Hospital Medicine An Evolution in Changing Paradigms

1. Hospital MedicineAn Evolution in Changing Paradigms Jeff Wiese, MD, FACP, FHM Professor of Medicine Tulane University Health Sciences Center

3. What is a Hospitalist?

4. Hospitalist Specialties The Society of Hospital Medicine National Survey; 2008

5. Employment Model of Hospital Medicine Groups The Society of Hospital Medicine National Survey; 2008

6. Hospitalist Characteristics The Society of Hospital Medicine National Survey; 2008

7. The Work of Hospitalists • Admissions, Follow-ups, Discharges: 73.6% • Consultations: 8.2% • Observation Days: 8.0% • Critical Care: 4.0% • Procedures: 2.0% • Office Encounters/Consultations: 1.1% • SNF/Rest Home Visits: 1.0% • ED Encounters: 0.9% • Other Encounters: 1.1% The Society of Hospital Medicine National Survey; 2008

8. The Expanding Role of the Hospitalist Non-clinical Roles Committee Participation 92% Quality Improvement 86% P&T Committees 64% CPOE/Information Systems 54% Teaching 51%

9. AHA 2006 Survey

10. Society of Hospital Medicine Membership # of Members

11. What drove the hospitalist movement? The physician The hospitalized patient Physician Issues Third party issues Patient issues Complexity of documentation Busy clinic schedule Physician quality of life Quality of care standards Joint Commission Quality improvement Supervision requirements Cost-containment * Admissions * Resource utilization * Discharge Increasing disease severity * Inpatient * Outpatient Higher standards of care Clinic reliability

13. Hospital Medicine in 2009

14. The Seven Deadly Sins

15. Seven Deadly* Sins of Hospital Medicine * Potentially

16. Sin 1: Failure to Advance Quality and Patient Safety

17. Quality: • Desired Outcomes Occur • Evidenced-Based Standard of Care Leads to the Outcome

18. Institute of Medicine Six Components of Quality Health Care Quality Time

19. Institute of Medicine Six Components of Quality Health Care Safe Timely Effective Efficient Patient-Centered Equitable Quality Time

20. Familiarity with the intricacies of inpatient disease management (specialization) Familiarity with many different sub-specialties Familiarity with non-medical services Closer relationship with nurses, administration, and technicians Greater availability to patients The rational behind hospitalists and quality of care Safe Timely Effective Efficient Patient-Centered Equitable

21. Hospitalists vs Gen Internists Length of Stay -0.4 days Costs -$268 Same mortality Same re-admit rate

22. Chan PS, et al. N Engl J Med 2008;358:9-17.

23. Gray A, et al. N Engl J Med 2008;359:142-51

24. Wachter R, et al., Ann Intern Med. 2008;149:29-32.

25. Quality and Patient Safety Quality: Patients received the highest standard of care such that expected outcomes are routinely achieved. Patient Safety: Adverse consequences of diagnostic and therapeutic interventions, including medical errors, are avoided. Committee on Quality Healthcare in America, Institute of Medicine. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century.

26. Overriding Aims of Patient Safety 1. Education 2. Raise Awareness 3. Accountability/Metrics 4. QI Projects/Research to change the system Wachter, R.M. Understanding Patient Safety. 2008

27. SHM-Developed Quality Improvement Initiatives • Quality Improvement Resource Rooms • www.hospitalmedicine.org/rrs • Acute Coronary Syndrome • Antimicrobial Resistance • BOOSTing Care Transitions • Glycemic Control • Heart Failure • Veneous Thromboembolism • Stroke • Peer-Submitted Quality Improvement Tools

29. Sin 2: Living in a Silo

30. Hospital Value-based Purchasing • Physician Quality Reporting Initiative (PQRI) • Expansion of Physician Feedback Program (Resource Use) • Value-Based Modifier for Physician Payment Formula • Reducing Hospital Acquired Conditions • Improving Quality • Accountable Care Organizations • CMS Payment Innovation Center • National Pilot Program on Bundling Acute &Post Acute Payments • Readmissions • Community Care Transitions Program • Medicare Physician Payment Update (SGR) • Medical Liability Reform • Provider Screening • Provider Compliance and Penalties (High Risk Referrals) • Primary Care Bonus Payment

32. Sin 3: Failure to Maintain Patient-Centered Care

33. 3. Patient-Centered Care Pay for hospitalists may, and likely will is, derived from hospitals. The fiduciary responsibility must remain with the patient. A strong connection to the patient, the patient’s family, and the patient’s primary care provider is necessary for maintaining this standard.

34. Patient Satisfaction Patients prefer to receive care from their primary care provider if: The primary care MD is consistently available The primary care relationship has been well-established. Patients prefer hospitalist care if The hospitalist regularly sees the patient (accessability) The hospitalist is in frequent communication with the patients primary physician.

35. Weissman JS, et al., Ann Intern Med. 2008;149:100-108.

37. Sin 4: Failure to Sustain Quality & Patient Safety: Transitions of Care

38. Transitions of Care Transfer of Information Transfer of Choice Transfer of Decision-Making “Enabling” Communications/Decisions Preservation of Patient-Centered Care

39. Transitions of Care - Inflow to Hospital Medicine - Primary Care Identification - Past Medical History - Patient wishes/personal history - Diagnostic coordination - Outflow to Primary Care - Primary Care Entry - Synching inpatient to outpatient continuum - Setting up the perfect first visit

40. SHM Initiatives – Care Transitions • Discharge Checklist • Halasyamani L et al. Transition of care for hospitalized elderly patients--development of a discharge checklist for hospitalists. J of Hosp Med 2006:354. • Resource Room • Safe STEPs • Project BOOST • Better Outcomes for Older adults through Safe Transitions • John A. Hartford Foundation $1.4 million

41. BOOST Toolkit: Primary Components • Tool for Identification of High-Risk Patients • Patient and Family/Caregiver Preparation • Diagnosis – primary cause for hospitalization and other Dx • Test results and interpretation • Treatment Plan during and after hospitalization • Contextualize • Follow-up Plans • Principal Care Provider identification • Who to contact with questions/concerns • Warning signs/symptoms and how to respond • Outpatient appointments • Pending tests • 4. Medication Reconciliation • 5. Discharge Summary Communication

42. Other Transitions

43. The Seven Organizational Sins • Overproduction • Waiting • Transporting • Inappropriate Processing • Unnecessary Inventory • Unnecessary Motion • Defects

44. Howell E, et al., Ann Intern Med. 2008;149:804-810.

46. Sin 5: Failure to Sustain The Art: Instruction of Quality and Patient Safety

47. Before the Work Hours After the Work Hours Extra Work

48. Before the Work Hours Solution 1: Shift the work to others (i.e., other residents/ hospitalists)

49. Before the Work Hours Solution 1: Shift the work to others Problem: 1) A proportion of the “good work” is lost ( ), or 2) You induce a system of high-output heartfailure

50. Before the Work Hours Solution 2: Go To Shifts