Up to this point I’ve been discussing continuity during a single admission. What about continuity from one admission to the next? Nearly all groups assign patients based on when they are admitted, and the hospitalist who cared for the patient during a prior admission may have little influence on which hospitalist admits them this time. If a patient is readmitted within a week or two, and the previous attending hospitalist is working, some groups will try to pair them once again through a bounce-back system.
It’s worth thinking about whether your group could make an effort to always have the same hospitalist care for a patient unless that physician is off—even if the admissions are months apart. This system would mean that on first admission to the practice a patient would be assigned to the hospitalist who is up next. In this way, each hospitalist in the group would develop his or her own panel of patients. This would be particularly valuable for patients who are admitted frequently; however, it would be difficult for a doctor to control how labor-intensive his patient panel might become. One person might have the bad luck to collect far more medically and socially complex patients than others in the group, and workloads might become unbalanced, making the whole group less efficient. I’m hopeful that a group will come up with a way to overcome these problems and create a workable system of good continuity from one admission to the next, but, as far as I’m aware, no group is doing this now. If you have a workable system, please let me know.
One group I worked with years ago addressed continuity from one admission to the next by using a system that matched each hospitalist with a panel of referring doctors. For example, the same hospitalist would always admit the patients “belonging to” a cadre of primary care physicians (PCPs), and another hospitalist in the group would always admit patients from another set of PCPs. The patient would see the same hospitalist each admission, and the hospitalist could develop a close working relationship with the panel of PCPs. The hospitalist and the PCP became familiar with each other’s practice styles, schedules, and days off, and memorized one another’s phone and fax numbers, the names of office and support staff, and so on, making for a very smooth working relationship that could benefit patient care. If the assigned hospitalist was off when a particular PCP’s patient needed admission, then a partner would provide interim care and turn the patient over when that hospitalist returned.
As you can imagine, this can be a difficult system to implement because there are many days on which a patient might be hospitalized when the assigned hospitalist is not around. Additionally, it is nearly impossible to divide PCPs and their patients equitably so that each hospitalist has a reasonable workload and patient complexity. I can imagine this group meeting periodically to match hospitalists and PCPs in a fashion similar to a fantasy football draft: “I’ll take PCP Smith and Williams from you, if you take PCP Wilson off my hands.”
I’m interested in hearing any additional ideas groups have developed to facilitate good continuity. The number of consecutive days worked by each hospitalist and the way new patients are assigned are significant ways to influence continuity, but there may be others that we should all keep in mind. And remember, maximizing continuity is not only good for patients; it enables the hospitalist practice to function more efficiently because it minimizes the number of new patients each hospitalist will have to get to know. TH