Home Discharges Walking the walk in transitional care

Walking the walk in transitional care

February 2012

Published in the February 2012 issue of Today’s Hospitalist

Over the years, the growth in the number of hospitalists has spawned a number of other “ist” movements, from laborists to surgicalists. But the latest twist on hospital medicine “what some call “transitionalists” “may be the most important yet. That’s because the new role promises to solve some of the most vexing problems facing hospitals and hospitalists alike: high readmission rates and gaps in post-discharge care.

Hospitalists who work at least some of the time outside of acute care “in a long-term acute care (LTAC) or skilled nursing facility (SNF) or even making house calls “may help hospitals not only improve patient care, but avoid financial penalties for preventable readmissions.

The role is a natural fit for hospitalists. As the spectrum of acute care becomes more broad, hospitalists can not only handle acute issues that pop up outside of the hospital, but they also can facilitate communication among post-acute physicians, traditional hospital-based hospitalists and primary care doctors.

While some hospitalists embrace the term “transitionalist” to define their new role, others bristle at it. In their view, physicians who handle acute care duties are hospitalists in deed regardless of setting, and they should be called hospitalists to avoid confusion.

The job is clearly not for everyone, but hospitalists who have found homes outside of the hospital say it can offer the best of all worlds. Here are four examples of hospitalists working outside a hospital and a look at how their roles are evolving.

A coordinated practice
As length-of-stay and readmission issues continue to have financial consequences for hospitals, hospitals will not only expect but demand that hospitalists partner with post-acute colleagues to better coordinate care and control costs. That’s according to Jerry Wilborn, MD, who’s worked as a hospitalist in both acute and post-acute care since 1998.

Now the post-acute care medical director for IPC The Hospitalist Company Inc., Dr. Wilborn says that demand is one big reason why IPC has expanded its huge hospitalist workforce from only acute care to post-discharge settings like SNFs and LTACs.

Already, IPC cares for patients in post-acute facilities in most of its 30+ markets. In one-third of those markets, dedicated groups spend virtually 100% of their time in post-acute facilities “and that number is growing. In other markets, IPC hospitalists working in LTACs still spend between 10% and 20% of their time in hospitals. As is the case in acute care, post-acute care teams “consisting of physicians, NPs and PAs “can range from small groups of two or three to larger groups of more than 10.

IPC’s post-discharge caregivers use everything from care coordinators to proprietary software and a discharge call center to help move information from one setting to another. The company says that putting hospitalists in post-acute settings allows for smooth patient transitions from the hospital and, ultimately, to primary care.

The key is to have everyone working for the same group and being comfortable with the decision-making of physicians you know. Kerry Weiner, MD, IPC’s chief clinical officer, says that physicians in what he calls a “coordinated practice” can easily exchange information and work efficiently to prevent readmissions.

An IPC hospitalist working in a post-acute facility, for example, will call the hospital-based hospitalist if a patient is headed back to the ED. Instead of being evaluated by the ED physician, the patient will be seen by the IPC hospitalist at the hospital. That process often averts an admission.

While he says the system works, Dr. Weiner is quick to acknowledge that post-acute care is not for every hospitalist. For one, in the past, there was the stigma that doctors who work in post-acute care are retired and looking “to kick back.” But according to Dr. Wilborn, as more attention is focused on transitional care problems, it’s getting easier to find hospitalists who want the work. Hospitalists in these roles also see first-hand the results of their efforts in terms of patients on fewer medications, fewer patient and family complaints, and improved patient outcomes.

As for what to call doctors who work in post-acute care, Dr. Wilborn says IPC prefers “hospitalist” over the new-fangled “transitionalist.” “It really underscores what we do in the post-acute space,” he says. “We’re not just internists. We work with the hospital and focus on outcomes.”

Private practice hours, team care
Imagine a hospitalist job with a flexible schedule and the ability to really get to know patients. That’s a reality for Robert Bernard, MD, a hospitalist with Select Medical Corporation, the nation’s largest provider of long term acute care. Dr. Bernard started working full time in a Select LTAC as a hospitalist after working within LTACs as a consulting nephrologist. He had noted that overall patient satisfaction and care quality were “compromised,” he says, by a lack of physician contact and continuity.

While he regularly confers with physicians and staff in referring acute care hospitals, he and two other internists (who came from the acute care setting) now work at the LTAC full time. They handle a census of 30 patients in a model Dr. Bernard describes as a blend of traditional medicine and primary care. With the exception of night and weekend call, physicians can decide their own hours.

The biggest change for traditional hospitalists, he says, is providing more comprehensive care over a much longer LTAC stay. But that’s also part of the appeal. Patients’ length of stay typically ranges from three to five weeks, and physicians may see them two or three times a day, often with a nurse or therapist. “We not only know our patients, but their spouses, children, siblings and visitors,” Dr. Bernard says. “It is very satisfying.”

This “high service” model extends to the referring community. Dr. Bernard says he recently accompanied one patient to an appointment with her cardiovascular surgeon. “Imagine the impact when the surgeon entered the room and I stood up, introduced myself as the attending physician and offered to answer any questions,” he says.

Although this full-time LTAC program in Harrisburg, Pa., has been up and running only since last June, Dr. Bernard says it’s already proving its value. Patient satisfaction scores have jumped between 50% and 60%, and there has been a steady rise as well in performance and quality benchmarks.

The ability to maintain a full census and keep utilization costs down more than compensates the LTAC for the cost of adding hospitalists. Dr. Bernard says the doctors play an integral part in those savings by regularly meeting with executives and setting up quality initiatives. Physician pay is based on performance and productivity.

“We do well when the hospital does well,” he notes.

And while he’s OK being called a “transitionalist,” Dr. Bernard hopes the use of the term doesn’t lead anyone to underestimate the quality of care that LTAC hospitalists provide. As an example, he describes a recent admission: a 50-year-old patient who developed septic shock from pneumonia, requiring tracheotomy and ventilator support. The patient also had acute renal failure requiring monitoring. It’s dialysis and a swallowing disorder with PEG placement.

“Give us our allotted time with him,” Dr. Bernard says, “and there’s a high probability that if I don’t send him home, I’ll be able to send him to acute rehab.”

The SNF connection
How are hospitalist groups handling the fact that a growing number of patients who used to be cared for on hospital medical/surgical floors are now being referred to SNFs instead? As hospitals reduce their number of less-lucrative custodial beds, one answer is to assign full-time hospitalists to care for SNF patients.

HealthCare Partners, a multispecialty group in southern California, took that approach more than a decade ago when it hired hospitalist John Wong, MD, to take care of patients in several SNFs. Acute care for these patients is provided by HealthCare Partners’ hospitalists.

The SNF program runs like a hospitalist program in acute care: The onsite physicians and care managers round as a group every day. Twice a week, rounding includes a rehabilitation therapy team, a nurse representative and a dietician.

When handing patients off to primary care, the physicians likewise dictate a discharge summary, call the primary care physician and send a medication reconciliation form. The program also places follow-up calls to high-risk patients. Those efforts have driven down the rate of readmissions back to the medical center to a mere 17%. (Dr. Wong says the national average is around 25%.)

Because of that success, the program has grown. Dr. Wong is now regional lead physician for post-acute care, overseeing six full-time clinicians (five hospitalists and one PA) and eight to 10 part-time staff (usually PCPs) for after-hours care. The census typically runs between 90 and 100 patients, but can reach 120 in the winter months across several core facilities.

When the SNF hospitalists admit a patient, they not only receive paper summaries but verbal handoffs from the acute care hospitalists. Because the hospitalists working at the SNF also have hospital privileges, they can all access the same EMR and review discharge summaries, labs and other paperwork.

SNF hospitalists also meet with the acute care hospitalists during joint biweekly meetings. According to Dr. Wong, those meetings give acute care hospitalists “a better understanding of what can be managed in a SNF setting as they consider discharge options from the hospital.”
While Dr. Wong says he is not bothered by the term “SNFist” or “SNFologist,” he identifies himself as a hospitalist to his patients. He’s concerned that “transitionalist” may not help overcome the stigma often associated with nursing home care.

But that stigma, he says, is easing, while patient acuity in SNFs is approaching that of acute care hospitals. Dr. Wong also notes that it takes a special kind of hospitalist to work in a SNF, one who’s comfortable with more patient and family meetings and with not doing critical care.
He also points out that many new acute care hospitalists with the group work in a SNF while waiting for hospital privileges. That serves as a reality check of sorts.

“Residents are used to having a lab report before noon,” Dr. Wong says. “In a nursing home, that may be by dinner time.”

Hospitalist house calls
If the idea of working as a transitionalist seems unusual, consider Ken S. Ota, DO. A family physician, he makes post-acute calls using a truck supplied by Banner Good Samaritan Medical Center in Phoenix.

The medical center’s transitional care program is a consult service designed to improve transitions from the hospital to the community. Dr. Ota manages patients considered to be at high risk for 30-day readmission by following them into any post-acute setting that they’ve been discharged to: home, LTAC, SNF or assisted living facility.

In those visits, Dr. Ota explains, he educates patients about how to manage their own disease and assesses their medications, living environment and psychosocial needs. He believes that by really getting to know discharged patients (both medically and socially), he can improve outcomes, reduce readmissions, and close the gap between inpatient and outpatient care.

“It isn’t just telephone monitoring,” he says. “It isn’t just asking, ‘What’s your weight today?’ or telling patients ‘Do this or that.’ It’s getting to see where patients live and what they have to deal with on a daily basis to tailor their management to their needs.” Dr. Ota says he proposed community visits as a “complementary service” of the hospital while he was still in residency. The hospital launched the innovation last fall, and Dr. Ota now works full time as a transitionalist.

He makes his visits within 24 to 48 hours of discharge. (A typical day might include two to four home visits, while Dr. Ota visits SNFs a few times a week.) Several factors, he notes, have helped make the program a success. One, patients are always able to contact him directly, either by phone or e-mail. And he has been able to establish very effective collaborations with hospice and palliative care organizations, as well as home health agencies “and ED doctors.

“I’m trying to create a system where we follow patients closely to ensure that they don’t ‘fall through the cracks,'” Dr. Ota says. Sometimes, he notes, “the right kind of care” the patient needs involves a readmission. “But I’ve found that this is not the case most of the time and that effective care can be delivered in post-acute settings.”
In making community visits, Dr. Ota has cared for patients who have a track record of one or even two dozen hospital readmissions “a year.

He got to know, for instance, one heart failure patient who dialed 911 whenever she had any unpleasant symptom including nausea or shortness of breath. After working with her, Dr. Ota says, he was able to educate her on how to properly use emergency services, and he designed a home palliative care program for her.

He’s also arranged hospice for other patients as the right alternative for frequent readmissions, noting that end-of-life discussions and planning need to “occur early.”

And working with Dr. Ota, one end-stage renal disease patient admitted that he wasn’t really suffering from shortage of breath, the symptom he always reported in the ED to be readmitted. Instead, he wanted to come back to the hospital for “strong pain medicine” for chronic back pain. The palliative care regimen that Dr. Ota helped initiate reduced the patient’s pain and has kept him out of the hospital since.

“Identify those who appear to overuse emergency response systems and find the underlying cause,” Dr. Ota advises to cut readmission rates. “And always engage patients with frequent admissions to discuss why they present to the hospital. They may just give you the answer.”

Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.

Who works outside the hospital?

ASK HOSPITALISTS HOW MANY WORK OUTSIDE THE HOSPITAL, and you may be surprised. While more than three-quarters of the physicians in the 2011 Today’s Hospitalist Compensation & Career Survey report working in hospitals exclusively, there are a fair number branching out into other settings or practices.

There are also regional variations: Among respondents from the Southwest, 63% report working only in the hospital, which is the case for 65% in the Mountain region. Hospitalists at nonteaching hospitals are less likely to work outside of the hospital (77% vs. 70% of teaching hospitalists). And older hospitalists are more likely to do some work outside of a hospital than younger colleagues.

Here’s a look at the responses: