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Inpatient debate update: Do hospitalists improve care?

Internet debate erupted this summer among industry experts involved in inpatient medicine. “Do hospitalists actually improve patient care?” was the subject of heated comments, calling the 12-year hospital medicine movement into question. The June 23 Archives of Internal Medicine issue released the arguments of two internal medicine thought leaders: Mark V. Williams, MD, FACP, professor and chief of hospital medicine at Northwestern University Feinberg School of Medicine in Chicago, and Robert Centor, professor of general internal medicine and associate dean of the Huntsville Regional Medical Campus at the University of Alabama. The two thinkers respectively authored the articles “Hospitalists and the Hospital Medicine System of Care Are Good for Patient Care” and “A Hospitalist Inpatient System Does Not Improve Patient Care Outcomes.”

Hospitalist care is indeed good for patient care, according to Williams in a Q&A by Today’s Hospitalist. According to Williams and Centor, they agree hospitals need to better utilize hospitalists. Read more in the upcoming November issue of Hospitalist Management Advisor and hear what Robert Centor and Mark V. Williams, MD have to say about their points of differences.

How to follow end-of-life wishes

As hospitals deal with patients’ end-of-life decisions, hospitalists tend to abide by state regulations regarding default surrogates, those who make medical decisions if a hospitalized patient is incapacitated. There are currently 37 U.S. states that have regulations determining who is to be appointed surrogate, oftentimes spouse and family members. However, default surrogates tend to make decisions incongruous with the patient’s wishes, according to an article by Hospitalist News. One way to comply with the patient’s end-of-life wishes is to set up an advance directive. Consider the following practices:

  • Encourage patients to seek surrogates that have values consistent with their own, not necessarily family members.
  • Provide surrogates with information for decision making.
  • Use a form called the physician order for life-sustaining treatment (POLST). Also known as medical order for life-sustaining treatment, medical order on scope of treatment, or physician order on scope of treatment, this form includes directives on how medical staff can approach resuscitation, medical intervention, antibiotics, and general treatment.

Choose a billing service

Selecting a billing service is the key step to building your billing process. If your hospitalist program does not conduct in-house coding audits, the billing company or service you choose may assist you with this task. Consider the following steps when evaluating each service for selection:

  • Seek recommendations and testimonials from people you trust who have used billing services.
  • Pay special attention to the medical specialty in which the billing service has experience. For example, a billing service who specializes in outpatient orthopedics might not understand the nuances of inpatient billing.
  • Ask if the service submits bills electronically.
  • Determine the average number of days in the AR (accounts receivable).
  • Check references. Billing services should provide at least two references for hospitalist/inpatient practices for which they currently bill.
  • Determine how many practices the billing service currently has and how many clients have withdrawn in the past year, and for what reasons.
  • Conduct an on-site interview at the billing service.
  • Once you selected a billing service, meet with the representatives on a regular basis. Also consider taking minutes on concerns for follow-up.

The above is an excerpt from The Hospitalist Program Management Guide 2nd edition by Kenneth G. Simone, DO, and Jeffrey R. Dichter, MD, FACP, published by HCPro, Inc.

Retention tip: The physician feedback forum

Some physicians might consider leaving their job if they feel the hospital administration does not care about their needs or well-being.  With the long-term goal of employee retention in mind, hospitals can implement a collaborative solution—a retention program. It doesn’t need to be complicated or expensive. One way to jumpstart it is to implement a physician feedback forum, made up of both existing hospitalists on staff and new hires. Some tips for hospitalist practice leaders include the following suggestions:

  • Schedule the feedback forum regularly
  • Give fair and legitimate consideration to the feedback by acting on issues that have merit
  • Consider a formal meeting or poll for groups of 20 or more physicians

A good mentoring program and a well-functioning feedback forum will be the backbone of an effective retention program.

The above is an adapted excerpt from Practical Guide to Hospitalist Recruitment and Retention by Kirk Mathews, foreword by John Nelson, MD, FACP, published by HCPro, Inc.

The strive for inpatient pediatric consistency

Although studies show that pediatric hospitalist care is efficient, there haven’t been as many studies about the quality of care or about variations in these types of programs.  A recent study by the Pediatric Research in Inpatient Settings, an organization that touts quality of care for hospitalized children, found that inpatient pediatric systems demonstrated substantial variation managing therapies for common patient conditions.  The study concluded that there is a need for a strong evidence base for pediatric hospitalist programs to reduce undesirable variations in care.

Palliative care programs save hospitals money

Hospitals saved $279-$374 a day on patients with palliative care programs, according to a new study by the Center to Advance Palliative Care (CAPC) and National Palliative Care Research Center. Palliative care, a subspecialty to improve quality of life, responds to an increasing aging population with serious illnesses, including cancer, heart disease, and kidney failure.

The study, “Cost Savings Associated with U.S. Hospital Palliative Care Consultation Programs,” published in the Sept. 8 issue of the Archives of Internal Medicine, evaluated nearly 3000 patients at eight hospitals and found that hospitals saved $1700-$4900 per admission of a palliative care patient.  For an entire hospital, this translates to savings in pharmacy, lab, and intensive care costs that total $1.3 million for a 300-bed community hospital or $2.5 million for the average academic medical center.

Since 2006, more than 41% hospitals employ a palliative care program, according to a CAPC press release this week.

Update: Cape Cod and Falmouth hospitals save hospitalist jobs

Cape Cod Hospital will keep on 19 fulltime hospitalists, thanks to a new agreement reached last week between administration of Cape Cod Healthcare and Medical Staff Leadership Group, according to a Falmouth Bulletin article last week.

The new agreement follows last month's announcement that parent company Cape Cod Healthcare would overhaul its 10-year hospitalist programs at Cape Cod and Falmouth Hospitals, cutting five hospitalist jobs to save $2.7 million in the budget. The employee layoffs led to concerns about the heavier workload and, last week, led to the resignation of three hospitalists, according to the Cape Cod Times. The new agreement will now save about $2.2 million with the hospitals’ adjusted plans.

University of Michigan launches specialty-hospitalist alliance program for collaborative research

Many academic hospitalist settings have been slow to create successful clinical research programs, according to the University of Michigan.  Because some programs fail to recognize the importance of specialists in clinical research in hospital-based academic centers, the hospitalist program at the university’s department of internal medicine created the Specialty-Hospitalist Allied Research Program, otherwise known as SHARP. Co-directed by a hospitalist and subspecialist, SHARP started two projects to combine the efforts of both medical staff groups in the following initiatives:

  • A collaborative trial between hospitalists and infectious disease specialists on antiseptic agents to reduce false-positive blood cultures
  • A study by hospitalists, clinical pharmacists, and geriatricians on techniques to reduce medication errors during patient discharges

SHARP currently pools data from single institutions but plans to expand to multi-center research, according to the study abstract.  From this research, SHARP hopes the collaborative specialty-hospitalist efforts will lead to improved inpatient care.

Documenting success for expansion

With hopes of expanding into 24/7 coverage, more full-time staff, or specialty inpatient programs, hospitalists and hospitalist program directors should provide documentation for the higher ups of the hospital. To pitch your program-growth ideas to hospital administrators, offer documented information on the program’s successes and failures, according to Jon Hersen, administrative director of Legacy Inpatient Medicine Service (LIMS) at Portland, OR. Show hard data in a monthly dashboard tool on patient admission and discharge rates. Also provide other information related to the program’s goals, including the following:

  • Monthly production reports
  • Annual goals and objectives
  • Long-term strategic plan
  • Daily patient census reports

Read the abbreviated online story, found in the September issue of HCPro’s premium monthly newsletter, Hospitalist Management Advisor.

How to measure quality and collect data

Many experts believe that the purpose of a hospitalist program is not simply to reduce the length of stay of patients, but to improve quality of care. With agencies such as the Joint Commission (formerly known as JCAHO) recommending that hospitals report performance data, hospitals are looking for effective ways to collect data and measure quality, particularly as pay-for-performance initiatives become more prevalent.

One method of collecting data is measuring the operational performance of an individual hospitalist. Quality officers can evaluate performance based on the following tracked data in a report card:

  • Patient discharge times
  • Readmission percentage
  • Pre-op totals
  • Total billed
  • Number of admissions
  • Number of night float admissions
  • Total number of discharges

The above excerpt is adapted from Tools and Strategies for an Effective Hospitalist Program by Jeffrey R. Dichter, MD, FACP and Kenneth G. Simone, DO, published by HCPro, Inc.

 

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