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Homegrown Health


 

Tucked away in the University of Florida (UF), which is—with 50,000 students—the state’s largest university and the nation’s fourth largest, is its School of Medicine’s Community Health and Family Medicine (CHFM) department, along with that department’s hospital medicine program. The department remains a touchstone for its graduates, past and present, and has created hospitalist leaders to be proud of. Much of that pride emanates from R. Whit Curry Jr., MD, CHFM’s department chairman, who is a friend and mentor to several generations of family medicine physicians.

In late 2001, after a private hospital medicine group headed by John Nelson, MD, a UF graduate, SHM co-founder and columnist for this publication, it was natural for Shands Alachua General Hospital (SAGH) to turn to Dr. Curry to start a hospitalist program. Dr. Curry, who says wryly, “If you’ve seen one hospitalist program, you’ve seen one hospitalist program,” knew he could build a unique team of family medicine physicians into a cohesive hospital medicine group.

UF’s CHFM department had staffed SAGH with residents for years before the hospital asked Dr. Curry to start the hospitalist program. The group’s coverage had been limited to inpatient care for about 20 primary care physicians, with a similar arrangement for a for-profit HCA community hospital across town. SAGH needed a more ambitious hospitalist program, one that would cover unassigned patients as well as inpatient care for local doctors. At that point, SAGH issued a request for proposals (RFP) for a hospital medicine group, accepting UF’s CHFM proposal to fill the vacuum left by the departing group. Initially, SAGH would handle the 20 private physicians’ inpatients covered by the existing group, the overflow of unassigned patients from residency workload restrictions, and admitting and co-management for specialists.

Dr. Curry started building his team with Elizabeth Chmelik, MD, recruiting her as the program’s director straight from CHFM residency. The program’s first year—2002—was whirlwind hectic. Fortunately for the group, Marcia Miller, MD, a 1988 graduate of UF’s CHFM department, had burned herself out running a local private practice with two partners. She turned to Dr. Curry, her mentor and confidant. “I called him, told him I needed a job, and he hired me as the hospitalist program’s co-director,” says Dr. Miller. Her community-based partners endorsed her new career path, and she joined Dr. Chmelik in working every day of the program’s first year. “It was challenging,” she says, “but, with inpatient medicine, I became the doctor I was trained to be.”

Sherri Swilley, the department’s coordinator of administrative affairs, recalls the patient census growing so fast that she struggled to keep up with getting doctors temporary privileges while pursuing credentialing for the permanent staff. “The hospitalists had a fierce work ethic that carried us through those early years,” says Swilley.

The hospitalists are deeply connected to the community, knowing when to bring in pastoral care or family therapy, as well as joining in celebrations for

Gainesville’s Medical Community

In spring 2003, the program added a local physician eager to exit private practice and a family medicine graduate who had worked in SAGH’s emergency department (ED) for 12 years. In June, they snagged two stellar family medicine graduates and a nocturnist. The nocturnist represents the program’s only turnover; her nightly 12 to 20 admissions proved too much to handle.

UF’s homegrown bunch of family physicians shaped this distinctive hospital medicine program. Dr. Chmelik, assistant professor and co-director of the UF College of Medicine’s hospitalist program at SAGH, says that although family physicians are outnumbered by internal medicine hospitalist physicians they add something special to the role.

“We want to go beyond the stereotype of the internal-medicine trained physician drudging through the hospital as an eternal extension of residency,” says Dr. Chmelik. “Family physicians excel at end-of-life issues and the biopsychosocial model of healthcare, both of which are very important in a hospital.”

Another addition to Dr. Chmelik’s black bag is her expert consulting on obstetric and pediatric patients; she can easily handle issues such as hypertension in a postpartum patient or post-appendectomy asthma in a child.

The Financial Tightrope

The University of Florida’s CHFM is closely tied to SAGH, a 75-year-old, 367-bed community hospital that serves as its training ground for residents and hospitalist fellows. Although SAGH is a vital part of Gainesville’s medical scene, its financial status has been shaky for some time.

In 2002, Moody’s Investor Service gave SAGH a negative rating, which was upgraded to stable in 2003.The upgrade of SAGH’s $312 million of outstanding debt issued by Alachua County Health Facilities Authority kept the wolf from the door temporarily. Talk persists that SAGH is in trouble, however, and a Gainesville group, the Health Care Is a Human Right Coalition, asserted in July 2006 that the hospital lacked leadership and that “there are no published plans to keep SAGH open beyond 2010.” SAGH spokesman Ralph Ives says, “Nothing could be further from the truth.” He points to SAGH’s investment in an 82-bed pediatric hospital in a renovated wing with its own hospital medicine group as an affirmation of the institution’s future.

Like other hospitals struggling with public payers and lots of unassigned patients, SAGH’s hospitalist program improves the hospital’s financial health by serving large numbers of patients cost-effectively. Conversely, hospitalist programs can sink because of inattention to financial basics. Early in SAGH’s history, the hospitalists were overwhelmed with a burgeoning census, leaving coding and billing for clerical staff to figure out at day’s end. This delayed billing and often failed to capture the correct diagnostic codes and level of severity for each patient encounter. As the program matured, the hospitalists and hospital administration agreed that physicians would do the coding themselves as they rounded. That change saved on the back end of clerical work and got the charges in promptly.

Each month, Swilley and the hospitalists review individual and group coding patterns, payer mix, the amount billed to each carrier, the amount of time bills spend in accounts receivable, and the services that have been denied. Hospitalists also receive daily reports on their charges and tips on improving coding. For example, if they’ve reviewed documents, Swilley reminds them to code that activity, just as she does a hospitalist who was swamped in the ED at 10 p.m. and left coding his encounters until 1 a.m., thereby losing one day of service. “A hospital is a business. Our hospitalists work hard; I teach them to work smarter and to pay attention to the bottom line,” says Swilley.

Being diligent about financial productivity matters greatly when it’s time for the CHFM department to negotiate with the hospital for its annual subsidy, which Dr. Curry says is about $500,000.

“When we present our budget, we include billing expenses, overhead, salary, and fringe benefits,” says Swilley. “The more detail we have on the number of patient encounters, [our] productivity, and the revenues we generate, the better position we’re in to get support.”

Like most other hospitals, SAGH struggles with tight reimbursement versus the need for an attractive physical plant. To that end, in 1998 it became the first hospital in Florida to adopt the Planetree model, which advocates patient-driven healthcare, serving body, mind, and spirit. “We’ve always been a deeply compassionate hospital,” says Lynne Mercadante, RN, SAGH’s director of Medical Staff Services, “and Planetree is a natural extension of our looking into our hearts and minds about treating the whole person.”

The hospitalists are deeply connected to the community, knowing when to bring in pastoral care or family therapy, as well as joining in celebrations for weddings and anniversaries.

SAGH has made typical Planetree physical changes, including remodeling one floor into six-patient nursing pods versus one nursing station for 42 patients, along with adding meditation rooms, libraries, a piano in the lobby, and a fish tank. Physicians, patients, and visitors are treated to Brahms’ Lullaby over the loudspeaker system every time a baby is born and can experience pet visitations and aromatherapy.

An Inpatient Day in Family Medicine at SAGH: April 17, 2006

  • 99 inpatients;
  • 74 inpatients seen by hospitalists: 55 admitted via ED, nine from hospital transfers, two from private physicians, one from a nursing home;
  • 25 inpatients seen by residents: 22 admitted via ED;
  • 77 patients with one or more consults;
  • 12 patients in the ICU or the CCU;
  • Most common consults by specialty: nephrology (16), orthopedics, GI (14 each), infectious disease (13), cardiology, pulmonary (12 each), general surgery (nine), neurology (six);
  • Top 10 diagnoses: diabetes (31), renal disease (18), anemia (16), hypertension (14), sepsis (nine), pneumonia (eight), fracture, encephalopathy (seven each), COPD/CHF (six each); and
  • Payer mix: Medicare (59%), Medicaid (16%), self-pay (11%), Blue Cross Blue Shield (10%), managed care (4%).

Source: R. Whit Curry, Jr., MD, 10/5/2006

UF’s CHFM Hospitalist Program At a Glance

  • Started in 2001
  • Co-directors: Elizabeth Chmelik, MD, and Marcia Miller, MD
  • Nine full-time equivalents (FTEs), one .6 FTE
  • Hospitalist fellowship offered annually
  • Practice at Shands Alachua General Hospital, 801 Southwest Second Avenue, Gainesville, FL 32601
  • www.shands.org
  • “Family Physicians as Hospitalists,” by Elizabeth Chmelik, MD. Available at: www.fafp.org/documents/Summer%20Florida%20Family%20Physician.pdf.

The Schedule

UF’s hospitalists initially adopted a rotation of seven days on, seven days off. When the group’s nocturnist left because of the heavy burden of night admissions, the nine hospitalists decided to cover call themselves instead of hiring a replacement nocturnist. Every ninth week, a hospitalist takes call Monday through Thursday, with residents carrying the weekend. It isn’t ideal, but it distributes call evenly and ensures hospitalists two free weekends a month.

Like most hospital medicine groups, UF’s hospitalists are trying to tinker with the schedule to make it more flexible. They had some give for Scott Medley, MD, who retired from his large Gainesville private practice of 10 physicians, 65 employees, five offices, and 40,000 patients in 2002 at age 55.

“My private [practice] kept me busy seven days a week. I had been there, done that, got the T-shirt,” says Dr. Medley. “I had enough of private practice, but I didn’t want to leave medicine. On reflection, I realized that what I enjoyed most is taking care of really sick patients, so I contacted Whit Curry, and he hired me as a hospitalist Monday through Friday mornings.”

Dr. Medley loves being an employee, doesn’t mind covering for younger colleagues on holidays, and is now collaborating with specialists who have been his friends and colleagues for 25 years. “I also enjoy teaching younger docs both the art and the economics of medicine—and not having to worry where my next paycheck is coming from,” he says.

Looking ahead, Dr. Miller relishes being a hospitalist at age 47, but wonders what the pace will feel like another decade out. To be more flexible, the group is considering allowing physicians to work more days but fewer hours, initiating job sharing, and recruiting more retirees like Dr. Medley, who can work shorter days and are willing to pinch-hit when coverage is tight. They are working toward consensus on maximizing flexibility while maintaining coverage. Still, there’s no easy solution to fluctuations in census, and Dr. Curry notes that some days span 7:30 a.m. to 3:30 p.m., while others stretch into the night. “We haven’t found a better solution yet to providing care 24 hours a day, 365 days a year,” concludes Dr. Medley.

Creating Value

Looking back at her quarter century at SAGH, Mercadante analyzes how the hospitalist medicine program improved things. “Without hospitalists, whoever was on call covered everyone in the ED, so you had neurologists treating patients with pneumonia. There was little continuity of care, unlike with the hospitalists who meet every morning discussing cases.”

In addition, the medical staff feel they have their lives back because call is covered, and they can count on the hospitalists to co-manage complicated cases. “When specialty physicians are in high demand and short supply, knowing that someone’s covering their hospitalized patients for chronic conditions is so important,” concludes Mercadante.

Looking to the future, UF’s hospitalists plan to build on their cohesiveness, collegiality, and emphasis on family medicine. With alumni of their school at the ready, they know where to turn to continue to grow the program. TH

Marlene Piturro also writes about scheduling in this issue.

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