Published in the January 2014 issue of Today’s Hospitalist
THE PILOT PROJECT has modest beginnings: The extensivist clinic staffed by hospitalists and started eight months ago by Holston Medical Group, a 150-doctor multispecialty group based in Kingsport, Tenn., has only five beds.
But the clinic has a very ambitious goal: creating a new care delivery model, says Chris Neglia, DO, a hospitalist and the clinics lead extensivist. While other extensivist clinics around the country provide post-discharge care or a medical home for patients with complex chronic diseases, the Holston clinic comes with a unique twist: It offers the group’s primary care physicians somewhere else to send acutely ill patients other than the ED, where they typically are admitted.
“If you can give patients a couple of hours of care, you can save an observation, let alone an admission,” says Dr. Neglia. He and his colleagues thought they would have a terrible time selling the concept to patients. “But there are a lot of savvy patients out there, and families are willing to work outside traditional boundaries to keep patients out of the hospital.”
The clinic is already running at capacity, and most patients treated there are released to their home, not the hospital. “All of our outcomes,” says Dr. Neglia, “have been very good.”
One big reason to launch the clinic was to cut costs. The group’s patients fall into several categories including fee for service, Medicare gainsharing contracts and some risk contracts. (The multispecialty is a partner in a primary care-based ACO that’s taking risk.) The group figured that “the big spend is in the hospital,” Dr. Neglia says. “The easiest way to save money is to not send patients to the hospital.”
But another big driver was concerns about the “post-hospital syndrome” described in a piece in the Jan. 10, 2013, New England Journal of Medicine. That syndrome was described as a toxic stew of sleep deprivation, pain, trauma and disorientation that can sabotage patients’ health and cognition for months.
“The clinic care we offer may be far better for elderly patients,” Dr. Neglia points out. “It’s the vulnerable elderly who are more likely to become confused and agitated.”
Another big motivator was hospitalist frustration. Time-strapped primary care physicians always default to sending a sick patient to the ER or an urgent care clinic. Urgent care clinics have only an hour, maybe two, to spend with patients. And EDs face so much throughput pressure that those physicians default to an admission.
“You have two physicians who have already established that this patient is going to be admitted,” Dr. Neglia points out. “But then the hospitalist has more time to sit down with the patient and realizes that this is probably not a hospitalization.”
The system is set up “to just send patients to the hospital and rack up a huge bill,” says Dr. Neglia, with no “in-between” besides a truncated office, urgent care or ED visit and a full-blown observation stay or admission.
“We are offering something in between with extended care to stabilize acutely ill patients,” he notes.
The luxury of time
Along with the hospitalists, the clinic is staffed by ICU or ED-trained nurses. The clinic can do its own labs and basic radiology, and physicians have access to physical therapists and surgeons in the same building.
But what the clinic really offers, Dr. Neglia says, is the luxury of time. Patients with heart failure, for instance, may spend 10 hours receiving IV Lasix and oxygen, while patients with cellulitis refractory to outpatient treatment can get “bigger-gun IV antibiotics.” Clinic patients may receive as many as 12 hours a day of “inpatient” interventions, which may be repeated for several days if clinically warranted.
When the clinic closes at 8 p.m., most patients or their families are given the option of taking patients home (and, often, having them return to the clinic the next day) or being admitted directly to group hospitalists in the hospital. Patients deemed too sick to go home are, of course, admitted.
“The big shocker to us is that many families will do almost anything to keep their loved ones out of the hospital,” says Dr. Neglia. “We have many cases where patients are very ill but being managed, sleeping in their own bed.”
Among patients who would normally require hospitalization, 78% are treated entirely within the clinic. (The other 22% ultimately require transfer to the hospital to complete their care.) Of the patients who go home from the clinic, none has bounced to the hospital in the middle of the night.
As for patients admitted to the hospital, “we have the hospitalist do orders from the clinic into the hospital,” he says. “It is almost like a transfer from one hospital to another, and we bypass the ER completely. There is no ER visit, physician charge, or redundant fees or labs.”
Providing acute care
As far as Dr. Neglia is concerned, such a clinic needs hospitalists staffing it. While some outpatient doctors who moonlight at the hospital on weekends are also involved, “many physicians who have not been in a hospital for a while don’t have the right comfort level foracute illness,” he points out. “They also have lost the sense of who needs to be admitted.”
Dr. Neglia admits that not all hospitalists are interested in the work. Among Holston’s 12 hospitalists, only five rotate through the clinic, each working a one-week, Monday-Friday block.
“It’s not for every hospitalist,” he says, “but the advantage of this clinic over a post-discharge setting is that you are doing acute care, so the adrenaline rush comes with it.”
What the clinic doesn’t have right now is a clearcut business model. For patients for whom the multispecialty takes risk, money saved avoiding an admission or observation stay offsets clinic costs. But the clinic can charge only outpatient fees for its services, which clearly don’t sufficiently reimburse services that last hours.
The clinic is also grappling with the ins and outs of inpatient vs. outpatient payments. A patient treated in the clinic with IV vancomycin, for instance, was billed by her insurer because she received those drugs as an outpatient. If she’d been admitted, she wouldn’t have been charged for the same treatment in the hospital.
“Why would the insurer charge this patient as an outpatient when it didn’t have to pay for a hospitalization?” Dr. Neglia asks.
The ability to use new transitional care codes for some patients will help. (The extensivist clinic does see a few complicated patients post-discharge.) In the meantime, “we are talking with local insurers as to them buying in,” says Dr. Neglia.
But eventually, he adds, something will have to change to allow this type of clinic to thrive. “We will not be able to continue this,” he says, “without some kind of new code for this ‘in-between’ care or assistance from private insurers and Medicare for delivering cheaper care than our competitors.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.