the internist in both worlds: the intersection of …...recruitment advantage for core...
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The Internist in Both Worlds:The Intersection of Hospital and Outpatient Medicine
Heather E. Gantzer, MD, FACPInternist, Primary Care, Park Nicollet ClinicNocturnist, Methodist Hospital, St. Louis Park MNChair-Elect, Board of Regents,American College of Physicians
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Disclosures
No financial disclosures
No conflicts of interest
Member of American College of Physicians
Member of Society of Hospital Medicine
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Flour Mill and Stone Arch Bridge
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Silos are for grain
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Where do you practice?
A. Hospital
B. Outpatient
C. Both
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Patient’s journey is fluid
Home
Clinic
Infusion center
Observation status
Inpatient status
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Post discharge clinic
Skilled nursing facility/transitional care unit
Hospital at home
Telemedicine
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Disease is often not contained solely within settings defined by humans : Coronavirus
This Photo by Unknown Author is licensed under CC BY-SA
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Outline
History of Hospital Medicine
Improvement opportunities in current systems at the intersection of inpatient and outpatient care
Looking to the future-the role of the Internist in the patient’s journey
Also-advice from Hippocrates
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Park Nicollet Hospitalists-our origin story
Early 1990s Saturday morning clinic retreat
• Dr. Paul Pattee identified lack of predictability in schedule of general internist as a major stressor
• Proposed taking turns rounding in Methodist hospital
• January 1994-first physician team on Methodist Hospital service in house 24 hours: 4 daytime rounders (one core hospital MD), one evening admitter, one night admitter
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1994 Dr. Richard Freese : “The 24-Hour Service is more predictable for physicians, causing them to make fewer cancellations and have fewer behind-schedule days which makes for happier clinic patients”
1999 paper Ann Int Med confirmed improved care, reduced costs including shorterlength of stay (.064d) and fewer specialty consultations, increased physician satisfaction, increased clinic patient satisfaction
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Patient and family satisfaction was maintained
Clinic nurse satisfaction was down (initially rotating clinic physicians were out of clinic and in hospital two weeks at a time)
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Current Park Nicollet Hospitalist Program
412 beds including 22 ICU beds, community hospital, part of multispecialty clinic system
51 core hospitalists, 4 NPs, 36 clinic rotating MDs
20 daytime rounding services of 13-15 patients with 1-2 admits and 3-5 discharges daily each
5 evening shifts, 1 moonlighting crosscover 6pm-10pm, 2 night shifts and a backup
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Some advantages of a hybrid system
Recruitment advantage for core hospitalists-schedule flexibility for choice of shift, less weekend and holiday work per hospitalist
Recruitment advantage for clinic physicians that want to continue in the hospital experience, and those that want to concentrate completely on clinic
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Moonlighting opportunities
Staffing flexibility for surges and lulls in hospital patient volumes
Increased interaction between hospital and clinic physicians
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Disadvantages of Hybrid System
“Herding cats”-can be difficult to meet regularly
Maintaining knowledge base of hospital medical content, protocols
Issues of procedural expertise-ultrasound, lines
Ongoing responsibility of clinic MDs for their patients-the inbasket does not go away
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Hospitalists: Drs. Wachter and Goldman
Bob Wachter MD inspired by a 7am Sunday morning ACP presentation in the early 1990s
August 15, 1996 NEJM Wachter Goldman article “The Emerging Role of “Hospitalists” in the American Health Care System”-also noted programs in Minnesota and Arizona
Motivation was physicians wishing inpatient focus
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Lee Goldman cautioned “by definition, hospitalists build in discontinuity”-passing the baton; this remains the Achilles heel of hospital medicine
Wachter “Hospitalists should have a systole (direct patient care) and a diastole (active relaxation phase) on quality improvement, teaching, research”
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Society of Hospital Medicine
Founded January 1997 by John Nelson and Winthrop Whitcomb
Goals: promote quality of care of hospitalized patients, advance state of art of hospital medicine through education and research, improvement through innovation, collaboration and patient centered care, and support a membership of hospitalists
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April 1, 2017 CMA implemented a billing code C6 to designate hospitalists as a specialty to better benchmark their specialty utilization (instead of combining them with office-based generalists)
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Improvement Opportunities in Current Systems: Communication
Howard Beckman MD “Three Degrees of Separation” Ann Int Med 2009-sobering commentary on negative aspects of hospital care when not given by primary MD
Communication issue: hospitalist and primary care
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Communication issues between hospitalist and consultants:
• Consult requests: direct verbal, voice mail, or electronic order
• Discussion of case
• Implementation of recommendations
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Primary Care Provider Preferences for Communication with Inpatient Team
“One Size Does Not Fit All” March 2018 Journal of Hospital Medicine
Surveys to three outpatient primary care practices near Johns Hopkins
42% received notification of hospital admits 88% wished communication at least once during
admit
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How did most outpatient physicians wish to be contacted by the hospitalist?
A. Electronic health record
B. Fax
C. Telephone
D. Homing Pigeon
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• 54% of academic group preferred phone• 8% of community groups preferred phone
• 77% of affiliated community group preferred EHR• 23% of academics preferred EHR
• 58% nonaffiliated community group preferred fax,• 0% of other groups preferred fax
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Conclusion: Identifying and incorporating primary care communication preferences may improve communication, though at potential expense of standardization and efficiency
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Bridging the Hospitalist-Primary Care Divide through Collaborative Care
Allan Goroll NEJM Jan 2015 Proposed PCP visit hospitalized patient within 12-
18 hours as a primary care consultant:
• Direction and scope of patient’s workup• Highlight pertinent family and psychosocial issues• Personalized inpatient evaluation and management
• Challenges: time, workflow, payment model
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Transitions of Care and Reducing Readmissions
October 2012, Patient Protection and Affordable Care Act established the Hospital Readmissions Reduction Program, authorizing CMS to impose financial penalties on hospitals for excessive readmissions within 30 days of discharge
Readmits affect 18.2% of Medicare beneficiaries and cost Medicare more than $15 billion
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A cry for help
2014-2017 firefighters visited 1,000+ patients recently discharged from Methodist Hospital, St. Louis Park, Minnesota, to discuss new medications, check blood pressure, and do a safety check around the house
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HOMERuN: Hospital Network Reengineering Program
Network of hospitals, hospitalists and care teams to use data to guide collaborative efforts to improve care of hospitalized patients
Funding from Association of American Medical Colleges
Graham, Kelly et, al, Preventability of Early Versus Late Hospital Readmissions in a National Cohort of General Medicine Patients. Ann Intern Med. 2018;168:766-744
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Which readmissions were found to be more likely to be preventable?
A. Early readmissions
B. Late readmissions
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Review of 822 patients readmitted to 10 US academic medical centers
301 early (within 7 days) readmissions 36.2% preventable
521 late (8-30 days) readmissions 23.0% preventable
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Early readmissions
Early readmits nearly doubled the odds of preventability compared with late admissions
Factors in early readmissions• Physician decision making (missed dx, inadequate rx)• Incomplete diagnostic workups (tests not done or
results pending)• Premature discharge
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Singh, H. Zwaan L. Reducing Diagnostic Error-A New Horizon of Opportunity for Hospital Medicine
Ann. Int. Med. 18 October 2016:165 (8) H02-H04
Diagnostic error: “missed opportunities to make a correct or timely diagnosis based on the available evidence, regardless of patient harm”
Note-the number of tests performed does not necessarily correlate with the accuracy of the diagnosis
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Noted-hospitalists face external pressure to decrease length of stay and shift nonurgent evaluation and treatment to the outpatient setting
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Late readmissions
Inadequate monitoring and management of symptoms after discharge (long wait times)
Factors outside the hospital
Issues of end of life care (disease progression in terminally ill patient who desires aggressive care)
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Understanding How to Improve Collaboration Between Hospitals and Primary Care in Postdischarge Care Nguyen DK et al. Journal of Hospital Medicine
November 2014:Volume 9 NO. 11: p.700-706
Hospitals have financial incentives to reduce readmission rate per the HRRP of CMS
Unless part of an ACO that rewards (or penalizes) primary care for readmissions, resources spent by primary care to reduce readmits are not well reimbursed
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Opportunities for Hospitalists to Improve Postacute Care Transitions-Ann.Int.Med 2018
Care after discharge in SNFs and HHC (postacutecare) can be a “black box”
”Hospitalists often lack clarity about available resources, processes of care, and outcomes for patients discharged to PAC. ”
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Problem 1. Unrealistic expectations
SNF physicians are allowed up to 30 days to complete and initial patient evaluation
SNFs are only required to have an RN 8 hours per day
Consider hospitalist training in SNF and HHC settings
Advise Hospitalist to take leadership in PAC decisions
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Problem 2. PAC Clinicians not receiving all information to provide optimal care
Need info re indications and expected duration for lines and catheters
Goals of care, code status, POLST Contact precautions Current cognitive and functional status Hospitalist contact info Paper copies of controlled substances (opiods)
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Problem 3. Little Feedback to Hospitalists about Outcomes of Patients to PAC
Often hospitalists are unaware of readmissions, and their causes
Hospitalists and trainees could lead joint hospital-PAC reviews of readmitted patients, with the goal of identifying gaps in transitional care
The ECHO-CT model could provide an opportunity for hospital and PAC clinicians to review readmissions together, identify opportunities for improvement
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Looking to the future
Examples of internists current working with subspecialized and general issues often crossing inpatient and outpatient settings: oncology, dialysis care, HIV care, medical directors of SNF/TCUs
Roles of support systems including EHR, order sets, teams, and families
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Roles of mutual respect and interaction
Roles of reducing diagnostic error, and of lifelong learning
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The site(s) of medical care in the future will continue to evolve
The medical expertise of the internist, and ability to work in effective teams to deliver care in settings that make the most sense in terms of effectiveness, safety, patient preference, and cost effectiveness, may be implemented in a variety of inpatient and outpatient areas
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Internal Medicine in Hospital and Outpatient Setting
Value of Internal Medicine training and perspective is foundational and strong in multiple settings
Communication with colleagues in different areas, and lifelong learning, are imperative
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Gustave Stickley Craftsman magazine 1901
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Geoffrey Chaucer, The Parliament of Fowles, 1382
“The lyfe so short, the craft so longe to lerne”
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Hippocrates, c. 460-357 BCE
“Life is short, and Art long: the crisis fleeting; experience perilous, and decision difficult.
The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate.”
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1962 ACP Mace, of Plane Tree, Isle of Cos,where Hippocrates taught
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Summary
Hospital medicine grew as a specialty in 1990s Internists may serve inpatient, outpatient or both As with other specialties, areas of focused
expertise balance with breadth of knowledge and experience
Our patients do not remain in silos but travel among areas depending on their need, and Internal Medicine supports them on their journey
Communication between physicians, mutual respect, and lifelong learning support their care
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References
1. Freese, Richard. The Park Nicollet Experience in Establishing a Hospitalist System. Ann Intern Med. 1999; 130:350-354
2. Wachter, Robert and Goldman, Lee. Zero to 50,000-The 20th Anniversary of the Hospitalist. N Engl J Med. 2016; 375:1009-1011
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3. Beckman, Howard. Three Degrees of Separation. Ann Int Med. 2009;151(12):890-891
4. Arnold, Philip. “Homing Pigeons as Medical Messengers.” JAMA 1989;XXXXII(4):193
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5. Lawrence, David et. al. Primary Care Provider Preferences for Communication with Inpatient Teams: One Size Does Not Fit All. J Hosp Med. March 2018;13(3):177-178
6. Goroll, Alland and Hunt, Daniel. Bridging the Hospitaist-Primary Care Divide through Collaborative Care. N Engl J Med 2015;372:308-309
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7. Nguyenm Oanh et al. Understanding How to Improve Collaboration Between Hospitalists and Primary Care in Postdischarge Care Transitions: A Qualitative Study of Primary Care Leaders’ Perspectives. J Hosp Med.2014;9(11) 700-706
8. Graham, Kelly et al. Preventability of Early Versus Late Hospital Readmissions in a National Cohort of General Medicine Patients. Ann Intern Med. 2018;168:766-774
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9. Singhn, Hardeep and Zwaan, Laura. Reducing Diagnostic Error-A New Horizon of Opportunities for Hospital Medicine. Ann Int Med; 2016;165 (8):HO2-HO4
10. Jones, Christine, and Burke, Robert. “Getting Past the “Black Box”-Opportunities for Hospitalists to Improve Postacute Care Transitions.” Ann Intern Med. 2018;168(10):HO2-HO3. DOI:10.7326/M18-0940
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11. Temkin, Owel. Isis. Vol.44 No.3 (Sept 1953) pp.213-225. Paper read at the joint session of the American Historical Society and the History of Science Society Washington DC, December 1952