Hospitalist Programs

A Hospitalist Program employs hospital-based physicians to assume the care of hospitalized patients in the place of patents’ primary care physician, providing treatment, care planning after the discharge and honoring the PCP’s existing referral relationship.

a. A State of the Art Hospitalist Program:

    • Has a dedicated group of talented and skilled physicians.
    • Recruits and maintains high-caliber physicians to manage inpatient medicine patients.
    • Continues to provide support to the Medical Staff.
    • Provides 24-hour, in-house coverage.
    • Assumes the on-call responsibility for the ED Unassigned Backup Panel 24 hours a day, 7 days a week.
    • Enhances inpatient management and improves utilization of Hospital resources.
    • Provides responsive and cost-effective care in support of the ED.
    • Develops a close working relationship with the Medical Center and Medical Staff.
    • Achieves effective problem solving with the Medical Center.
    • Provides outreach to community and out-of-area physicians interested in utilizing a dedicated
    • Hospitalist Program.
    • Supports the specialists.
    • Provides both co-surgical and co-specialty management support.
    • Supports the recruitment and retention of nurses.
    • Provides cost-effective care for fee-for-service and managed care patients.
    • Establishes a sustainable and affordable Hospitalist model to achieve long-term success, which can be held up as one of the best programs in the community.
    • Has aligned incentives in order to provide the best possible service.

b. Why invest in a Hospitalist Program?
Because of value through:

    • No treatment delays
    • Volume-based experience
    • On-site constant attention
    • Improved ED coverage
    • Reduced ALOS
    • Reduced Cost per Discharge
    • Safety of patients having increased access to a physician
    • Minimal patient down-time
    • Continuous, rapid fine-tuning of therapeutics over the course of hospitalization
    • Improvement of patient and family communication
    • Knowledge of “how to get things done around here”
    • Greater confidence in early discharge
    • Discharge planning that begins at start of admission
    • Positions the Hospital for Population Management
    • Efficient Information Transfer

c. Common challenges often facing Hospitalist Programs are as follows:
1.  Lack of a Fully staffed team

    • 6-month time for new hire: It takes at least six months to recruit new full-time physicians, so this creates gaps in the scheduling requiring either part-time and/or locum tenens staffing.

2.  Census Variable

    • Percentage of “unassigned” from ER
    • Created by seasonal fluctuations and increasing ED volume. It is very difficult to have a consistent, efficient and effective physician to patient staffing ratio (ideally 1:15).

3.  Specialist “dumping”
The majority of specialists want ED patients evaluated and admitted by the Hospitalist, and then they want to be consulted for their respected subspecialty. This is creating additional workload for the Hospitalists that needs to be addressed.
4.  Patient Handoffs
Need a better method of handing off patients between Hospitalist Teams.
5.  Communicating with Hospitalists
Sometimes it is difficult contacting the PCPs to arrange timely follow up care after discharge.
6.  Cultural Issues
As Hospital-based physicians, the Hospitalists have a different perspective on the practice of medicine, as well as different lifestyle expectations, than the office-based physicians.
7.  Unassigned Patient Volume Increasing
As volume continues to increase, the number of unassigned patients that need to be cared for by the Hospitalists also increases.
8.  Information Transfer
Not all physicians are on the same EHR System, which impacts the amount of information the Hospitalists can learn about the referred patients and slows the communication process and reduces efficiencies.

    • IM Hospitalists are physicians whose primary professional focus is the medical care of hospitalized patients. Hospitalists are typically physicians who are board-certified in Internal Medicine or Family Practice and have chosen to focus their practice on inpatient medicine rather than establish an outpatient practice. Hospitalist Programs provide in-house coverage for sick inpatients while reducing inpatient costs. An effective Hospitalist Program adds value through no treatment delays, volume-based experience, on-site constant attention, improved ED coverage, reduced ALOS, reduced cost per discharge, safety of patients having increased access to a physician, and improvement of patient and family communication. These benefits have led to improved efficiency and improved quality of care to Hospitalist Programs nationwide.
    • With a Fourth Generation Hospitalist Program, the return on investment is typically 2:1.

Internal Medicine Hospitalist Programs typically assist with the following hospital issues:

    • ED over-crowding: Need a Hospitalist Program that will assist in both timely patient evaluation and Hospital admission of ED Unassigned patients.
    • Patient satisfaction performance: The Hospital would like to improve their patient satisfaction scores to meet their overall goals.
    • Quality indicators performance: Need to provide monthly, quarterly and semi-annual reports to monitor and track both quality and financial indicators.
    • Bed utilization: Need to develop systems to improve patient throughput to make more beds available and minimize Hospital diversions.
    • Perceived program leadership: Sometimes a change in leadership is required to improve the growth and direction.
    • Disconnected physicians on the Medical Staff: Need more Hospitalist participation in Hospital committees and in their process improvement initiative.

A valuable Hospitalist Program:

    • Manages patient admissions and ALOS to an optimum level, especially the Capitation patients.
    • Achieves patient satisfaction scores at a level no less than the 90th percentile, as measured by the patient survey instrument.
    • Admits patients from the ED in a timely manner, reducing ED wait times.
    • Works in a collaborative manner with the sub-specialists taking ED Call.
    • Cooperates with the Hospital in an effort to achieve all quality goals and indicators.
    • Cooperates with the Hospital with medical record entries, which fully document all co-morbid conditions and the severity of illness.
    • Participates in Medical Staff activities, meetings and leadership.
    • Provides education to the Nursing Staff.
    • Takes a leadership role in “end of life” decisions and communications with the patients and families.
    • Actively coordinates with PCPs to assure timely follow up to prevent unnecessary readmissions.
    • Pediatric Hospitalists are Pediatricians dedicated to providing pediatric care in the hospital setting. Pediatric Hospitalists focus their practice on inpatient medicine rather than establish an outpatient pediatric practice. Typically a Pediatric Hospitalist Program complements the Neonatology program as they take care of general pediatric issues.
    • With a Fourth Generation Pediatric Hospitalist Program the return on investment is typically 2:1.

The Pediatric Hospitalist Program should:

    • Staff with a small group of talented and skilled physicians trained in Pediatrics,
    • Recruit and maintain a high caliber practice to manage inpatient pediatric medicine patients,
    • Assume the on-call responsibility for the ED call panel 24 hours a day, 7 days a week,
    • Enhance inpatient management and improved utilization of Hospital resources,
    • Provide responsive and cost effective care in support of the ED,
    • Enhance the service and reputation of the Pediatric department in order to grow referrals, especially through the Transfer Center,
    • Support the designation of the Medical Center as an accredited Children’s Hospital.
    • Develop a close working relationship with the hospital and medical staff,
    • Allow the general Pediatric staff to stay focused on their outpatient practices,
    • Achieve effective problem solving with the hospital, and
    • Establish a sustainable model to achieve long-term success.
    • Orthopedic Hospitalists are Orthopedic Surgeons dedicated to providing care for emergency unassigned orthopedic cases within the hospital. Freeing up orthopedic surgeons from unassigned ED call allows them to focus on their outpatient practice and perform more elective cases. Orthopedic Hospitalist Programs improve patient access to better quality care and supports growth of the Orthopedic service line.
    • With a Fourth Generation Orthopedic Hospitalist Program the return on investment is typically 3:1 due to reduced length of stay.

If a viable option, the Medical Staff and Administration are interested in an Orthopedic ED coverage program that:

    • Takes all ED Unassigned, Trauma and Private Referrals (also referred to as Mega call),
    • Has a small group of talented and skilled surgeons,
    • Has designated OR time during daylight hours,
    • Employs a dedicated mid-level extender,
    • Provides a high caliber practice to manage inpatient orthopedic patients,
    • Helps maintain the Trauma Level designation,
    • Coordinates well with the existing Traumatologist and Hospitalist Program,
    • Enhances inpatient management and improves utilization of Hospital resources, including Operating Room (OR) time.
    • Provides responsive and cost effective care in support of the ED and trauma center,
    • Develops a close working relationship between the Hospital and Medical Staff,
    • Achieves effective problem solving with the Trauma Center,
    • Positions the Medical Center as a Regional Referral Hospital with an effective Transfer Center capable of receiving out of area referrals and
    • Establishes a sustainable model to achieve long-term success.
    • May use local orthopedic surgeons or new surgeons recruited specifically for the Program.

Opportunity for an effective Orthopedic Hospitalist solution to:

    • Appropriately support the ED and trauma programs,
    • Allow better compliance with the Federal Emergency Medical Treatment and Active Laboratory Act (EMTALA),
    • Allow the Orthopedic surgeons to participate in ED coverage without an excessive number of days on rotation,
    • Enhance the capabilities of the trauma service,
    • Achieve Medical Staff acceptance and support,
    • Provide effective coverage to the ED unassigned patients,
    • Provide a market differentiation for the Hospital,
    • Be more receptive to out of area referrals into Hospital and
    • Provide responsive and cooperative working relationships with the nursing staff.
    • An Intensivist Program provides dedicated Medical ICU services for the hospital. An Intensivist is a critical care physician with special training and experience treating critically ill patients. An Intensivist Program can support the following Hospital initiatives:
        • Enhance Rapid Response Team
        • Improve ED patient throughput to assure bed availability and minimize holding times
        • Improve bed capacity to minimize transfers to other facilities
        • Facilitate out-of-area transfers into the hospital
        • Improve utilization of hospital services including LOS
        • Improve efficiency and quality of care
        • Improve patient safety
        • Effectively communicate with patient and family
    • With a Fourth Generation Intensivist Program the return on investment is typically 4:1.

State-of-the-art Intensivist Programs have the following characteristics:

    • Staffed by Board Certified pulmonologist/intensivists,
    • Core group of talented and skilled intensivists,
    • Provides continuous on-site coverage of the ICU without outside distractions,
    • Leads the Interdisciplinary Rounds each day,
    • Maintains a high caliber of intensivists to care for critically ill patients at all hours of the day and night,
    • Meets state and national benchmark guidelines,
    • Provides in-house assistance to the nurses and Medical Staff in managing critically ill patients,
    • Assists with the on-call responsibility for the ED call panel 24 hours a day, 7 days a week, for patients needing direct admission to the ICU,
    • Becomes a member of the Rapid Response Team,
    • Enhances inpatient management and improves utilization of Hospital resources,
    • Provides responsive and cost-effective care in the ICU,
    • Appropriately provides End of Life counseling to ICU patients,
    • Develops a close working relationship with the Hospital and Medical Staff,
    • Allows the Medical Staff to have the option of referring to a service that is not considered mandatory or competitive to their practices,
    • Creates a practice model that will be appealing to pulmonologists and/or intensivists interested in moving into the community,
    • Achieves effective problem solving with the Hospital,
    • Monitors both the clinical and economic results of the Program, and
    • Establishes a sustainable model to achieve long-term success.

An Intensivist Program can support the following additional Hospital initiatives:

    • Positively impact the quality of critical care provided to patients in the critical care units
    • Enhance the Rapid Response Team
    • Continue the standardization of protocols
    • Support the implementation of the CPOE Program
    • Support the establishment of evidence-based order sets
    • Provide appropriate consults to subspecialists as requested
    • Improve ED patient throughput to assure bed availability and minimize holding times
    • Improve bed capacity to minimize transfers to other facilities
    • Facilitate out-of-area transfers into the Hospital
    • Position the Hospital to negotiate more favorable contract rates with health plans by improving utilization of Hospital services (LOS)
    • Provide training to the residents and nursing staff during daily rounds
    • May utilize existing intensivists as part of the solution
    • A Trauma Surgicalist Program involves designating an in-house surgeon for Trauma, SICU and/or Acute care Surgery. Advantages to this program include integration with case management and SICU nursing staff, improved ALOS, and potential to be recognized as a higher Level Trauma designation and regional referral center. Additionally, hospitals that implement an acute care Surgicalist Program generally experience a significant increase in surgical volume. Enhanced patient satisfaction, reduced length of stay and cost per discharge are benefits of the program.
    • With a Fourth Generation Acute Care Surgicalist Program the return on investment is typically 3:1.

Opportunity for an effective Traumatologist solution to:

    • Appropriately support the ED and trauma programs,
    • Allow better compliance with the Federal Emergency Medical Treatment and Active Laboratory Act (EMTALA),
    • Allow the Orthopedic surgeons to participate in ED coverage without an excessive number of days on rotation,
    • Enhance the capabilities of the trauma service,
    • Achieve Medical Staff acceptance and support,
    • Provide effective coverage to the ED unassigned patients,
    • Provide a market differentiation for the Hospital,
    • Be more receptive to out of area referrals into Hospital and
    • Provide responsive and cooperative working relationships with the nursing staff.
    • May utilize existing General Surgeons in the Program.
    • Laborists are hospital-based obstetrician-gynecologists who are dedicated to delivering babies in the hospital setting.
    • Laborists are specialists who help fill a void of the growing number of obstetrician-gynecologists who have stopped delivering babies because of grueling on-call schedules and high malpractice insurance costs. Implementing a Laborist Program may improve quality of care, patient safety, and efficiency for deliveries.
      With a Fourth Generation Laborist Program the return on investment is typically 2:1 or more if reduction in risk is included
    • Extensivist Medicine is an area of medicine focusing on high-risk patients beyond the inpatient setting. An Extensivist Physician is generally trained in Internal or Family Medicine and is responsible for coordinating care to post-acute patients with complex medical issues. Extensivists have the ability to coordinate patient care across multiple settings and providers and are sometimes part of a Patient Centered Medical Home program. Advantages to an Extensivist program include reduced ALOS, decreased 30-day readmission rates, and improved quality across the continuum of care.
    • A Billing Audit Service assesses the current revenue management process and recommends improved efficiency and structure for the practice or healthcare system. The revenue process includes the entire process leading up to and including the billing and collections of revenue for clinical services rendered to patients. This service evaluates the management of the patient census, virtual registration, time of service activities, charge posting, payment posting, third party recovery, statement management, and compliance and oversight of the entire process.
    • With a Professional Billing Audit, the return on investment is typically 15:1
    • In addition, HMR has vetted the best billing and collection companies for effective billing for hospital based programs.