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The Future Role of Hospitalists


 

Since the mid 1990s when Robert Wachter and Lee Goldman first coined the term ''hospitalist',' we have seen the nation's hospitals and health systems open their doors to these ''specialists in inpatient medicine'' (1). We have also seen publications and academic studies that outline the benefits of implementing hospitalist programs. As the CEO of an integrated delivery system, I can recount firsthand how our hospitalist program, in existence since 1995, has improved patient care in our facilities. Not only have our hospitalists saved the system thousands of days in length of stay and reduced our costs per day, but they have also improved quality of care. In addition, members of our hospitalist groups have emerged as physician liaisons, championing education and training initiatives and serving as a bridge between the medical staff and management.

As our experience and the articles included in this supplement suggest, hospitalists add value on multiple levels and have imbedded a new model of care within the nation's hospitals. What's next? How will hospitalists continue to improve the comprehensiveness and continuity of healthcare across the patient care continuum? And, perhaps more importantly, how do we get there from here?

While hospitalist programs are burgeoning, many hospitals and health systems have yet to realize the full value added by hospitalist programs. As it relates to the healthcare industry, hospitalist programs are still in their infancy. Early adopters continue to refine and modify program models to meet changing physician and patient needs as well as to decrease the financial cost to the hospital. In addition, preliminary results of an AHA study (2) on hospitalist programs suggest that larger hospitals have a higher probability of having a hospitalist program than smaller hospitals. The same study also suggests that hospitalists have a greater impact on smaller hospitals. As a result, the population of hospitals that benefits the most from hospitalist programs has barely begun to realize the value of such programs. The message is the same for both early and late adopters. ''When you come to the fork in the road, take it'' (Yogi Berra).

In looking farther to the future, one role that hospitalists may increasingly assume is that of change agent. In August 2004, Robert Wachter gave an interview to Health Leaders describing how hospitalists can "contribute to the notion of changing systems'' (3). In the article, The Emerging Role of ''hospitalists" in the American Health Care System, Wachter and Goldman explain that the hospitalist model "creates a core group of faculty members whose inpatient work is more than a marginal activity and who are thus committed to quality improvement in the hospital'' (1). As the work of hospitalists generates from within the hospital, they have a personal stake in the hospital systems and the improvement of these systems (1). The nature of the hospitalist’s work ideally situates him to act as a change agent, enabling him to identify process improvement initiatives and corral physician support. As a result, hospitalists will increasingly serve as administrative partners and leaders of medical staff initiatives to help facilitate organizational change.

In addition to serving as change agents, hospitalists themselves may become the solution to some of the systems that need changing. They are already helping to solve on-call challenges by providing 24/7 coverage and by taking call. Hospitalists have also assumed a greater role in caring for patients in the ED by managing patients that otherwise would have been admitted by on-call medicine physicians. As more and more physicians decrease the time they spend in the hospital and as more patients are admitted with chronic care needs, the hospitalist will play an integral role in meeting these challenges.

Hospitalists may also become more involved in providing continuity to the delivery of healthcare services. Consider the opportunities that exist to involve hospitalists in improving preoperative and postoperative patient care. For example, hospitalists could play a role in the management of patients who require perioperative beta-blockers to decrease cardiac events in major non-cardiac surgery. Hospitalists may also continue to diversify their clinical roles by coordinating care in ICUs where intensivists are unavailable or by caring for patients in post-acute settings (4,5).

With the ability to manage varying aspects of a patient's care, hospitalists can help resolve the disconnect that exists as a patient moves across the continuum of care. A patient may enter the system through the ICU, followed by a transfer to a Medicine Unit, and then be discharged to his primary care physician or a nursing home. The reality of ineffective communication and incomplete hand-offs may result in poor information exchange that impacts the care of the patient. By involving a hospitalist in this process, the coordination of patient care becomes seamless and the chance for medical error decreases.

In order to expand the current hospitalist model to the clinically diverse and dynamic model of the future, all stakeholders, from management to physicians, must take proactive steps. Part of this process will involve the development of an economic model that accounts for the value that hospitalist programs bring. The more quantifiable these programs become, the easier it will be to prove their value and implement them in capital-strapped facilities. Another part of moving the hospitalist model to the future centers on relationship management. A lack of understanding of the benefits that hospitalists provide and the roles that they assume in hospitals prevents collaboration with other specialties. Lines of communication must be opened and issues of distrust resolved to facilitate the relationship between hospitalists, the medical staff, and management. Finally we must educate the community about the benefits of hospitalists in the delivery of patient care. The success of hospitalist programs is just as dependent on the development of an external support network as it is on the existence of a strong internal infrastructure.

Without a doubt, hospitalists add value to our nation's hospitals. An exciting debate is emerging about how hospitalists will continue to change the model of healthcare as we know it, and what implications this will have for our hospitals and health systems.

References

  1. Wachter RM Goldman L. The emerging role of ''hospitalists'' in the American healthcare system. N Engl J Med. 1996;335:514-7.
  2. 2003 American Hospital Association (AHA) Annual Survey (preliminary results)
  3. Olsen K, Wachter R. The word on medical mistakes. Healthleaders News. Aug 20, 2004.
  4. Pham HH, Devers K, Kuo S, Berenson R. Health care market trends and the evolution of hospitalist use and roles. J Gen Intern Med. 2005;20:101-7.
  5. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287:487-94.

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