In spite of all the gadgets and technologies available to hospital-based physicians nowadays, Jerome Wilborn, MD, FCCP, sees a much simpler symbol of patient care. Dr. Wilborn, national medical director for post-acute care services at IPC Healthcare, Inc., in North Hollywood, Calif., believes stethoscopes are key to post-acute patient care, and hospitalists are the ones “redefining” the practice. It’s not just a metaphor for working in settings that lack access to the specialists, equipment, and other resources of the acute-care hospital, he explains. A stethoscope, he says, reflects on the physicians’ clinical acumen and listening skills.
“Acute-care doctors need to understand that in the post-acute setting, it’s not about ordering labs. It is important to talk to the family,” he says. “Over the next 14 to 30 days, you can really dig into relationships with patients, optimize their medical care, reduce poly-pharmacy, and even prevent readmissions.”
These are among the sickest of patients, with multiple co-morbidities and limitations in activities of daily living (ADLs), Dr. Wilborn notes.
“Many internists and hospitalists who come to the nursing home are astounded by the clinical acuity of the patients and don’t appreciate how, even without the hospital treatment armamentarium they are used to, they can still make a big difference in the care,” he explains. But the key, he adds, is for doctors to go into the facility often enough to have an impact, with regularly scheduled presence and a commitment to standardizing the care.
For hospitalists who are more accustomed to the high-intensity, fast-paced world of the acute hospital, post-acute care may not seem very sexy.
“But that’s changing, along with the medical landscape,” Dr. Wilborn says. “For those who can appreciate the opportunity to build relationships with patients and to practice more independently, it could be a great place to change your career trajectory and have an immediate impact on the quality of patient care.”
What Is the Post-Acute Space?
Although post-acute care could refer broadly to all settings for care following the patient’s discharge from the hospital, including home care, three post-acute settings, defined by their licensure, are more likely to involve physicians such as hospitalists:
- The inpatient rehabilitation facility (IRF) , which is a freestanding rehabilitation unit or hospital inside an acute hospital for patients who need rehabilitation care in order to function effectively and are medically stable and able to participate in rehabilitation therapies;
- The long-term acute-care hospital (LTACH), a hospital that specializes in treatment and recovery of medical patients who require prolonged lengths of stay, typically measured in weeks;
- The The skilled nursing facility (SNF), which focuses on the health, social, and personal needs of chronically ill or disabled patients, either for rehabilitation stays of two weeks to a month or longer stays for chronic illness.
Although hospital medicine began as a practice specific to the inpatient setting, increasing numbers of hospitalists are spending at least part of their working lives outside of the hospital, visiting patients in post-acute settings. IPC is just one of the many national hospitalist management companies, medical groups, and hospital-employed practices that are defining new roles for their physicians, nurse practitioners, and physician assistants in these settings.
The presence of hospitalists in post-acute care is growing, according to the Society of Hospital Medicine, with 25.4% of adult hospital medicine groups in its most recent survey saying that they see patients in post-acute care facilities.1 In response to this trend, SHM in 2012 impaneled the Post-Acute Care Task Force, chaired by Sean Muldoon, MD, MPH, senior vice president and chief medical officer of Kindred Healthcare’s Hospital Division, Louisville, Ky. The task force was formed to help SHM members explore post-acute care and learn about what to expect. The task force developed a toolbox and a transitions quality improvement toolkit, and a new white paper, “Primer for Hospitalists on Skilled Nursing Facilities.”
“Why does it matter to hospitalists?” Dr. Muldoon asks, rhetorically. “Everything in terms of acuity is being pushed down to lower-level settings. If hospitalists think they will only do hospital work in the future, well, they will miss much of inpatient care because of the shift from the hospital to other hospital-like settings.”
At HM15 in late March, the task force outlined its agenda for the coming year, including promotion of its toolkit, development of a web-based CME seminar, and creation of a web-based reference repository.
Scott Rissmiller, MD, chief hospitalist at the 43-hospital Carolinas Healthcare System in Charlotte, N.C., says the transformation now taking place in post-acute care is more than just hospitalists doing some or all of their work in long-term care facilities. Post-acute care is becoming less of a side job for moonlighting hospitalists, with more of a focus on integrated care. Dr. Rissmiller, a member of SHM’s Multi-Site Hospitalist Group Task Force, says hospitalists are bringing to the post-acute arena the same standardization, accountability, and quality improvement the field has brought to hospitals across the country.
For Carolinas Healthcare and other multi-site hospitalist groups, the goal is to elevate the quality of care in LTACHs and other long-term care settings.
“It’s upping the game in post-acute care. It’s looking at the whole continuum of care from a systems perspective, improving handoffs and transitions,” Dr. Rissmiller says. “For years, we tried to improve communication with post-acute providers. It wasn’t until we started partnering with these facilities that we started to see changes.”
Dr. Rissmiller believes the best practice is to have one cohesive team caring for patients in both hospital and post-acute settings, under the leadership of the hospitalist group. The goal is to ensure that patients go to the proper level of care—and only for as long as they need to be there—using the system’s resources correctly.
Not every member of the hospitalist group will go to post-acute care facilities, while others will choose to specialize in that setting, he says, “but they meet every month with their acute care counterparts to work on improving care.”
What Should We Call This?
The amount of medical care being provided by hospitalists in post-acute facilities is growing, experts say, inclusive of physician assistants and nurse practitioners working as part of hospitalist groups. As many as 30% of SHM members are involved in post-acute care, according to the latest SHM survey, with large management groups like IPC, TeamHealth, and Tacoma, Wash.-based Sound Physicians, expanding rapidly in this area.1
“I don’t think that hospitalists have taken over from PCPs in post-acute care in general, but they make up a significant physician cohort,” Dr. Wilborn says.
IPC has a presence today in more than 1,700 post-acute care facilities, with 20% of its physicians working in both acute and post-acute care, more than 2,800 affiliated clinicians, and a third of the company’s revenue coming from the post-acute space, Dr. Wilborn notes.
Interestingly, what to call these providers seems to be a problem.
“Hospitalist groups are employing people who, strictly speaking, aren’t really hospitalists, although the post-acute setting marries up very well with the hospitalist model, mindset, and historical leadership role,” Dr. Rissmiller says. “It requires a different skill set.”
He prefers the term “post-acute specialist.”
Others refer to these providers as “SNF-ists,” although that word doesn’t exactly roll off the tongue, nor does it convey the scope of post-acute care.
“If hospitalists are doctors who round in acute-care hospitals, the parallel term for doctors who round in post-acute facilities is not well established,” Dr. Wilborn says. “It’s site-specific care. I call them post-acute care providers. This certainly is a specialty, for a lot of different reasons. It’s post-acute care medicine, and the hospitalist term isn’t going to stick.”
Scott Sears, MD, FACP, chief clinical officer of Tacoma, Wash.-based Sound Physicians, which has physicians deployed in roughly 100 post-acute settings, labels his providers “transitional care physicians.” Most of them are dedicated full time to post-acute care.
“Our main source of transitional care doctors are former hospitalists who are interested in more than a three-to-seven day relationship with their patients,” Dr. Sears says.
“It’s almost an art in itself,” he adds. “That’s why it’s not in the patient’s best interest to have a doctor who just dabbles in post-acute care. That’s where the dedicated provider with a passion and vision for the work is so valuable. We also have more success with people who have more experience.”
General Medicine PC, a Novi, Mich.-based company of physicians, NPs, and PAs who specialize in treating geriatric and chronically ill patients in long-term care settings, calls itself “the post-hospitalist company.” It claims its primary customers tend to be payers and managed care systems.
“We use the term post-hospitalist, and we are the country’s largest provider of post-hospitalist services,” explains CEO Thomas Prose, MD, MPH, MBA, who founded the company in 1983. “We tailor services to the needs of each accountable care organization, hospital, and integrated health system we contract with, in order to improve patient care and reduce hospital readmissions, ED visits, and overall spending.”
The company has posted readmissions rates lower than 95% of the industry, with higher quality metrics, he says, adding that the majority of General Medicine’s physicians are not transitioning hospitalists but doctors who were drawn to geriatrics and long-term care settings from the outset.
What’s Driving the Post-Acute Space?
A significant portion of healthcare expenditures is in post-acute care, and that money hasn’t always been well spent, experts interviewed for this article emphasized. Without adequate physician involvement in their care, many of these patients would be sent back to the hospital for complications that might have been managed outside of the hospital. Often it is payers, managed care plans, health systems, medical groups, and other risk-bearing entities that are driving the growth of physician involvement in post-acute care—just as insurers had a role in pushing the early growth of hospital medicine—and accountable care organizations (ACOs) are more often acting and contracting like payers.
In fact, spending on post-acute care overall, not just the physician’s role, is growing rapidly enough to attract the concerns of policymakers, reflected in a recent hearing by the U.S. House Energy and Commerce Committee that found drastic variations in payment rates across settings, with overall Medicare spending of $59 billion on post-acute care in 2013.2 The Bundling and Coordinating Post-Acute Care Act, a bill first introduced last year by Rep. David McKinley (D-W. Va.) and reintroduced in 2015 as HR1458, aims to address these growing costs while preserving patient choice by requiring a single bundled payment for post-acute care services under Medicare parts A and B.
Bundled payment is definitely coming, Dr. Rissmiller says, and will fuel the move to inpatient-outpatient partnerships.
“A lot of this work is in preparation for ACOs and bundled payments, even if the new models are not yet dominant in the marketplace.”
Bundling payment for an episode of care, including the hospital stay and all of the post-acute follow-up, will be a game-changer, Dr. Wilborn adds. CMS is now testing bundled payment models and, by 2017, he says they will be an established fact in nursing homes, with half of their reimbursement coming from some kind of bundle.
James Tollman, MD, FHM, heads a small HM group, Essex Inpatient Physicians, which he started in 2007 in Boxford, Mass. Essex includes full- and part-time physicians and physician extenders and has contracts with several hospitals, but Dr. Tollman estimates that 95% of the practice is in post-acute care.
“For us, as a small group in the current environment, it’s a good idea to diversify,” Dr. Tollman says. “It’s important to be flexible and have a foot in many venues.
“I view myself as a hospitalist by personality and history,” he adds. But experience working in post-acute care enables physicians to view the hospital in perspective—as part of the larger continuum of care and not the center of the universe.
Dr. Tollman says risk contracts with ACOs are the new frontier for hospitalists in post-acute care.
“Who manages the money is an important question,” he says. “The quality metrics are still poorly aligned with what the SNF-ist does. Right now, we’re entering contracts with three different ACO-type exchanges. None of them have really figured out what we are about, and we don’t have much leverage yet.”
Larry Beresford is a freelance writer in Alameda, Calif.
- Society of Hospital Medicine. 2014 State of Hospital Medicine report. Philadelphia, Pa.; Society of Hospital Medicine; 2014.
- Firth S. House panel considers medicare reform for post-acute care. Medpage Today. April 18, 2015. Accessed June 10, 2015.