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Hospitalist wing patients have fewer readmissions
Improved communication, follow-up key
By dedicating a wing of the hospital to patients being cared for by hospitalists, St. Mary's Health Center in St. Louis has decreased the length of stay by 4% compared to a 2% reduction in the non-hospitalist unit, as well as improved patient satisfaction and decreased the 30-day readmission rate for patients on the hospitalist unit.
In January 2010, the average 30-day readmission rate was 11.5%, down from 14% in the program's first month, a 22% reduction since the program started. In the same period of time, readmission rates dropped from 19% to 18%, a 5% decrease on a non-hospitalist unit.
The key to the success of the program is increased communication between the hospitalists and the rest of the treatment team, as well as better communication between physicians and other post-acute providers and follow-up calls after discharge, says Philip Vaidyan, MD, head of the hospitalist program and practice leader for IPC The Hospitalist Company.
"Before the hospitalist unit was established, case managers were assigned to specific doctors and followed them all over the hospital. It was very fragmented and chaotic, and we spent a lot of time trying to track down the doctors," says Ruth Karimi, RN, case manager on the 32-bed hospitalist unit.
St. Mary's Health Center is a 582-bed hospital with a psychiatric unit and a rehabilitation unit in addition to the acute care beds. The hospital contracts with a national hospitalist organization to provide care for about 60% of the patients in the hospital, Vaidyan says.
In June 2008, the hospital designated a 20-bed nursing unit as a specialized hospitalist unit on a trial basis.
After the pilot began, the hospitalists found that they were saving about 60 minutes a day because they were seeing patients in just one unit rather than all over the hospital and that they received 65% fewer pages a day because they were in closer proximity to the nurses and case managers, Vaidyan adds.
The pilot project was so successful that the hospital opened a new 32-bed hospitalist unit in March 2009. About 40% of patients treated by the hospitalist team are on the unit. The others are in specialized units such as the telemetry or intensive care unit.
The new approach centralizes care and maximizes the time that physicians spend with patients and the other members of the treatment team, Vaidyan says.
"All members of the team work in close proximity to each other. Communication is very robust, and the team works together to create a plan of care for patients," he adds.
Many of the patients on the hospitalist unit are uninsured, under-insured, have low health literacy, and/or do not have a primary care provider.
"These patients are the most highly vulnerable for readmission. We all work together to coordinate their care while they are in the hospital. The case manager and social worker help them find a primary care provider and coordinate other services they will need after discharge," he says.
The hospitalist team includes nurse practitioners who work in the emergency department and act as a liaison between the emergency department physicians and the hospitalists.
When patients come into the emergency department, the ED physician starts the work-up and a nurse practitioner starts the orders in the ED, performs medication reconciliation, and ensures that patients are on the proper protocol.
The emergency department physicians like the arrangement because they can hand off the patient quickly without waiting to talk to the unit hospitalist, Vaidyan says.
"It is a great advantage for the nurse practitioner to get the treatment started when the patient is still in the emergency department. This way, the patient gets treated in a timely manner and the floor nurses don't have to call the physician for orders when the patient is moved to the floor," Vaidyan says.
The team on the hospitalist unit has been able to ensure safe and timely discharges by meeting regularly and collaborating on patient care, Vaidyan says.
The hospitalist team, including the nurse practitioner, meets every morning and reviews the case of every patient on the unit. Halfway through the meeting, they are joined by the unit-based case manager, the social worker, and the unit nursing team leader.
"We discuss every patient in the unit, who is scheduled to go home, any issues we have to focus on before discharge. The daily meetings help us move the patient quickly through the continuum of care because we identify any roadblocks and concentrate on overcoming them," Karimi says.
When the meeting is over, Karimi knows which doctors she is going to be working with that day, what tests and procedures have been ordered for her patients, and their clinical needs.
"We decide at the meeting what the patient is going to need so we can provide consistent care in a timely manner. I work with the physicians to make sure that any consults the patient needs are ordered quickly and pursue them to make sure they occur in a timely manner," she says.
The case managers throughout the hospital screen 100% of patients on admission and assess their living situation, social abilities, community support, and functionality to determine what they are likely to need at discharge. They make referrals to social services, nutrition, or physical therapy if needed, Karimi says.
"We find out if patients can afford their medication, if they have a primary care physician, if they feel safe at home. During the morning meetings, I tell the physicians my concerns about the patient and work with them to establish a plan of care for the day, and often for the week," she says.
If patients have no insurance and may be eligible for Medicaid, Karimi calls in the hospital's Medicaid intake coordinators. If they don't have a primary care physician, she helps them identify one.
In addition to the daily meetings, the treatment team has twice-weekly hospitalist-led multidisciplinary meetings during which they discuss discharge planning, quality measures, and outcomes data.
Half of the hospitalist team meets twice a week for an hour with the entire treatment team, including the unit-based case manager, the wound care nurse, the nutritionists, the pharmacists, and chaplain to discuss all patients on the unit.
The other half attends biweekly walking rounds with the unit-based nursing staff.
"We instituted the walking rounds to give the frontline nurses the ability to participate in the rounds. We know they are out there working with the patients so we made the decision that half of the hospitalists would walk to the patients' bedsides so the nurses and their care partners can participate in the meeting," Vaidyan says.
When a patient is discharged, the discharging hospitalist sends a discharge summary electronically to the patient's primary care physician and/or specialist who will provide the follow-up care, usually within an hour of discharge. The one-page summary includes medications, lab and test results, pending tests and procedures, and other information needed for follow up.
Physicians who see patients in post-acute facilities also receive the discharge summary.
"The case manager and social worker usually know which physician is going to take care of patients in the post-acute facility and make sure the discharge summary is directed to them," Vaidyan says.
The hospitalist firm also sends the discharge summary to its post-discharge call center. The center is staffed by case managers who make follow-up calls to patients within 72 hours of discharge to ensure that they have a follow-up appointment, that their post-discharge services are in place, and to identify any problems the patient may be having. They use a "smart survey" that is customized to the patient's clinical situation.
For instance, if a patient was discharged on anti-coagulants, the survey has a question that determines if the patient knows what symptoms indicate a complication.
If the case manager can't address the problem over the telephone, she alerts Karimi or the hospitalist who cares for the patient in the hospital.
The results of the survey are faxed to the same physician who received the discharge summary so that all key team members are kept informed, Vaidyan says.
(For more information contact Philip Vaidyan, MD, head of the hospitalist program and practice leader for IPC The Hospitalist Company, St. Mary's Health Center, e-mail: Pvaidyan@ipc-hub.com.)