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Healthcare Down Under

From: The Hospitalist, November 2006

Australia begins pilot hospitalist program

by Norra MacReady

The hospitalist movement is going Down Under: In a pilot program starting in January 2007, 20 hospitalists will begin working in 11 Australian hospitals as the country tries to adapt to the new realities of healthcare. The move reflects an ongoing debate in Australia concerning the best way to confront the challenges facing many developed nations in the 21st century: how to provide hospital care to an aging patient population that is growing sicker as medical costs skyrocket.

Current Concerns

Currently, Australia, like the United Kingdom and other Commonwealth countries, has a consultant-led medical system in which a specialist, or consultant, admits a patient and “owns” that individual for the duration of his or her hospital stay. The patient’s day-to-day care generally falls to a senior resident (or registrar) and a junior physician—both of whom consult with the supervising physician on rounds. In the meantime, little attention is paid to standardized indications and protocols for admission and discharge, and many observers complain about the lack of coordination and organization of care and patient flow.1

“In some cases, patient flow through our system can be disjointed, leading to delays in care and frustration from patients and staff,” says Katherine McGrath, MD, deputy director of General Health System Performance in New South Wales (NSW) Health, whose department is overseeing the pilot study. “We believe a new role, like that of the hospitalist, will fill the gap between the current non-clinical time requirements and patient needs.”

Others in Australia agree. “What we’re looking for is a senior presence in the hospital who can provide continuity of care,” says William Lancashire, MD, acting director of intensive care at Port Macquarie Base Hospital in Port Macquarie, NSW.

Rural care is another concern. Currently, 34% of all Australians and 70% of Australian aborigines live outside major urban centers and depend on “bush” hospitals when they become ill. Yet only 23% of medical specialists and 27% of general practitioners work in these remote areas.2 Hospitalists, with their expertise in general medicine and comfort with teamwork and coordination of care, are seen by some as an answer to the shortage of medical personnel in the bush. Some authors have suggested that physicians who work in these settings are already de facto hospitalists.3

The program is also an effort to improve quality of care, in response to studies reporting a troubling rate of medical errors and as many as 10,000 to 14,000 preventable deaths occurring within the Australian hospital system annually.4 When the Australian authorities first considered a hospitalist model and began studying programs in other countries, “we noted the rapid growth in hospitalist numbers and the positive contribution they have made to patient flow and patient safety,” says Dr. McGrath.

The Program

The participating hospitals are all located in the state of New South Wales: Westmead, Nepean, Bulli, Shellharbour, Shoalhaven, St. George, Sutherland, Fairfield, Manly, Mona Vale, and Hornsby. Depending on the institution, hospitalists may work in geriatrics, cardiology, renal, or emergency care.

In an address to the NSW state parliament, Minister for Health John Hatzistergos explains that hospitalists will coordinate care across departments to ensure that patients enjoy a smooth stay. They will also participate in hospital governance and organization, as well as staff education, giving them a say in developing policies and procedures. “The proposal is tantamount to patients having their own general practitioner in the hospital with them to ensure continued quality care,” he says.5

Many of the new hospitalists will probably come from the ranks of career medical officers (CMOs), general physicians recruited directly out of training to work in underserved rural and suburban hospitals. Most CMOs are concentrated in emergency or critical care, but they can be found across a wide range of specialties, including orthopedics, community medicine, and even sexual medicine.4 CMOs may also follow patients after they have been admitted by a specialist.

But even the CMO position is still relatively new, having been created only in the 1980s. “They’ve been an absolutely invaluable resource in non-metropolitan Australia, but we still don’t have a formal system for their ongoing training or certification,” Dr. Lancashire tells The Hospitalist. “We need to provide a clear certification and career structure for these individuals.”

Participation in the hospitalist program is voluntary, says Dr. McGrath. Successful candidates “will be skilled in care coordination, patient flow management, patient safety systems, negotiation, procedural skills relevant to their roles, and clinical specialty modules relevant to the areas of specialty in which they are now working, such as geriatrics and emergency care.” Training will be on the job, “with skills assessment and ‘up-skilling’ as necessary to meet the responsibilities of the role they are filling in the local service.”

Still, the program reflects a tweaking—rather than a full-fledged revamping—of the Australian system. “The hospitalists will work with the consultants, who know them and trust their judgment,” says Abd Malak, executive director of workforce development at Sydney West Area Health Service, which is recruiting hospitalists for Westmead and Nepean hospitals. This means that hospitalists will have the authority to change a patient’s medication or other treatments when they deem it necessary, without waiting for the admitting specialist to come on rounds—but the admitting physician will still bear the ultimate responsibility for the patient’s outcome.

“The hospitalists will answer to the specialist clinicians for their patient care as well as management for patient flow and care coordination,” explains Dr. McGrath.

This approach represents a philosophy that differs sharply from the hospitalist’s position in the United States, in which a hospitalist has full responsibility for the patient’s care as long as that patient is in the hospital. In the Australian model, hospitalists will function almost as middle managers, exercising authority up to a point, but ultimately reporting to a more senior physician. Those who favor this arrangement describe it as organizing a patient’s care, rather than taking it over.4

Not surprisingly, some doctors are taking a dim view of this policy. “I think it’s a mistake. It’s just like giving the specialist another registrar,” says Dr. Lancashire. At Port Macquarie Base Hospital, he is leading the effort to develop a hospitalist program that is closer to the U.S. model because it will give those physicians primary responsibility for their patients.

Challenges

Indeed, good communication among a patient’s various doctors, always an essential element of good care, will be especially critical in the Australian system, says John Nelson, MD, medical director of the hospitalist practice at Overlake Hospital in Bellevue, Wash. “The hospitalists and consultants should try to preserve a collegial culture in which they talk to each other regularly,” he says. “Otherwise, you could wind up with a situation like the one in some European countries where hospital doctors and office doctors seldom communicate and don’t even see themselves as peers.”

Dr. Nelson, who has consulted on the establishment of more than 150 hospitalist practices, also warns the Australians against taking a one-size-fits-all approach. “Each hospital has its own culture, so they should acknowledge that the experience will play out differently at each institution,” he says.

Many Aussies agree with Dr. Nelson. “We find that the outcomes are better when the hospitalists are in charge of patient care,” adds Peter Jamieson, MD, division chief, acute care family medicine at Calgary Health Region in Canada, which has a hospitalist practice of about 80 physicians serving five hospitals. “Hospitalists take a holistic view of the patients and their problems. For example, at discharge they can reconcile a patient’s medications and, in general, make sure the ball isn’t dropped. These are skills that specialists don’t focus on and by putting hospitalists in a secondary, supportive, or bedside role, I don’t think they will capture those benefits.”

Another challenge concerns the effect of a hospitalist program on primary care physicians who practice outside the hospital setting, such as family physicians. “Will they lift those doctors from the community to work in the hospital, or will they employ full-time hospitalists?” asks Dr. Jamieson. “A new program is easiest to administer when you have full-time people on rotation, but it robs the community of some primary care physicians. In Calgary, we have a mix, so as not to deplete the community of those doctors.”

More concrete challenges concern funding streams and convincing hospital and, in a single-payer system, governmental authorities that hospitalists are worth the investment. “Demonstrating value is the first step,” says Dr. Jamieson, who helped develop the hospitalist program in Calgary.

The timely sharing of records is also critical, so electronic medical records or sophisticated faxing systems should be in place as well. “The hospital should send the patient’s records to the office doctor by the end of the day on which that patient is discharged,” explains Dr. Nelson. “If it takes two weeks for the community doctor to get the records, that’s going to be a problem.”

In general, he advises Australian hospitalists to listen well but make their needs and interests clear. “I would tell them to be frank about what they are looking for and how they want their practices to go. I encourage them to develop an ongoing dialogue with North American hospitalists: we can learn from each other.” TH

Norra MacReady is a regular contributor to The Hospitalist.

References

  1. Hillman K. The changing role of acute-care hospitals. Med J Aust. 1999 Apr 5;170(7):325-328.
  2. Murray RB, Wronski I. When the tide goes out: health workforce in rural, remote and indigenous communities. Med J Aust. 2006 Jul 3;185(1):37-38.
  3. Hore CT, Lancashire W, Roberts JB, et al. Integrated critical care: an approach to specialist cover for critical care in the rural setting. Med J Aust. 2003 Nov 3;179(9):95-97.
  4. Egan JM, Webber MG, King MR, et al. The hospitalist: a third alternative. Med J Aust. 2000 Apr 3;172(7):335-338.
  5. Hatzistergos J. Health care work force innovations. Address before the Parliament of New South Wales, published in NSW Legislative Council Hansard, August 31, 2006, page 1221. Available at: www.parliament.nsw.gov.au/prod/PARLMENT/hansArt.nsf/V3Key/LC20060831012. Last accessed October 10, 2006.

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