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Transitional care

Hospitalists push back on providing care after discharge

November 2013

Published in the November 2013 issue of Today’s Hospitalist

WITH HOSPITALS NOW ON THE LINE for readmission penalties, some facilities are thinking hard about having hospitalists migrate out of the hospital to provide post-discharge or post-acute care.

The conventional wisdom says that complex patients, particularly those who might not be able to see a primary care physician for weeks, may benefit from one or two post-discharge visits with a hospitalist who’s more comfortable with high-acuity care. But that version of the future for hospital medicine is running up against some fierce opposition from within the specialty.

Take David J. Yu, MD, MBA, medical director of adult inpatient medicine services with Presbyterian Medical Group at Presbyterian Hospital in Albuquerque, N.M. As far as he’s concerned, that view of post-discharge clinics “at least, with hospitalist staffing” has it all wrong.

“The concept of post-discharge clinics is basically turning a hospitalist into a temporary primary care physician, bringing the hospitalist movement around full circle,” says Dr. Yu.

He sees transitional care problems as symptoms of a lack of resources in primary care. But he acknowledges that hospitalists are a much easier target.

“Hospitalists are right there in the hospital, usually just one or two groups,” Dr. Yu points out. “That’s vs. all these primary care physicians out there in private practice, maybe 50 different doctors. That’s like plowing the ocean.”

But adding another layer of care with another physician who won’t be following patients long-term is only delaying the inevitable. “You have to cut the cord and make the handoff,” Dr. Yu notes, “so why not do it right the first time?”

A better investment
What limited data are available indicate that Dr. Yu is far from alone in thinking that hospitalists shouldn’t move into post-discharge clinics. Research newly-discharged patients, with published online by the Journal of Hospital Medicine in September, for instance, found that two-thirds of hospitalists said that they didn’t feel they should see patients in such clinics. (See “Who should staff post-discharge clinics?“)

David Friar, MD, CEO of the 100-provider Hospitalists of Northern Michigan based in Traverse City, couldn’t agree more.

“All you’re doing with post-discharge clinics is kicking the can down the road, trying to get past 30 days,” Dr. Friar says. He argues that hospitals and hospitalist groups should instead invest resources into other solutions to improve patient compliance and strengthen primary care.

The hospitals where his group works, for example, now partner with local pharmacies to deliver medications to patients’ bedside before discharge. And he and his colleagues have worked hard to give primary care physicians the information they need to manage newly-discharged patients, with autofaxes sent every time a hospitalist does a dictation, whether it’s a consult, history and physical, or discharge summary.

“In the old days, a discharge summary might take between five and 10 days to reach a primary care physician,” says Dr. Friar. “Now, it’s between five and 10 hours.

Strengthening primary care
And hospitals in northern Michigan have started investing in primary care. Hospitals are for the first time helping to fund signing bonuses and moving expenses to make it easier for outpatient practices to recruit. Hospitals are also investing in a free clinic, with funding and professional services such as nurses and pharmacists. (A number of hospitalists, Dr. Friar notes, donate their time to help staff the clinic as well.)

And one hospital where the group works “Munson Medical Center “has partnered with regional insurers to ensure that primary care physicians have the expertise they need to manage high-acuity patients, which Dr. Friar says is a major problem in transitional care. The Northern Michigan Diabetes Initiative helps pay for one local endocrinologist, who maintains a diabetes clinic, to spend an afternoon with various community physicians, getting them up to speed on best practices in diabetes management.

“It’s not cheap,” says Dr. Friar, “but it’s a great value to ensure that diabetics in the community stay out of the hospital for far longer than 30 days.”

As for heart failure, which he calls “a notorious diagnosis for bouncebacks,” Munson Medical Center runs a specialty clinic for complicated heart failure patients. But that clinic is staffed by cardiologists, not hospitalists.

“The goal isn’t to keep people well for only 30 days,” Dr. Friar explains, “but for as long as possible. The clinic sees these patients indefinitely, with a goal of keeping them healthy and out of the hospital.”

A role in post-acute care?
One concept that might have more appeal is hospitalists delivering post-acute care in a SNF. For Dr. Yu, that makes a lot of sense. The SNF medical director, in fact, reports to Dr. Yu, and two hospitalists in his group work half of their time as a SNFist.

Traditionally, before Medicare clamped down on reimbursement, Dr. Yu points out that patients spent about six days in the hospital.

“Now, we’re getting patients out in three or four days, so they need two or three days of acute-care rehab,” he says. “Patients haven’t changed, but we’ve broken down hospitalizations into an acute phase and a convalescence phase.”

Besides, Dr. Yu adds, some hospitalists want to do SNF work. “It’s like hospital medicine on Valium,” he explains. “It’s the same kind of work, but at a much slower pace, so it helps avoid burnout.”

But in northern Michigan, Dr. Friar says that none of his colleagues is working in SNFs. While hospitalists have collaborated with local SNF physicians to standardize transition forms and make sure those doctors get the information they need, Dr. Friar says there are too many barriers to hospitalists taking on some of that work themselves.

For one, working in a SNF is potentially much less rigorous than working as a hospitalist, with its burden of working weekends and nights. So how would you compensate hospitalists or inpatient nurses to move to working in SNFs? Cut their income? But the biggest barrier is what Dr. Friar calls “the endless shortage of hospitalists.”

“We don’t have the luxury to go out and staff any kind of post-discharge or post-acute care,” he notes. “We don’t have the bodies to say, ‘Now that we’re fully staffed, let’s get into other areas.'”

Taking full risk
While hospitalists may resist the idea of working in post-acute care, experts have said that health care reform may force the specialty to reconsider its role. But that hasn’t necessarily been the experience of hospitalists who work in mature managed care settings that already resemble the post-health care reform landscape.

In southern California, for example, the giant medical group HealthCare Partners is responsible for staffing SNFs, and it has hospitalists rotating through some of those shifts. The group coordinates care for more than 700,000 managed care patients, taking full risk for all of those patients under a group-practice model. Some patients “belong” to employed primary care physicians in the group, but even more come from an affiliated independent physician association (IPA).

Manoj K. Mathew, MD, a regional medical director for the group, says that HealthCare Partners does a fair job finding hospitalists who agree to work several months a year in well-appointed SNFs that function like medical/surgical floors. But most hospitalists prefer to provide only short-term acute care, making staffing SNFs a significant challenge.

“They don’t have the prior exposure or personal disposition to handle this intermediary level of acuity,” says Dr. Mathew. “There are unique skill sets, both clinical and nonclinical, that you need to deal with this subset of the care continuum.”

Big benefits from integration
And because HealthCare Partners takes full risk, the group has had to find ways to discharge patients effectively while reducing readmissions.

Dr. Mathew thinks health care is now evolving into three separate branches: inpatient, outpatient and post-acute. So far, he points out, his group has found solutions that largely keep hospitalists in the hospital.

Hospitalists in his group can discharge complicated patients to one of a series of what Dr. Mathew calls comprehensive care clinics before those patients return to their primary care physician. But instead of asking hospitalists to staff these clinics, Dr. Mathew explains, the group relies on “complex care physicians who are comfortable managing higher acuity patients or who have palliative care training.”

HealthCare Partners has found it needs such clinics, he points out, because patients just out of the hospital may need a post-discharge visit that’s a half hour or longer, not the standard 10 or 15 minutes.

“Sometimes, the comprehensive care clinic is finished with the patient after one visit,” Dr. Mathew says. “But invariably, most discharged patients are added to that clinic’s panel. The clinic often becomes the primary care site for this high-risk population.”

Hospitalists can also refer complex patients for post-discharge home visits, which are provided by clinicians including nurse practitioners. And because HealthCare Partners is integrated, with outpatient and inpatient physicians sharing the same EMR and staff, transitioning patients out of the hospital can run more smoothly.

“We’re able to plan for a primary care visit for most patients within two or three days,” Dr. Mathew points out. “We have the infrastructure that helps make transitional care much easier, so we don’t need to use a post-discharge clinic as often.”

He is quick to acknowledge, however, that hospitalist programs that don’t have the luxury of such infrastructure may find themselves on the hook for post-acute care. Dr. Mathew also adds that as the population ages, the sophisticated infrastructure his group has built may not be able to keep up with the growing demand for patient care after discharge. If that happens, all bets are off on whether hospitalists will be asked to work outside of the hospital.

“Hospitalists are always going to be on the short list as far as staffing places like post-discharge clinics,” Dr. Mathew admits. “We’re just fortunate that we haven’t been forced to do that yet.” But on a positive note, he adds, “It’s job security for years to come.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

Who should staff post-discharge clinics?

WHILE FEW HOSPITALS nationwide have explored the use of post-discharge clinics, that may be about to change.

In the Today’s Hospitalist 2013 Compensation & Career survey, we asked hospitalists how they saw their role changing in terms of providing post-discharge care. Nearly one in four (23.2%) planned to be involved in setting up or staffing a post-discharge clinic. Another 13.1% thought they may be treating post-acute patients in a skilled nursing facility.

But while nearly one-quarter of the hospitals represented in our survey plan to set up a post-discharge clinic, hospitalists may be reluctant to staff them. Research published online by the Journal of Hospital Medicine in September asked more than 220 hospitalists if they felt they should see patients in a clinic after discharge. Two-thirds (62%) said no.

However, results indicated a wide range of perceptions among doctors on when their clinical responsibility for patients ends. Twenty-eight percent said that they see their responsibility ending for patients at discharge, but 18% felt their responsibility ends between one and three days post-discharge. Twenty-five percent felt their responsibility extends to between four and seven days post-discharge, and another 18% saw their responsibility lasting as long as two weeks. Another 8.8% put that time frame as up to four weeks, while 1.3% listed three months.

Manoj K. Mathew, MD, is a southern California regional medical director for HealthCare Partners, a large national medical group that accepts full risk for many of its patients. Hospitalists in his group, Dr. Mathew says, are accountable for patients up to 30 days post-discharge, at least in terms of having their patients’ 30-day readmission rates tracked and evaluated. Those data are used to determine hospitalists’ year-end evaluations and financial incentives, as part of the group’s quality metrics.

While other hospitalists may not have income tied to readmissions, Dr. Mathew notes that analyzing readmissions and tracking when they occur can give programs insights into how to improve. His group, for instance, tracks the number of readmissions at two, seven and 30 days.

“If patients are coming back in in two days, maybe the hospitalists discharged those patients too soon,” he notes. “Then the opportunity to improve may be more on the hospitalists’ side.” For readmissions occurring within seven days, “that could be a hospitalist issue or a PCP one,” he says. “Were patients discharged too soon, did a PCP never see them, or did home health or durable medical equipment not arrive?”

As for readmissions that take place more than seven days post-discharge, the group tries to get a handle on what caused them. “Is that an operational problem of not getting the patient in and cared for in the right setting? Did we not have a good care plan, or was the patient not educated enough? Where did we go wrong?” Overall, Dr. Mathew adds, “the value of a clinically integrated group is that we take collective accountability and are able to collaborate with a singular purpose.”