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