The “one-visit follow-up clinic”
A frequent impediment to reducing length of stay with the unassigned (or “no-doc”) patients is the lack of an outpatient physician with whom the patient can get an appointment. In many, many places around the country, primary care physicians have overflowing practices and cannot take on the unassigned patient very easily.
One solution to this dilemma is what I call the “one-visit follow-up clinic”. At Inpatient Management Inc., we are about to launch our first such clinic. The idea works like this: we, as the hospitalist team, will provide one follow-up visit to patients who do not have a primary care physician. The clinic might see patients two half-days per week, depending on volume, and can be staffed by a nurse practitioner with supervision from one of the hospitalists.
This clinic can really help in a number of areas. As mentioned earlier, this clinic has the potential to help reduce length of stay. It should also help bring down readmission rates since such a large percentage of readmitted patients confess to not having seen any primary care physician since discharge. This clinic also improves continuity of care, from the inpatient setting to the ambulatory setting since the patient will first be seen as an outpatient by the same team of caregivers that provided inpatient care. During this visit, the care team can also answer questions about medications, dressing changes, and other discharge orders. The appointment for this clinic visit can easily be scheduled at the time of the patient’s discharge from the hospital.
Of course, some (perhaps most?) patients will still not have a PCP after the one visit, but the one visit has provided some follow-up care and direction following their hospital episode. There are other potential pitfalls as well, but overall, we believe this will provide a big value-added service to both our patients and our hospital clients. I am certain we are not the first to do this, and I am eager to hear your stories about such adventures. If your program staffs such a clinic, please give your comments, good or bad about your experience. What are the benefits? What are the obstacles? I look forward to your comments!
About the Author: Kirk Mathews is the CEO, principal, and founder of Inpatient Management, Inc., a national hospitalist management company in St. Louis. Prior to cofounding Inpatient Management in 1997, he was senior vice president of Cejka & Company, responsible for managing one of the nation's largest physician recruiting enterprises with a search portfolio of over 300 clients. His experience includes management, sales, operations, recruiting strategy, physician compensation and benefits planning and design, and employment contract design and negotiations. In 1989, he served as vice president of Clayton Medical Associates after serving as senior recruiting consultant with Jackson & Coker, the nation's largest physician recruiting firm at the time. Mathews received his B.S. in accounting and MBA from Northwest Missouri State University. Mathews is a member of the the Society of Hospital Medicine.
Matteo Valenti, DO, FHM | Oct 29, 2009 | Reply
I do think this is a potentially good idea however I know that my previous group considered doing this but we got such a negative response from our primary referral doctors. They saw it as us moving into outpatient care and were threatened by it. Politically it did not work.
One way we grew our business was by having an “insurance policy” that we would not compete for outpatients–specifically, we had no outpatient presence at all.
In other areas or markets this may work, but I would caution groups considering this to get a feel for what potential backlash there might be.
Abhay Padgaonkar | Nov 3, 2009 | Reply
In addition to political considerations, there have to be economic and cost-benefit analysis considerations as well. Obviously, the supposed benefit is reduced LOS. The additional cost is utilizing a hospitalist and a NP in a potentially sparsely occupied, lower reimbursement outpatient clinic. Whether it makes economic sense or not would depend on many factors at play at each location, not to mention hospitalists’ willingness to do outpatient work.
Instead, why not sign up several PCPs and have one of them on call each day and instruct hospitalists to refer “no doc” patients to the PCP on call for follow-up? That way, the PCPs become part of the solution, rather than being part of the problem. If the patients are not going to follow up with the assigned PCP, it is unlikely that they will visit the “one-visit follow-up” clinic either.
Abhay Padgaonkar
CEO, Polaris Medical Group, LLC
abhay@pobox.com | (602) 628-1234
Steven Meyerson, MD | Nov 4, 2009 | Reply
I would be very concerned about the liability risk of establishing a doctor patient relationship in an outpatient setting and not being able to provide for continuity of care.
What will the follow up clinic do when the patient needs more follow up? Uninsured patients often spend extra days in the hospital for lack of a “safe discharge.” By extension, the clinic will have to see patients for further follow up (or worse, readmit them) if additional care is needed and there is no PCP or specialist willing to provide it in an office setting.
Consider the risk of a charge of abandonment under these circumstances. I guess you could have the patient can sign a contract in advance agreeing to one visit and absolving the clinic of liability for any damages that may occur as a result of terminating care after that single visit but I doubt it would be enforceable.
If this were easy, every hospital would have as follow up clinic.