Necessity, as they say, is the mother of invention, and the growing focus on the need for high-quality and cost-effective care is bringing a host of new innovations to light. One that hospitalists are likely to hear about far more about is the evolving role of an “extensivist,” an inpatient provider who ventures to outpatient settings to assist with care transitions.
In many ways, the expanding discussion of what extensivists are and do reflects the success of hospitalists in coordinating inpatient care and improving such metrics as length of stay (LOS). Why should that coordination end upon discharge? healthcare experts have wondered. Instead of a pure hospitalist system, could the experience and training of hospitalists be extended to include transitional or interim settings that provide a safety net between the hospital and a primary-care physician (PCP)? Might that improved inpatient-outpatient coordination help with other metrics, such as reduced rehospitalizations (see “All Aboard,” p. 1)?
We write an order of discharge to a skilled nursing facility, and patients go off into the community and we have no idea where they’re going, who they’re going to, what’s the quality of care out there, what’s the capacity of care.—Adam Singer, MD, CEO, IPC: The Hospitalist Co., North Hollywood, Calif.
One tangible result of those questions has been the growth of high-risk clinics. Hospitalist programs can provide clinic referrals for discharged patients who still require hands-on care, while PCPs can likewise refer some of their more complex patients. The clinic, then, becomes an alternative to hospitalization, or a preventive measure to avoid rehospitalization.
Philip Sanger, MD, founder and former CEO of Houston-based Inpatient Medical Services (now Intercede Health), is credited with one of the first uses of the term “extensivist.” Initially, it only described a hospitalist or other care provider who sees high-risk patients in an outpatient clinic.
Writing in Managed Healthcare Executive in 2002, Dr. Sanger explained: “To move from generally sick to generally well, high-risk patients need something extra—more attention than a busy PCP can offer [and] more individualized care than most protocol-driven disease management programs can provide. A high-risk clinic system is one way to fill this care gap. Also referred to as transitional-care clinics, these outpatient clinics focus on preventing hospital admissions and stabilizing high-risk patients.”1
Adam Singer, MD, CEO of North Hollywood, Calif.-based IPC: The Hospitalist Co., says this extensivist model provides a respite for hospitalists, who typically spend a month at a time in these transitional clinics before heading back into the fray of the hospital. As hospitals, independent physician associations, and managed-care organizations try out new models of care, though, the definition of an extensivist has broadened to include providers in a range of outpatient settings, such as skilled nursing facilities, assistant living communities, and even home health services. California’s CareMore Medicare Advantage plan, in particular, has been cited by the Agency for Healthcare Research and Quality (AHRQ) for using hospitalists as extensivists in both outpatient clinics and skilled nursing facilities to reduce hospital readmission rates, LOS, and inpatient resource use.
The CareMore model reduces the caseload of its hospitalists to about six or eight patients per half-day, giving doctors more time to talk to patients and their family members. Based on those conversations, the extensivist works with a case manager to provide needed resources to each patient after discharge. The doctors also spend roughly half of each day in clinics seeing their own recently discharged patients, and one or two days each week in a skilled nursing facility to visit patients transferred from the hospital (for more details, visit www.innovations.ahrq.gov/content.aspx?id=2903).