studies from the previous three months.
Referring physicians receive a checklist of the requested items and admission protocol when they commit to admitting patients to the hospitalist service. This not only closes the “information loop” during admission, but it ensures that patients don’t receive duplicative “and expensive “tests.
- Daily communication, via a dedicated voicemail system, on inpatient status and treatment decisions. Hospitalists report daily on patients’ status and the action plan for the next day using a voicemail system. (Each referring physician has his or her own box.) The voicemail system pages referring physicians when a message has been sent. When major treatment decisions need to be made, hospitalists alert the referring physician in advance, if possible, using the voicemail system.
- A process to make sure that referring physicians receive a complete discharge summary within three hours of the patient’s departure from the hospital. This feature works because the hospital’s transcription department has promised to turn around hospitalist dictations within an hour of receiving them. Transcriptionists immediately send the completed summary to the referring physician via fax or e-mail.
- A post-discharge survey sent to referring physicians and patients. After every admission, both the patient and the referring physician receive a written survey about the patient’s care and the services provided by the hospitalists.
“If someone doesn’t get the services we’ve promised, we know about it immediately,” Dr. Simone explains. He adds that he and the hospitalist service’s clinical director and quality assurance manager meet with high-volume admitting physicians once a month. They update those physicians on utilization and other issues, and they ask for feedback on any problems they “or patients “have experienced.
Of all the elements of the program’s communication strategy, the voicemail system has been the best received by both the referring physicians and hospitalists, Dr. Simone says.
“The referring physicians appreciate not being called out of the exam room to take a phone call from the hospitalist when they’re in the middle of a procedure,” he explains. “And the hospitalists like it because they don’t have to wait on the line or wait for a return call. It’s just more convenient and efficient for everybody.”
The system, which costs $250 a month for 50 mailboxes, has more than paid for itself over the years, Dr. Simone notes. He admits that his hospitalist service has “dropped the ball on occasion” from a communication standpoint, but he adds that the open flow of information between referring physicians and hospitalists ensures that occasional problems don’t become major issues.
Requiring hospitalists to notify referring physicians of major treatment decisions and the initial patient data have both proven invaluable for hospitalists, particularly when they have to make big decisions quickly. For example, Dr. Simone explains, an elderly patient might come in with acute abdominal pain and other problems. Without adequate patient information and prior communication from the referring physician, however, the hospitalist is likely to err on the side of caution.
“Let’s say a patient comes in with a dissecting aneurysm and a history of terminal metastatic cancer. If we don’t know the patient, we would just take the patient to surgery,” he says. “With the system in place, the hospitalist on duty simply calls the referring physician and explains that the patient has an abdominal aortic aneurysm that looks as if it will rupture.”
In some cases, Dr. Simone explains, the referring physician may explain that the patient wouldn’t want the surgery, or that he’s a poor surgical candidate. Conversely, the referring physician might say that the family has indicated they want the patient to receive all treatment.
The discharge summary serves multiple purposes, most notably to clear up the communication mishaps that so often occur when patients move from one care setting to another, or to home. “It helps to have the physician in the loop, so that when the patient’s wife calls the referring doctor a few hours after her husband gets home to ask about a medication that’s been ordered or post-surgical care issues, the PCP knows what happened,” Dr. Simone says.
Although communication is at the core of the group’s success “the group plans to hire an 11th hospitalist next September to manage its growing patient volume “the effort expended in solidifying the relationship between the hospitalist group and its referral base is what seals the deal. Both entities see the arrangement as a partnership rather than a “handing off” of patients.
“Our referring physicians buy in to our system because they look at the hospitalists as their partners “partners who happen to work in the hospital,” Dr. Simone explains. “They’re not likely to tell their patients that they’re going to refer them to ‘someone at the hospital who will take care of them,’ but that they’re referring them to their partner Dr. Jones, who will see that they get out of the hospital sooner. That goes a long way into helping the patient buy into the system as well.”