Keep hospitalists on the right track with proper Incentives

Work closely with hospitalists from the first day

At Medical City Dallas Hospital, there is a "healthy competition" between two hospitalist groups who compare their outcomes with those of the other group and all the physicians in the hospital, says Beverly Cunningham, MS, RN, director of case management.

The hospital’s outcomes studies include length of stay (LOS), case-mix index, cost per case, and compliance with the Joint Commission on Accreditation of Health Care Organizations’ (JCAHO) core measures for congestive heart failure and pneumonia.

The case-mix index is an important part of the outcomes studies, Cunningham says.

For instance, when Cunningham studied only LOS, she found that one group of hospitalists had a longer average LOS but had a higher case mix than any others. When the case mix was factored in, the group was getting better outcomes than any other medical practice.

Christiana Hospital in Newark, DE, generates a report card for its hospitalist groups each month covering items such as average LOS, cost per case, number of consults, commercial insurance denials, number of nonacute days, compliance with the 11 a.m. discharge time, and other factors, says Thomas Mannis, MD, senior medical advisor to case management and head of the division of hospitalists.

The hospital looks at the hospitalists’ top DRGs, their LOS vs. Centers for Medicare & Medicaid (CMS) averages, and any other benchmarks to give them an idea where they stand. Under the new care management model, the hospital will generate report cards for the unit including LOS, cost per case, and compliance with JCAHO, CMS, and other indicators. "Hopefully, the care manager and hospitalists will review the data with the nurse, and it will work out very well," he says.

Many hospitals include incentives in the contract when they employ hospitalists. "They need to know what’s in it for them. We have talked about this because we don’t have incentives tied into the practice," she says.

When a hospitalist is not employed by the hospital, the financial incentives require a little more thought. Some hospitals base the number of days the hospitalists work in the emergency department (ED) on their outcomes.

"This is a great idea. The better the outcomes, the more emergency department calls they get, and the more calls they get, the more patients they’ll have," Cunningham says. At Medical City Dallas Hospital, hospitalists get referrals from the ED and from physicians in the community.

It’s in the hospitalists’ best interest to move patients through the hospital quickly and free up beds for new patients, Cunningham points out.

"If the hospital is full, they can’t accept referrals because we have no beds. This cuts into their referral base," she says.

Here are some other tips for more effectively working with hospitalists:

  • Set up the program in such a way that the hospitalists are not overburdened and overworked.
  • Make sure there are a minimum of three hospitalists, preferable four or more, in a group so they can provide care at the hospital every day and rotate the night coverage.
  • Promote continuity of care for patients by avoiding having hospitalists care for all the patients they admit, rather than working a particular shift and going home.
  • Work closely with the hospitalists from their first day on the job and create a close relationship with them so they realize the value of working with case managers.
  • Develop a forum to address delays the hospitalists experience. This could be in the form of a hospitalist or inpatient physician committee that discusses issues related to the hospitalist program.