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Another New Frontier


 

When HM was just a twinkle in Bob Wachter’s eye somewhere around 1998, the nascent board of the National Association of Inpatient Physicians (later to become SHM’s board of directors) tried to look forward to the scope and breadth of this new specialty they were hoping to help shape. With just 300 or so hospitalists in the country at that time, it is not surprising that the original board’s vision was that someday hospitalists might replace the inpatient work being done by 30% to 40% of internists and family practitioners. Now, a little more than a decade later, HM has a vista that in some ways can’t be contained inside a hospital’s four walls.

Today, with more than 30,000 hospitalists actively seeing patients in most U.S. hospitals, there has been a reinvention of primary care, with many of the inpatient duties now assumed by hospitalists. Although direct patient care likely will remain the primary role for hospitalists in the foreseeable future, it is not the whole story.

More and more, hospitalists have a leading role in improving the function of the hospital as a cohesive force in the healthcare community. Hospitalists are active in performance-improvement strategies, both in the implementation as well as the measurement and reporting of outcomes.

More and more, hospitalists have a leading role in improving the function of the hospital as a cohesive force in the healthcare community. Hospitalists are active in performance-improvement strategies, both in the implementation as well as the measurement and reporting of outcomes. Hospitalists are expected by other hospital health professionals to actively participate in the team approach to healthcare. As hospitals work to reinvent themselves to meet the challenges of the 21st century, whether driven by The Joint Commission, insurers, the business community, or government, the C-suite sees “their” hospitalists as part of the calculus for change.

And as surgical care and subspecialty care evolves, hospitalists are key partners. The fastest-growing aspect of HM today is the growth in the individual hospitalist’s role as the comanager of the surgical or specialty patient. This is much more than a consult. Comanagement involves a division of labor and accountability in which surgeons do what they do best and engage their partner hospitalists to prevent VTE, provide coverage to control perisurgical complications, and share the flow of information to the patients and their families.

So in some sense, the hospitalist provides the multiuse toolbox for all things “hospital,” sort of the Swiss Army knife of healthcare:

  • Direct patient care;
  • Systems fixer;
  • Quality and safety officer;
  • Teammate and team leader; and
  • Partner to the surgeon and the cardiologist.

It’s quite a lot of value and versatility all wrapped up in one package.

But wait: That is just today. There is more out there on the horizon. (That, by the way, is hospitalist-speak for “some of this is already happening in real time; it’s just not being done by everyone.”)

HM: The Problem-Solver

Hospitalists are being engaged at the ebb and flow of healthcare. Most of us know that even when we do the A-1 job in the hospital that the voltage drops when patients are flung into the white space of the discharge process. Hospitalists know that a patient’s hospitalization doesn’t end at the hospital’s threshold. In many cases, the patient is not cured or returned to full function, but more often than not, the patient is just no longer sick enough to warrant the expense and the intensity of hospitalization.

SHM and our hospitalist leaders have been tackling the discharge process with our Project BOOST (Better Outcomes for Older Adults through Safe Transitions), with funding coming from the Hartford Foundation. Our goals are to give hospitalist-led teams of health professionals the tools and training to reduce unnecessary readmissions and ED visits, and to improve the satisfaction and confidence of our patients and their families. Not an easy task and not one that is over and done, but SHM and our hospitalists have a plan and a path to success.

But wait: There is more.

The patient flow within most hospitals is anything but smooth, error-free, or efficient. The issues develop as the patient travels from the ED to the ICU and out to the floor. The problems arise when multiple physicians manage a patient. There are potential cracks in the system (e.g., shift changes from nurse to nurse, or pharmacist to pharmacist). And, of course, the hospitalist-to-hospitalist handoff still could use some work.

But HM isn’t waiting for someone else to fix this problem. SHM is actively talking to funders about applying some lessons we have learned in our BOOST pilot sites and other performance-improvement efforts. We are beginning to provide the framework to ensure our patients a safe and error-free hospital stay.

It might seem like quite a leap for a specialty that was started to replace direct patient care for a small segment of primary-care physicians. But now, there may be even more for hospitalists to tackle. As policymakers talk of redefining accountabilities, it appears that hospitals will be held financially—and possibly even legally—responsible for patients’ outcomes, not just while they are an inpatient, but for 30 days or more after discharge, too. Tackling this would be daunting if every hospital were surrounded by an entire neighborhood of medical homes, but, of course, that is very much not the case today.

So when the hospital is charged with making sure that their recently discharged patients take the entire course of their prescribed treatment, get the follow-up testing at the right time, follow up on any abnormal results that came up during and after hospitalization, and basically do all the sub-acute care that patients should and often don’t receive, who do you think they will look to?

That’s right: Say hello to the “sub-acutist,” the next member of the hospitalist family tree, which already has nocturnists and SNFists. Most HM groups are busy enough just seeing their inpatients and making the hospital safer, improving quality, and co-managing the surgical and specialty patients. Now it looks as if hospitalist groups will be the fallback to see a patient for the first two or three post-discharge visits, especially when the hospital needs to be accountable for patient outcomes after a patient leaves the hospital. This is definitely not a jump into outpatient medicine, but more of an attempt to “complete” the hospitalization in a new world in which the expectation of the patient and the payor is that the acute illness doesn’t end at the hospital door.

Those of us who think strategically need to analyze what these varied roles for hospitalists mean for the selection of the right people to enter HM, and what education and support the next wave of hospitalists will need to be successful and deliver on the promises being made to our healthcare communities.

SHM and numerous hospitalist companies and organizations are on the leading edge, thinking through these possibilities, and building HM for the future—which, by the way, already is here.

They used to say in a commercial, “This is not your father’s Oldsmobile.” Well, tomorrow’s HM is looking very much like not your older brother’s HM. Love the change; live the change. TH

Dr. Wellikson is CEO of SHM.

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