Hospitalists Are Changing Care Both in And Outside the Hospital

They’re still concerned with individual patients, but they’ve also been enlisted to provide care to populations.

Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD

More hospitals are utilizing hospitalists in a variety of ways in an effort to improve outcomes. The percentage of hospitals using hospitalists has risen dramatically over the past dozen years, from just 29% in 2003 to 50% in 2007 to 72% in 2014—and it’s probably even a larger percentage today.

Many of these hospitalists are taking on responsibilities outside of their historical role as providers focused on inpatient care. The traditional role of the hospitalist in hospitals is based on results such as those reported in a study of Medicare hip fracture patients that showed that care involving a hospitalist decreased time to surgery, time from surgery to discharge, and length of stay (LOS).

Changes like these result in more cost-effective inpatient care. But improved transitions of care also have the effect of reducing admissions—and fewer admissions means less revenue. In the past, that would have scared off hospital executives.

But many of the hospitals hiring hospitalists are part of health care systems with leadership that is looking ahead to when revenue will be based more on overall management of care rather than volume of admissions. This shift was illustrated well in a recent advertisement for Mount Sinai Hospital in New York City. The ad has a photo of a Central Park filled with people playing. The tagline says, “If our beds are full, it means we have failed.”

CMS is one of the major forces pushing hospitals to be more focused on efficient and effective population health through penalties for readmissions and several different bundled payment programs. CMS has come out with research showing that bundled payments can be the instrument for aligning incentives for all types of providers—hospitals, post-acute care providers, physicians, and other practitioners. Expect those health systems that utilize hospitalists to be most successful with bundled payment—and the most success may come when hospitalists work across settings, not just in inpatient care.

What they are doing at Beth Israel Deaconess Medical Center in Boston is a good example. Hospitalists there have begun working in a post-discharge clinic. The clinic provides care to patients shortly after discharge from either the hospital or the emergency room. The aim is to make transition out of the hospital and back to the community as seamless as possible. Hospitalists in these situations can help with medication reconciliation, patient and caregiver education, coordination of services, and a clear handoff to primary care providers.

Major changes in the way that hospitals are getting paid are accelerating the involvement of hospitalists in post-acute care both in the community and settings like skilled nursing facilities (SNFs). This includes hospitalists serving as “SNFists” as they re-create their role in the hospital in the skilled nursing facility setting.

Shift in focus

In addition to changing where they practice, hospitalists are changing how they practice. This shift is forcing hospitalists to shift their attention from decreasing LOS and preventing payer denials to decreasing hospitalizations, even if that might result in a longer LOS. Yes, a longer LOS. Because in some cases, an extra day in the hospital could help avoid a hospital readmission because patients leave the hospital better prepared for the transition back to the community and their homes. Hospitalists today are becoming managers of population health rather than hospital-centric providers, devoted to inpatient care, maximizing “heads in beds” and decreasing LOS. These changes in the expanding roles and responsibilities for hospitalists may hit all of three parts of the Triple Aim—improving patient experience as well as population health while reducing costs. In the end, this will mean a significant benefit for patients and payers.

Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD, is chief medical officer of the Access Group, a member of the Managed Care Editorial Advisory Board, and actively involved in MCOs and health system redesigns.

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