Stacy Goldsholl, MD, BC IM (1/03-present)
Medical Director, Covenant Healthcare Hospital Medicine Program
1447 North Harrison
Saginaw, MI 48602
Hospitalist Support Associate
Covenant HealthCare, Saginaw, Michigan
Abdo Alward, MD, BC IM (8/04)
Anu Gollapudi, MD, BC IM (5/03)
Noel Lucas, DO, BC IM (5/03)
Iris Mangulabnan, MD BC IM (8/03)
Hassan Nasser, MD, BC IM (5/03-5/04)
Sayed Naqvi, MD, BC IM (4/04)
Shelene Ruggio, MD, BC, IM (9/03)
Devanshu Thakore, MD, BC FP (7/03-8/04)
Holly Krenz, Hospitalist Support Associate
Mary Burr, Certified Coder
Eight of the physicians are board certified in internal medicine; one is board certified in family practice.
The Health System
Covenant HealthCare is a nonprofit regional tertiary health care system serving 18 counties throughout East Central Michigan, offering high-quality medical care with 20 inpatient and outpatient facilities, including two acute care hospitals with 643 licensed beds and 40 adult critical care beds, 20 short-term skilled nursing beds, and 41 inpatient rehabilitation beds. A 30-bed long-term acute care hospital also rents space on the hospital main campus. Covenant’s new state-of-the-science Emergency Care Center provides critical and trauma care with an annual volume in excess of 73,000 patient visits and offers a helicopter service that was added in January 2004. Additionally, Covenant provides comprehensive medical services in cardiovascular, neurosciences, surgery, orthopedics, obstetrics, and all ancillary services. Covenant HealthCare also features Michigan’s northernmost regional neonatal and pediatric/pediatric intensive care units to serve the needs of children.
As Michigan’s sixth largest hospital and most comprehensive health care facility north of Detroit, Covenant HealthCare has been nationally recognized for its superior service, having received such distinctions as a Solucient Top 100 Hospital for cardiac care and orthopedics from 1999 to 2003. Covenant is the recipient of the 2003 Governor’s Award of Excellence for Improving Care in the Hospital and Emergency Department for Heart Attack, Heart Failure, and Pneumonia, and is a five-time recipient of the National Research Corporation’s Consumer’s Choice Award. Covenant HealthCare ranks among the top 5% of hospitals its size nationwide for patient satisfaction.
All of the physicians and staff are employed by Covenant HealthCare. Pediatric services for the pediatric patients of the family practice physicians utilizing the hospitalist program are provided by a contractual arrangement with Synergy Medical Alliance Family Practice residency program, an affiliate of Michigan State University.
Management and Operational Structure
An on-site Medical Director is responsible for all administrative aspects of the Hospital Medicine Program. Clinical responsibilities vary according to the service needs. The Medical Director reports to the Vice President of Medical Affairs. All team members report directly to the program’s Medical Director.
A full-time support associate (M-F) is responsible for all communications with primary care physicians, other hospital departments, and general office maintenance. A part-time certified coder is available twice weekly for charge capture reconciliation, billing, and documentation audit and physician education.
Multidisciplinary rounds are conducted daily (M-F) at 9 a.m. with all rounding physicians, the program director, case managers, and liaisons from skilled nursing, inpatient rehabilitation units, and home health/hospice. During this time, patient status is updated, and discharge planning is initiated. Case managers also bring non-hospitalist patient medical necessity reviews to the director/hospitalists who also serve as physician advisors to case management.
The CHC Hospital Medicine Program is a 24-hour in-house service that operates in a shift-based (7a-7p) block model. There is one nocturnalist that covers 15 night shifts per month. Hospitalists are scheduled 15-18 12-hour shifts per month and are paid for additional shift coverage. Sign-in/out is face-to-face at 7 a.m. and 7 p.m. Day-time shifts are covered by two physicians 7 days per week, with an additional 0.5 FTE available M-F (medical director). Night shifts have single-physician coverage. Beginning in January 2005, day-time coverage will expand by one FTE.
All physicians are salaried. An annual bonus of up to 10% base salary is available at each physician’s anniversary date. The bonus is based heavily upon quality/FCCS certification (30%), team and referral physician satisfaction (20%), Press Ganey Patient-Physician Satisfaction scores (15%), and operational efficiency/organizational benefit (35%).
Standard benefits are provided, including malpractice coverage with tail, health, dental, vision, life insurance, 403b and 457b plans, short- and long-term disability. CME/Professional fee allowances of $3000 are provided. Initially, all physicians received 37 days of paid time off while contracting for 18 shifts/month. This has evolved into a 15-shifts/month schedule with no additional PTO.
Patients are admitted to the Covenant HealthCare Hospital Medicine Service from three main avenues: unassigned emergency department admissions, private admitting relationships, and direct regional referrals. The hospitalists cover approximately 85% off all ED unassigned admissions. In addition, the service admits exclusively (all-or-none) for 35 local and regional primary care physicians. Covenant HealthCare serves as the tertiary referral for a number of small rural and critical access hospitals. These regional partners have ease of access with a “one pager” call number for the admitting hospitalist. Additionally, the hospitalists co-manage patients with various surgical specialties (orthopedics, neurosurgery, general surgery) and offer a medical consultation service. All of the Covenant Hospitalists have ACLS and Fundamentals of Critical Care Support certification, allowing them to serve as intensivist extenders (ICUs are open). As such, the service acts as Code Blue attending and the Medical Response Team for pre-code emergencies.
The average daily census is 30 with an average of 8-10 admissions per day. The Case Mix Index is 1.2617.
Communication was emphasized as a priority with the development of this new program. The position of a hospitalist support associate was created to serve as the point person for all external and internal communication. This is a full-time equivalent Monday through Friday. Hospitalist dictations are expedited via medical records transcription and faxed to the hospitalist office. All primary care physicians receive a notification of patient admission by fax on the morning following admission. This notification identifies the hospitalist attending, accompanies the dictated history and physical, and makes a request for pertinent outpatient information. Follow-up appointments are arranged by the hospitalist support associate prior to patient discharge. Discharge summaries are completed in real-time and faxed to the primary care office at the time of discharge.
Each hospitalist carries their own designated pager. A universal pager is passed between day and night physicians and is the “one call” direct contact for both the hospitalists’ private admitting relationships and regional referrals. Primary care physicians also have the opportunity to identify their preferred subspecialty consultants on enrollment to the hospitalist service. Laboratory and Radiology also utilize the universal pager for communication of critical values.
In conjunction with business development, primary care physician enrollment packets, patient brochures, hospitalist fliers, a regional referral manual, and DVD have all been compiled to assist in the education of patients, staff, and physicians.
The greatest challenge to our program has been the facilitation of a culture of direct communication between the hospitalists and the medical staff consultants. Additionally, in our system the emergency department physicians routinely write admitting orders (“bridging orders”) for the private medical staff attending admissions. It has been a shift in culture to request the emergency physicians not to write bridging orders for the hospitalist admissions but to allow the hospitalist physician the opportunity to evaluate and admit hospitalist patients in real time in the emergency department.
First-Year Experience (fiscal 2004)
Code Blue (CPR/critical care): 107
The Covenant Hospital Medicine Program was initiated with single-physician (four MDs) coverage 24 hours per day, 7 days per week in May 2003. The Medical Director was on-site for institutional and medical staff education, consensus building, physician and practice recruitment, and program planning for 4 months prior to program opening. Initially, the service admitted 90% of all unassigned emergency department medical admissions and enrolled two family practices as private admitting relationships. Over the course of the first year, the service grew to attend for 25% of all internal medicine admissions, and expanded the private admitting relationships to over 30 physician practices. Three additional FTE hospitalist physicians were added by September of 2003. Length of stay (2.94 CMI) and cost per case was reduced by 33% and 14%, respectively, versus the internal medicine physician admissions (nonhospitalist). Hospitalist inpatient mortality was 17.5% less than expected mortality as calculated by the Michigan Hospital Association database. The hospitalist readmission rate was 25% less than the internal medicine physician group (non-hospitalist). Profitability, as defined by net patient revenue minus total cost, was $707 for each hospitalist case compared to-$80 for each patient cared for by general internal medicine (non-hospitalist).
An intensive outreach program to our rural regional hospitals and critical access hospitals resulted in growth of regional referrals from 5% to 15% of the total hospital medicine program census over the course of the first year. Additionally, the medical consultation service, which was not offered at the initial start-up in order to control growth, now accounts for an additional 15% of the service volume.
The Covenant Hospital Medicine Program has a 78% retention rate for hospitalists in the first year. No physicians recruited to the program have had previous hospitalist experience. Two of the physicians left after one year; one to join a large hospitalist group in the West and the other to initiate a hospitalist program on the East coast.
Goals and Future Plans
Physician recruitment is the rate-limiting step for further growth and expansion. Two FTE hospitalists will be starting in January 2005 to accommodate the growth of the service to date. Two additional physicians will allow expansion to our off-site transitional care unit and inpatient rehabilitation unit to further provide for continuity and quality of care over the continuum. A fifth hospitalist is also sought to serve as an emergency department designated hospitalist in attempt to maximize daytime physician workflow.