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)?
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).
Average inpatient LOS among the plan’s 44,000 members dipped to 3.2 days, compared with 5.8 days for Medicare fee-for-service providers and 4.5 days for traditional HM programs in the state. Last April, CareMore’s 30-day readmission rate averaged 13.4%, compared with a 19.6% rate for Medicare.
Baltimore-based Bravo Health has begun opening its own transitional advanced-care centers for members of its Medicare Advantage program, offering case management for complex conditions and immediate care when a PCP is unavailable. Another model has been advanced through team approaches practiced by the likes of Kaiser Permanente, though hospitalists aren’t necessarily the ones providing outpatient follow-up care. No matter what the model is called, Dr. Singer says, the main point is the same: “trying to connect the dots so that we get patients continuing to get better along the continuum without having to be readmitted.”
In December, IPC did some more dot-connecting of its own with its announced acquisition of Senior Care of Colorado, which operates more than 200 geriatric-care facilities in the Denver area. Don Murphy, MD, IPC’s practice group leader for Senior Care of Colorado, says the model emphasizes a continuum of care and information flow from hospitalists in the hospital to affiliated providers in skilled nursing facilities and other outpatient settings. “We think that model, where we tie everything together, will be one of the best that we can do,” Dr. Murphy says.
From Dr. Singer’s perspective, the growing opportunities have sprung from efforts to address a persistent challenge. “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,” he says. One of the central ideas of healthcare reform—creating true accountability around an episode of care—will require doctors to be linked “not just during what used to be the episode of care in the hospital,” he adds, “but throughout the continuum until that patient is really returned healthy back to wherever they’re going to be living.”
With a new emphasis on avoidable hospitalizations, hospitals will increasingly need to team up with other providers to avoid fragmentation of care. Using extensivists to help avoid gaps might be a good fit for accountable-care organizations, and Dr. Murphy says the process may be easier for big systems, such as Ochsner in New Orleans or the Cleveland Clinic, which are working in a confined geographic area with a defined patient population.
“The real challenge will be those of us out there in larger metropolitan areas where we’re not under the roof of one big conglomerate but still having to work together creatively and effectively to smooth the continuum,” Dr. Singer says.
Other trends are making inpatient-outpatient partnerships, whether formal or informal, an increasingly necessary part of providing high-quality healthcare. “We are seeing folks come out of the hospitals who 30 years ago clearly would have been in the hospital for a prolonged stay,” Dr. Murphy says. “A lot of these [patients], instead of going to SNFs, are going back to their homes and to assisted living with additional services; they require a lot of follow-up.”
Dr. Singer says he’s seeing another trend in which PCPs are likewise transitioning to newly created extensivist roles in sub-acute settings such as nursing homes. The position, he says, offers the attraction of a high-impact, longer-term relationship with patients without the high overhead of standalone clinics. The blurring of lines between outpatient and inpatient providers has created questions for hospitalists, too. For example, at what point does a hospitalist working much of the time in an outpatient clinic or skilled nursing facility no longer fit the traditional definition of a hospitalist? Does that detract from the doctor’s hospital duties? TH
Bryn Nelson is a freelance medical writer based in Seattle.
- Sanger, P. Health plans juggle precarious patients. Managed Healthcare Executive. 2002:40-41.