Hospitalists and case managers team up for better outcomes

Trend toward inpatient specialists is on the rise

When Christiana Hospital in Newark, DE, first instituted its hospitalist program in 1994, the hospital experienced a big drop in length of stay, especially with the uninsured patients who had no particular physician watching over them, recalls Thomas Mannis, MD, senior medical advisor for case management and head of the division of hospitalists. "We have been very happy they are here. It’s nice to have a group of doctors you know and can turn to. Hospitalists increase the hospital’s efficiency because they can make rounds more than once a day and they’re available to come back and discharge patients," he adds.

If your hospital doesn’t already have a hospitalist program, there could be one in the works in the near future, experts say. In particular, more large hospitals are turning to hospitalists to provide care for inpatients, improve timely discharges, and ultimately affect the hospital’s bottom line.

Hospitalists are physicians who only take care of medical inpatients. They don’t have an office practice but only see patients in the hospitals.

When a hospitalist and a case manager work together as a team, the two of them can carry a bigger patient load than both can alone, says George Martin, MD, team leader for VHA Inc., an Irving, TX-based health care cooperative.

The most effective programs at VHA’s member hospitals create a close working relationship in which the hospitalist writes the medical treatment plan and the care manager makes sure it is carried out appropriately and in a timely fashion.

A hospitalist alone can care for about a dozen patients, Martin says. A case manager can carry a caseload of 15 to 20 patients. "Put the two together and the hospitalist, with the assistance of the case manager, can cover 18 or 19 patients. Because the case manager can easily reach the hospitalist when necessary, she can carry a load of 24 to 28 patients a day."

"This is a big deal in terms of efficiency and cost savings," he adds. In one successful hospitalist model, case managers work with a hospitalist to manage about 18 medical patients and also manage the care of six to eight surgical patients who are not the responsibility of the hospitalists and typically require less coordination of care than a medical patient, Martin says.

Hospitalists focus on inpatient care. Because they’re on-site, they see patients more quickly and move them through the continuum efficiently, points out Beverly Cunningham, MS, RN, director of case management at Medical City Dallas Hospital.

"Hospitalists make a lot of sense from a financial standpoint, from a quality of care standpoint, and from a patient satisfaction standpoint," Martin adds. For instance, instead of having 200 internists who admit several patients a month, there are six or seven hospitalists who admit the majority of the medical inpatients.

Case management staff find it easier to get a response to questions, implement standardization of care initiatives, measure care, and determine accountability for glitches in the system.

It’s much easier to provide feedback to six or seven hospitalists than to 200 internists, adds Cunningham. "It’s easier to develop a relationship with hospitalists than other physicians. They are constantly in the hospital as opposed to being in and out like other doctors," she says.

At Cunningham’s hospital, many of the large multispecialty groups refer their hospitalized patients to hospitalists. Having hospitalists in the hospital at all times speeds up the discharge process and improves patient care, she says. "The hospitalists move the patients in and out of the hospital. These days, that’s not just decreasing costs, but it’s also freeing up beds."

Christiana Hospital has two hospitalist groups for adult medicine and a small pediatric hospitalist group, Mannis says. The two groups are independently owned and tied into the hospital under contractual standards. The hospitalists at Christiana Hospital provide care for about 65% of the medical patients and 20% of all patients.

The program was started when a group of hospitalists approached the hospital in 1994. "Patients in the hospital are sicker and sicker. Family practitioners and general internists don’t always feel comfortable treating them. They started handing off care on weekends and at nights," Mannis says.

The hospital has a division of hospitalist medicine, headed by Mannis, who meets with the hospitalists regularly, gives them data, and talks to them about any problems that have been identified.

The hospital changed its case management model in March 2004 to a unit-based model. At present, each hospitalist cares for patients who are scattered all over the hospital. The hospital is working with the hospitalist groups to persuade them to be unit-based so the hospitalists and care managers will be in contact all day long, Mannis says.

In the previous model, the utilization nurses were unit- and product-based, the case managers were unit-based, and the social workers were not assigned to a particular unit. "This arrangement worked well, but it didn’t meet all our needs. We wanted someone on the unit to drive the performance indicator issues," he says.

Under the new model, the case managers are called care managers and are assigned by unit.

The care manager does the initial case management assessment, identifies who is ready for discharge, and handles discharge planning. The care manager guides the patients through the process of choosing home health vendors.

The care managers make rounds every day with the charge nurse and the primary care physician, looking at the Joint Commission on Accreditation of Healthcare Organizations and Centers for Medicare & Medicaid Services indicators.

The length of stay at Christiana Hospital has been creeping up lately, he says, possibly because the hospital’s case mix includes more acutely ill patients. "It’s hard to compare. So much has changed in hospital medicine since the program," Mannis says.

Medical City Dallas has unit-based case management and social work with one social worker assigned to the two adult hospitalist groups, says Cunningham. "In the first year of the program, the hospitalists had their own case management, but once they understood medical necessity, we switched to unit-base social work and case management." If there isn’t a hospitalist, the attending physician makes rounds and writes orders but may not be back to the hospital to review the results until the evening or the next day. This delayed follow-up by the admitting physician sometimes increases the patient’s length of stay, she explains.

Anytime an intervention is ordered, whether it’s a test or a procedure, the hospitalist is right there and can monitor the progression of the order. For instance, a radiologist may call the attending physician at his or her office if there is a question, but it may be hours before the physician can return the call, leading to a delay in testing and a delay in discharge.

The hospitalists see the patients in the morning, check on the tests later in the day, and may make several interventions during the day. If the test results show the patient is ready for discharge in the afternoon, the hospitalist can issue the discharge orders. "It’s not easy for a physician who is not hospital-based to do this when they are providing an office practice at the same time," Cunningham says.

Referring their hospitalized patients to a hospitalist for care is advantageous for family practice physicians, internists, and pediatricians, Martin points out. A typical general practice physician may have only two or three patients in the hospital at one time. Driving to the hospital, finding parking, seeing the patients, and driving back to the office can take an hour or two. "It doesn’t add to the bottom line either in time basis or dollar basis," he explains.

With a hospitalist, patients should have short lengths of stay, lower costs, and should be able to move through the health care system more quickly, Cunningham notes.

With an average cost of about $500 a day, discharging patients on time represents a tremendous savings, Martin adds. At the same time, if a patient takes a turn for the worse, the hospitalist is on the premises and can evaluate his or her condition and start treatment immediately, he says.

Because of the nature of their jobs, hospitalists become inpatient disease specialists and are very familiar with the inpatient disease processes, whereas a primary care physician may have only a general knowledge of some diseases that require hospitalization, Cunningham points out.

Hospitalists may be employed by the hospital or be in an independent practice that is affiliated with the hospital through an arrangement similar to those for ancillary physicians such as radiologists and emergency department physicians. But unlike those physicians, who have mainly ancillary functions, hospitalists provide direct patient care in the hospital setting.

Some physician groups set up a rotation of office physicians who take turns being the hospitalist. For instance, they may be out of the office and in the hospital once every eight weeks.

Hospitalists oversee the comprehensive care of the inpatient. The patient typically has an internist or family practice physician but needs inpatient care. Patients are referred for admission by the internist or a surgeon, especially if they are medically complex patients having a surgical procedure.

Hospitalists most frequently are found in larger hospitals. A hospital 350 beds or smaller may not have enough patients to support three or four hospitalists, the minimum necessary to cover the hospital 24 hours a day, Martin says. About 10% of VHA’s member hospitals have a hospitalist program, and an additional 25% to 30% are considering setting one up, he adds.

Burnout can be a problem

While hospitalists can be effective and efficient, the programs don’t always work to everyone’s satisfaction. Burnout from long periods of time on call is one problem cited by Cunningham and Martin.

One big drawbacks with hospitalists is that many patients have gone to the same family practitioner for years and want their familiar physician to take care of them in the hospital. "They’re being seen in the hospital by a doctor they don’t know at all, and there is always that potential patient satisfaction issue," Cunningham says.

A hospitalist program works best if the hospitalists are in independent practice, as opposed to being employed by the hospital, Martin states. Hospitalists employed by the hospital typically work in shifts like emergency department physicians, leaving the patient without continuity of care, he adds.