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Advances & Insights: General Health

January 5, 2007 

What the news means for you


Caudill, T. Shawn MD, MSPH, FACP

Shawn Caudill, MD, MSPH
Internal Medicine 

UK hospitalists coordinate care

UK Chandler Hospital and Kentucky Children’s Hospital use hospitalists to co-manage care with primary-care physicians or specialists. We began using hospitalists several years ago, and it’s really changed the way patient care is managed because of the co-management with specialists and surgeons.

It has really benefited orthopedic patients to have their care co-managed with the hospitalist and surgeon..."

Co-managing patients
For instance, most patients over 60 years old who are coming in for hip surgery are admitted by a hospitalist, not an orthopedic surgeon. The hospitalist manages the overall care and the surgeon handles the surgery. It has really benefited orthopedic patients to have their care co-managed with the hospitalist and surgeon because the hospitalist oversees the patient’s entire care regimen and understands how the hospital systems function. We’re seeing more of that from our other subspecialty surgeons as well.

For instance, most patients over 60 years old who are coming in for hip surgery are admitted by a hospitalist, not an orthopedic surgeon. The hospitalist manages the overall care and the surgeon handles the surgery. It has really benefited orthopedic patients to have their care co-managed with the hospitalist and surgeon because the hospitalist oversees the patient’s entire care regimen and understands how the hospital systems function. We’re seeing more of that from our other subspecialty surgeons as well.

I like the term ‘co-manage’ to describe how a hospitalist works with a specialist. Say a person is coming to UK Hospital to see a liver specialist for a liver evaluation. I defer any decisions in that area to the liver specialist. But the patient may also have high blood pressure or diabetes, or if the patient is 70 years old and has geriatric issues, that ís where the hospitalist comes in.

The hospitalist may do a preoperative evaluation risk assessment on the patient’s heart and lungs, check on diabetes and makes sure it’s under control, as well as helps manage pain. The surgeon focuses on what he or she is skilled at doing, and my team manages the post-operative care by helping arrange the rehabilitation placement to get the patient back on his feet.

It’s co-managed care; it’s not my patient or the surgeon’s patient, he’s just our patient. It’s the responsibility of the hospitalist to make sure all the patient’s needs are met, not just the one thing the patient was admitted for, but all of the needs. The hospitalist will look at the whole picture, all the organ systems, whereas the specialist may just look at a single organ system.

Sometimes a patient will have two or three different specialists taking care of them and the patient doesn’t know who their primary doctor is. We give patients a brochure with a photo of their hospitalist so they know who to go to for help and any questions. Patients and family members are reassured that they have someone who knows all about the case.

Managing transition to outpatient care
It’s a key part of the hospitalist’s responsibility to make the transition out of the hospital as seamless as possible. When the patient is ready to go home, one of our team members contacts the referring physician to let them know the patient is being discharged and what medications they’re on. We also send a discharge summary so there’s a written record of what we did for the patient in the hospital.

Having hospitalists does help reduce the length of stay. When you know the system, you can work through it quicker. The hospitalists learn how to efficiently manage the hospital system, who to call and how to get things done. One time I might call a specialist, and that doctor tells me another doctor might be better suited to handle the issue. That could add a day to the hospital stay. If I work in the hospital every day, I learn those things very quickly.

Managing patients whose conditions are worsening
Hospitalists are also involved in administrative initiatives regarding patient safety and quality. They are the frontline workers and they know best how to identify the problems and work with teams in the hospital to fix the issues. For example, we have a rapid response team - a group of physicians, clinicians and nurses who are on call for anybody in the hospital who sees a patient who may not be doing well.

The rapid response team comes right to the bedside to do an evaluation of the patient and discuss the patient with the doctor. The team has decreased the number of patients who have had to be moved into intensive care.

With hospitalists on duty, we can identify patients who are not doing well and intervene immediately, instead of trying to contact the doctor taking care of the patient. That doctor may not be available because they’re seeing patients in their office or a clinic or they’re in a meeting, whereas these folks run right to the bedside and do an immediate evaluation.

Anyone - a nurse, even a member of the housekeeping staff - who sees a patient who doesn’t look good can call the rapid response team. It’s like a 911 call in the hospital. That’s definitely an improvement in patient care that our hospitalist group has implemented.

Hospitalists expand at UK
In the next two to three years, we’ll be adding hospitalists to take care of our aging population. More specialty surgeons will co-manage patients with us, the same as we were doing with our orthopedic surgeons. We’ll be expanding to help meet the changes that are going on in our society.

Dr. Caudill is chief of general internal medicine at UK Chandler Hospital and an associate professor of medicine at the UK College of Medicine.

Hospitalists shorten hospital stays and improve patient care

While many people value the relationship they have with their family physician, when they enter the hospital a hospitalist physician may enter the picture to care for them instead of their family physician.

Use of hospitalists results in a shorter length of stay for patients, with patient outcomes at least equal to and usually better than the traditional solo model of primary physician care in hospital settings. 

Fast-growing new specialty

Researchers Robert M. Wachter, MD, and Lee Goldman, MD, coined the term 'hospitalist' in a 1996 article published in the New England Journal of Medicine. Back then, there were about 800 physicians working in hospitals. Today, that number has grown to about 15,000, or about as many physicians who practice gastroenterology or neurology, according to the Society of Hospital Medicine.

A hospitalist is a hospital-based specialist physician who cares for patients while they are hospitalized. At the time of hospital discharge, patients return to the care of their personal physicians. When hospitalized, a patient’s care is co-managed between the hospitalist and the patient’s primary care physician (PCP). Each physician plays a role in the patient’s care, with the patient’s PCP continuing the long-term relationships patients value.

Proven impact

Recent studies have shown the use of hospitalists results in a shorter length of stay for patients, with patient outcomes at least equal to and usually better than the traditional solo model of primary physician care in hospital settings.

A study at UCLA Medical Center published in the February 2006 edition of the Journal of Nursing Administration measured length of stay, hospital costs, mortality rates and readmission for four months after discharge for 1,207 patients. The study followed 581 patients in the experimental group and 626 in the control group. The control group of patients received care in the traditional model. Care management in the experimental group had three components: an advanced practice nurse who followed the patients during hospitalization and 30 days after discharge, a hospitalist medical director and another hospitalist assigned to the patient, and daily multidisciplinary rounds.

After measuring outcomes for four years, the average length of stay was significantly lower for patients in the experimental group, cared for by hospitalists and nurse practitioner, than in the control group. The experimental group had an average stay of five days versus six days. There were no significant group differences in mortality or readmissions.

This study concluded that collaborative physician/nurse practitioner multidisciplinary care management of hospitalized medical patients reduced length of stay and improved hospital profit without altering readmissions or mortality. The study attributed the positive outcomes to the common aspects of the hospitalist model:

• Comprehensive discharge planning for each patient group
• Home visits
• Multidisciplinary team planning
• Expedited discharge
• Assessment after discharge

A study by Drs. Wachter and Goldman, published in JAMA (Journal of the American Medical Association) in 2002, found that the average length of stay decreased 16.6 percent and hospital costs decreased an average of 13.4 percent under the hospitalist model. Results in other aspects, such as inpatient mortality and readmission rates, were not totally conclusive that use of the hospitalist model improved those aspects of patient care.

Hospitalist role

The duties of a hospitalist include patient care, teaching, research and leadership related to hospital care. Hospitalists also consult on and treat patients referred by surgeons and medical subspecialists during their hospitalizations. Hospitalists provide care at night in hospitals and care for ‘unassigned’ patients, usually those who don’t have a primary-care doctor.

According to the Society for Hospital Management, about 75 percent of practicing hospitalists are trained in general internal medicine, while 11 percent are trained in general pediatrics, 3 percent in family practice medicine, 4 percent in an internal medicine subspecialty, 3 percent in internal medicine pediatrics and 3 percent are physician assistants or non-physicians.

A new paradigm

The use of hospitalists is a departure from the traditional hospital care model in which a busy primary-care physician travels to the hospital and makes rounds once a day, usually early in the morning. Patients and families are frequently frustrated because it’s hard to communicate with the physician to find out what is going on with the patient’s care. Primary-care physicians make hospital rounds in between ever busier office schedules.

Hospitalists, on the other hand, don’t have outside responsibilities such as office visits. In academic medical institutions, they do a large amount of teaching for doctors in training. They also have become leaders in quality, patient safety, information technology, palliative care, medical education and more.

Hospitalists have become valued partners in patient care. Office-based, primary-care physicians rely on hospitalists to co-manage their patients in the hospital, allowing office-based doctors to see more patients.

If a patient must see a specialist, such as a cardiologist or an orthopedic surgeon, the hospitalist coordinates care with the specialist. When the patient is discharged, the hospitalist coordinates care with the primary physician or specialist physician in the outpatient setting.

After 10 years, research supports the use of hospitalists to improve inpatient efficiency without any harmful impact on quality or patient satisfaction.

Related resources:

For more information, see:

The effect of a multidisciplinary hospitalist/physician and advanced practice nurse collaboration on hospital costs, The Journal of Nursing Administration, v. 36, no. 2, February 2006

Health care market trends and the evolution of hospitalist use and roles, Journal of General Internal Medicine, v. 20, no. 2, February 2005

The hospitalist movement 5 years later, JAMA, v. 287, no. 4, January 23, 2002

The hospitalist movement 10 years later: Life as a Swiss army knife, MedScape General Medicine, Medscape.com, August 4, 2006

 

UK Healthcare resource

General Internal Medicine, UK HealthCare

Hospitalist Program, Kentucky Children's Hospital, UK HealthCare

 

For more information, or to make an appointment with a UK HealthCare physician, please call UK Health Connection at 1-800-333-8874. 

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