Richard Rohr, MD
300 Seaside Avenue
Milford, CT 06460
Christine Chen, MD
Andrew Chow, MD
Renee Giometti, MD
Richard Rohr, MD
Michael Rudolph, MD
Keith Swan, MD
Yelena Titko, MD
The Milford Hospital Hospitalist Service program started in 1996 with 1 physician hired to provide coordination for inpatient medical care on weekdays. The hospital had previously offered only night coverage provided by moonlighting cardiology fellows. Milford Hospital has 100 beds, does not participate in any medical teaching programs, and competes with 5 teaching hospitals located within 10 miles. The community has traditionally preferred treatment in the local area, but concern about quality of medical services led many local residents to seek treatment at larger hospitals. The hospital had studied the hospitalist concept from its inception, but the medical staff did not immediately embrace the idea and feared encroachment upon their incomes. After several years of steadily increasing the role of the daytime care coordinator, the administration decided to convert the moonlighting positions in 2001 to 5 full-time employed physicians who provide 24-hour coverage in the facility. The medical staff has gradually become more comfortable with the hospitalist concept, although the internists still prefer to treat their own established patients. The community also recognizes the higher level of medical care provided, and the average daily census has nearly doubled since starting the program.
The service has been scheduled with 2 daytime physicians for 8 hours on each weekday, 1 daytime physician for 8 hours on Saturday and Sunday, and 1 physician for 16 hours every night. The staffing pattern was developed to accommodate an active joint replacement service with significant consultation needs on weekdays. The orthopedic service is expanding, and other surgeons have recognized the importance of immediate consultation, particularly as their malpractice premiums rise. The hospital administration has recognized the need for additional staffing, and the service will operate with 2 daytime physicians and 1 nighttime physician every day of the week starting in July 2005. An additional position has been created to meet the personnel needs.
The physicians are employed directly by the hospital and participate in the hospital’s benefit programs, including pension, disability insurance, life insurance, and a malpractice liability trust. There is presently no incentive plan, but the program has achieved a high level of effort from the staff. This is largely due to the culture of the hospital, which is highly collegial and patient-focused. Employees at all levels of the organization are treated well, and staff retention levels are quite high. Out of the first 10 full-time hospitalists hired, 4 are still in the program, 5 have pursued additional training, and 1 left to join her husband in California. One physician hired from a leading academic residency program found it difficult to adjust to a community hospital and resigned prior to year‘s end. The service has not experienced other personnel problems.
The program met its early staffing needs with physicians who had recently completed residency in internal medicine and were waiting to start a fellowship in 1 year. This type of staffing allowed the service to get started but required constant training in billing, continuity of care, and medical staff relations. As the program has become established in the region, it has attracted physicians who have previous experience with traditional private practice but have chosen to concentrate on inpatient care. This has allowed the program director to concentrate on advanced skill building with the staff and to spend less time on recruiting and scheduling.
Physicians are required to work 1,800 hours each year and may work additional hours for extra payment. The service admitted 600 patients (one-fourth of all medical admissions) in 2004 and provided consultation on 800 patients. The service also manages intensive care patients and handles emergencies throughout the hospital; there were 800 critical care visits last year. The staff performed a total of 6,200 billable patient visits in the past year and provided assistance to private physicians on 1,000 additional admissions. The number of billed admissions and visits has been constrained by limited weekend staffing. The service presently carries no more than 12 patients on weekends and up to 20 patients on weekdays. With the new staffing pattern, the service will round on up to 24 patients, with additional patients seen on a 1-time basis. Hospitalists normally admit patients who are not affiliated with a private physician on the hospital staff. When the hospital medicine service reaches its patient cap, private physicians must admit unaffiliated patients in rotation, as they did before the hospitalists were available. This accommodation will remain in place until the hospital medicine service is able to meet the entire demand for inpatient internal medicine services.
Postdischarge care coordination has been a major challenge. Approximately one-third of patients are discharged to nursing homes. Most of the others are affiliated with primary care physicians located in other communities who are not members of the Milford Hospital medical staff. Communication with these physicians has been improved by an electronic record management system that allows automated fax transmission of discharge summaries. Limited outpatient services are available for Medicaid patients and for those without insurance. The hospital medicine service does not provide outpatient care.
Another challenge involves care for critically ill patients. Although there are several physicians with training in pulmonary disease on the private staff, the hospital had not developed effective critical-care services. There are 2 hospitalists with critical-care training, and we have been working with the other staffers to improve their competence in critical care. The hospitalists provide 24-hour response to unstable patients throughout the hospital and have dramatically reduced unexpected mortality.
Future development will focus on improving hospitalist productivity with information technology. The hospital has undertaken installation of an integrated clinical-information system, which will include direct physician order entry and deployment of wireless technology. It is expected that many of the difficulties experienced by other hospitals with physician order entry will be ameliorated by hospitalist involvement, as the staff is comfortable with computer use. We also expect that the hospitalists will develop leadership roles within the medical staff and develop skills in quality improvement.