Home Comanagement Crafting the best comanagement agreements

Crafting the best comanagement agreements

Finding the right fit

January 2020

WHEN CARDIOTHORACIC SURGEONS at WellStar Kennestone Hospital decided in 2016 that they wanted to spend more time in the operating room, they asked the local hospitalist group to take responsibility for their patients postop.

But the hospitalists in the Marietta, Ga., hospital were wary. Any comanagement pact couldn’t result in hospitalists feeling they were “a dumping yard” for the cardiothoracic surgeons, says Sonia Camphor, MD, a Kennestone hospitalist and the director of WellStar’s acute collaborative care program.

It also couldn’t let surgeons off the hook for continuing to engage with patients once the surgery was done, and it couldn’t cross boundaries of scope of practice. That’s when intense negotiations to produce a written comanagement agreement began.

“I need to be able to pick up the phone and say, ‘This person is not looking good.’ “

–Sonia Camphor, MD

~ Sonia Camphor, MD
WellStar Kennestone Hospital

Dr. Camphor’s position was that the hospitalists would be happy to become “captains of the ship” for these surgical patients with medical problems. But in exchange, “I need to be able to pick up the phone and say, ‘This person is not looking good,’ and know the cardiothoracic surgeons will promptly respond.” Another condition: The surgeons needed to assign an advanced practice provider to carry a dedicated phone or pager and participate in daily interdisciplinary rounds.

“When I go into a room, I want to be able to say, ‘Mr. Smith, we are doing the rounds in collaboration with our surgical partners. They are here to answer any surgical questions, and I am here to answer any medical questions,’ ” she explains.

Relying as it does on both interdisciplinary rounds and geographic cohorting, the comanagement structure that Dr. Camphor and her colleagues hammered out may not be typical. But it is a successful example of what’s become a major focus of many hospitalist groups: how to improve comanagement. That’s because comanagement has become not only one of the most common parts of their jobs but, for many, one of the most frustrating.

Ripe for improvement
While nearly all hospitalists comanage patients with surgeons and other specialists, many say the experience is among the least agreeable parts of their job.

They point to chart wars in lieu of face-to-face dialogue, poor engagement on the part of specialists who sign off way too early, a pervasive perception of disrespect or mistrust, and irritability—and even burnout—due to overwork and lack of control. They rue missed opportunities for teamwork that could improve care quality and patient experience, reduce duplication, and cement provider satisfaction for a job well done.

But even given those hard feelings, hospitalists say there are ways to improve comanagement. They point out that programs like Dr. Camphor’s in Georgia are leading the way.

“If the hospitalist doesn’t take the lead in establishing ground rules, they will never get done.”

–Asim Usman, MD

~ Asim Usman, MD
Envision Physician Services

“To me, that’s what we do: comanage,” says Asim Usman, MD, the Dallas-based senior vice president at Envision Physician Services who has oversight of about 25 hospitalist groups throughout the central and western U.S. In his experience, turning around a bad comanagement situation always starts with improving communication, even if doctors are looking for a quicker fix.

“If the hospitalist doesn’t take the lead in establishing these ground rules, they will never get done. You have to own it,” Dr. Usman says. Because it can be hard to get the surgeons to the table, “I usually go to their meeting rather than having them come to us. And you stay on it until you come to an agreement.” Far from being resolved overnight, “it’s a 12-to-18 month process.”

Mutual complaints
During those meetings, Dr. Usman says he expects “complaints from the hospitalists that they are being dumped on or the surgeons won’t come in and see their patients on time.” From the surgeons, he’ll often hear that the hospitalists don’t know enough about postop care or “they’re not prompt enough for my patients.”

His recommendation: Get the hospital’s chief medical officer (CMO) involved. Not only can CMOs act as a mediator or referee, they often chime in with useful information about metrics and certifications that should be incorporated into comanagement agreements. Plus, they can provide insights into the value-based purchasing requirements that may be behind a C-suite’s call for more comanagement across service lines.

And when surgeons complain that the hospitalists aren’t managing patients appropriately, “I say, ‘Bring me a case example and we’ll go over it,’ ” says Dr. Usman. Such cases are often fewer and farther between than the surgeons initially let on.

But they can reveal legitimate quality problems. “Are you ordering too many labs or not being aggressive enough treating infections?” he asks. “Or are you working up too many low-grade fevers?”

“We need to have everyone sitting in the same room at the same time.”

Joan Stalzer, MD

~ Joan Stalzer, MD
Augusta Health

Grumbling may also highlight practical problems that need to be fixed. In several different hospitals, for example, Dr. Usman has encountered surgeons who insist they can’t come in every day because ” ‘I don’t have the bandwidth.’ It’s then clear that the hospital needs to hire an advanced practice clinician to work with the surgeons to do those visits.”

Who attends?
Then there’s the perennial debate over who will attend. Recently, Augusta Health in Fishersville, Va., hired a new neurosurgeon. Not surprisingly, the administration also decided that patients with intracranial hemorrhages could now be kept in-house—and that the hospitalists would be called upon to attend on these patients. That quickly drew the 25-provider hospitalist group into a debate over the limits of comanagement.

The hospitalists knew that caring for these high-dollar cases could improve both the hospital’s bottom line and access to necessary care for Shenandoah Valley residents. But not everyone was convinced the job was something hospitalists should be doing.

“We already do a lot of comanagement because that’s part of hospital medicine,” explains Joan Stalzer, MD, one of the group’s co-medical directors. But the hospitalists were nervous. “The risks were high and our expertise was low.” Moreover, the hospital’s one neurosurgeon “can’t be on 24/7, and patients don’t follow a call schedule. We did not feel comfortable attending on patients with an intracranial bleed without any backup.”

Rather than just saying “yes” and then complain and worry, or “no” and appear obstructionist, the group researched and bargained. The new neurosurgery-hospitalist comanagement agreement they were able to craft takes effect this winter.

That agreement contains a key compromise: Neurosurgery will be first attending for any patients with an intracranial bleed. The neurosurgeon can then transfer care of patients with ongoing medical problems to the hospitalists, but only once patients have been stabilized.

“Everybody needs to put their egos aside and decide if comanagement is a good thing.”

sheryl l williams, md

~ Sheryl Williams, MD
Baptist St. Anthony’s Health System

Arriving at that compromise took time. In addition to having to spell out expectations and limitations, the hospitalists needed to reach out to neighboring hospitals with neurosurgical programs and set up transfer processes to offload patients when Augusta Health’s neurosurgeon is unavailable.

The hospitalists also committed to upping their knowledge of neurocritical care. Their new interdisciplinary intracranial group—neurosurgery, neurology, critical care, hospital medicine—meets regularly. “We need to have everyone sitting in the same room at the same time because everybody was saying the other person would do something,” says Dr. Stalzer. “Everybody needs to know which group owns what.”

Improving patient care
Physicians across specialties say that misperceptions can lead to a lot of comanagement frustration. The common complaint from hospitalists—that surgeons just want hospitalists to admit all their patients because they want to maximize their income in the OR—may be true. But it’s not necessarily the whole truth.

“This is where everybody needs to put their egos aside and decide if comanagement is a good thing,” cautions Sheryl Williams, MD, a hospitalist and medical director of quality at Baptist St. Anthony’s Health System in Amarillo, Texas.

“We have seen quite a few hip-surgery complications that might not have turned into complications if we had been involved earlier,” Dr. Williams points out. And even if what is being billed as comanagement is really a convenience service, it still “may be a good thing because the administration wants it. You can later go back to administration and say, ‘I have improved such and such for your X and Y service,’ and administrators say, ‘OK. Here’s more funding for your program.’ ”

At the same time, Dr. Williams says that before entering into any comanagement agreement, hospitalists have to realistically assess their capacity to absorb additional work. Only then can they “set up the rules. As long as you know what the playing field is, then you can play.”

Hospitalists and specialists also have to keep in mind that both sides of the comanagement equation can harbor inaccurate assumptions that drive discontent. Natascha Lautenschlaeger, MD, is the hospitalist medical director and chief medical informatics officer at Margaret R. Pardee Memorial Hospital in Hendersonville, N.C.

“Cardiac rehab wasn’t even on my radar, especially when a cardiologist was on the case.”

~ Natascha Lautenschlaeger, MD
Margaret R. Pardee Memorial Hospital

She points out that hospitalists used to assume that specialists weren’t responding when called to see a comanaged patient because “they were too busy and wanted us to do all their work.” In fact, with a new EHR at the time, those patients weren’t showing up on the specialists’ patient list.

At the same time, the hospitalists weren’t always seeing specialty requests for consults. It took designing team lists in the EHR to address those challenges.

And in one comanagement arrangement, it was the cardiologists who were unhappy. They complained that hospitalists were providing poor quality care because they were failing to order appropriate cardiac rehab. “Part of that was us assuming the cardiologists would be ordering that, and they assumed we were,” Dr. Lautenschlaeger says. “But the major aspect was not knowing. Cardiac rehab wasn’t even on my radar, especially when a cardiologist was on the case.”

Understanding cardiac rehab—how it works for the patient and who does what—”made a big difference.” Education from the cardiac rehab director and straightforward dialogue between both services cleared up the misunderstanding over ordering cardiac rehab.

And ongoing dialogue between the hospitalists and all the specialties takes place regularly, Dr. Lautenschlaeger reports. “Bringing all groups to the table for quality initiatives and to address challenges has been key, and it’s an ongoing process.”

Write it down
Just about everyone involved in comanagement underscores this point: Get everything in writing. At the very least, says Dr. Stalzer with Augusta Health, “we want the nurses not to be constantly calling only one person”— usually the hospitalist—”just because the hospitalists are more accessible and easier to get along with.” Having each service’s responsibilities written out “allows us to not feel like jerks when we tell the nurses that postop pain is something they need to call the surgeon for. On the flip side, we will be doing the diabetes management, so call us then.”

“Burnout results when you believe you are not adding value to patient care.”

~ Hardik Vora, MD, MPH
Riverside Health System

Hardik Vora, MD, MPH, hospital medicine medical director at Riverside Health System and Riverside Regional Medical Center in Yorktown, Va., agrees. Written agreements help hospitalists avoid predictable arguments over scope of practice. They also protect against redundancy and missed or delayed treatments, mitigate medicolegal exposure, and guard against burnout.

“Burnout results when you believe you are not adding value to patient care, and that can happen when people feel they are being dumped on,” Dr. Vora says. “A clearly spelled out agreement about who is going to do what part of patient care gets both provider groups engaged in the patient’s care, no matter who the attending is.”

As chair of the Society of Hospital Medicine’s practice management committee, Dr. Vora has been collecting examples of comanagement agreements that hospitalists have negotiated. This year, the committee plans to release a toolkit based on that collection.

“I personally think our hospital medicine specialty needs to up its game” and figure out how do more comanagement, not less, he says. But the key is figuring out how to provide that service without stressing its providers—and ensuring that providers practice within the boundaries of their training and skills.

“Surgical specialists have limited knowledge of how to treat medical conditions, and we now see many more patients with multiple medical comorbidities, even if they are coming in for surgery,” Dr. Vora says. Hospitalists need to be involved with these patients, he adds, in some cases as attendings. But only if “specialists continue to have skin in the game.”

Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.

Comanagement and comfort level

ACCORDING TO the 2019 Today’s Hospitalist Compensation & Career Survey, 84% of hospitalist respondents said they comanage patients with specialists—and that they were comfortable taking care of nonmedical patients most of the time. The exceptions? Psychiatry and neurosurgery. While only 63% said they were comfortable comanaging patients with neurology/neurosurgery, even fewer (46%) reported being comfortable comanaging with psychiatry.

And when asked if they receive “adequate support” from subspecialists in comanaging medical patients, more than 80% of hospitalists said “yes” in terms of pulmonary/ critical care, cardiology, nephrology and infectious diseases. However, that percentage fell to only 75% for comanagement with neurology—and only a bare majority (52%) were positive about support from psychiatry.

Published in the January 2020 issue of Today’s Hospitalist
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Sheryl Williams, MD, LinkedIn
Sheryl Williams, MD, LinkedIn
February 2020 6:12 pm

Most important of all, comanagement requires communication. Have to have input from all parties to make it work.

Seref Bornovali, MD, LinkedIn
Seref Bornovali, MD, LinkedIn
January 2020 10:24 am

There is no “one size fits all” formula. The way I have seen over the years, best balance is achieved when everyone does their own job, and specialists handle what their specialty requires.

Kurt Pfeifer Twitter
Kurt Pfeifer Twitter
January 2020 8:45 am

Good article discussing the real-world challenges & ways of dealing with them related to hospitalist co-management of surgical patients.

Nathan Grunewald, MD
Nathan Grunewald, MD
January 2020 8:46 am

Like so much of the confusion and misunderstanding in the world, communication remains the key. Start with asking why.