Hospitalists working in the outpatient setting requires a change in mindset, acceptance of responsibility for patients' care across settings
by Larry Beresford
Not all post-discharge clinics are established by hospitalist groups or their parent hospitals. As Tallahassee (Fla.) Memorial Hospital’s experience with a collaborative approach shows (see “Is a Post-Discharge Clinic in Your Hospital’s Future?”), health plans might take an interest in successful discharge protocols to prevent unnecessary readmissions. In other cases, medical specialty practices have established clinics for patients with specific diseases—CHF, COPD, even post-ICU delirium.
In Southern California, two large, established physician groups that assume financial risk or insurance functions see the potential benefit, given that their financial incentives are more obviously aligned to such clinics than are hospitals’. Cerritos, Calif.-based CareMore is a Medicare health plan that started out as a medical group and remains a care delivery system for Medicare Advantage patients, making significant use of hospitalists.
“We call ourselves ‘extensivists,’” says CareMore medical director and hospitalist Hyong Kim, MD. The company’s hospitalists generally work mornings at an assigned hospital, then spend their afternoons either making rounds on CareMore patients at a skilled nursing facility or staffing one of the group’s post-discharge clinics, located in its disease-management-oriented comprehensive clinics. Hospitalists might even make take over from primary-care physicians (PCPs) the ongoing management of the most difficult or most frail patients, Dr. Kim says. That demands a change in mindset by the hospitalist to accept responsibility for the patient’s care across settings.
“This approach wouldn’t work in fee-for-service, but it works well in pre-paid environments. We pay our PCPs a capitated rate, and they continue to receive capitation after the hospitalist takes over the care,” he explains. “Our extensivists are salaried, with incentives based on readmissions.”
The company uses chronic-disease managers, who check in daily with the hospitalists. “We also have a house-call physician program, sending physicians and social workers to patients’ homes after discharge,” Dr. Kim says.
Torrance, Calif.-based HealthCare Partners, a large, physician-owned multispecialty medical group, operates in many ways like a health plan, says Tyler Jung, MD, medical director for hospitalists, high-risk groups, and post-discharge clinics. “We’re fully delegated. We accept financial risk from virtually all of the major health plans in the area,” he explains.
Dr. Jung’s team views the first 30 days after patients leave the hospital as “the riskiest time period for our members. We’ve had hospitalists for 15 to 20 years, and just recently we began looking at the post-discharge clinic option,” he says. “I’m still undecided: Is it a Band-Aid or something we need to intervene in the post-discharge period?”
HealthCare Partners operates six community care and disease management centers across Southern California, each of which houses a post-discharge clinic staffed by a doctor, social worker, and case manager. The post-discharge physicians are internists, not necessarily hospitalists, “although many moonlight in our hospitalist program and the most successful ones have hospitalist experience,” Dr. Jung says. “Our clinics are designed for 45-minute appointments: The patient meets with the doctor and maybe the social worker and case manager—a real multidisciplinary approach.”
Three-fourths of referrals are patients coming home from the hospital and a quarter are high-risk patients identified in primary-care clinics. “The first visit deals with medically complicated issues, but the next couple may have more to do with reinforcing the care plan that was established,” as well as looking at social issues, he says.
Finding the right physician is no easy task. “They’ve got to get it,” he says. “You need to be judicious about how long to keep the patient—versus referring them back to primary care—and setting limits is hard. We don’t have magic criteria for this. It’s mostly subjective right now.”
Another challenge is measuring success. “These clinics can be expensive to run, and we need to show the return on investment,” he says.
Larry Beresford is a freelance writer based in Oakland, Calif.
The Hospitalist newsmagazine reports on issues and trends in hospital medicine. The Hospitalist reaches more than 25,000 hospitalists, physician assistants, nurse practitioners, residents, and medical administrators interested in the practice and business of hospital medicine.