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Hospitalists take charge in the post-acute world
By: MARY ELLEN SCHNEIDER, Hospitalist News Digital Network
Twenty-five years after the first hospitalist programs began, the hospitalist model of dedicated,
site-specific care is starting to make its way into post-acute care settings.
They may be called SNFists or post-acute care hospitalists, but whatever the name, physicians
are staking out more of a physical presence in skilled nursing facilities (SNFs), inpatient
rehabilitation facilities, long-term acute care hospitals, and other post-acute care settings.
In some cases, hospitalists are migrating into post-acute facilities part-time. Under this hybrid
model, traditional hospitalists are continuing their work in the hospital, but may also care for
patients in a nearby skilled nursing facility.
The other model that has been developing over the past 3-4 years looks more like the
traditional hospitalist model of care, but may not always involve hospitalists. Under this
dedicated model, physicians work exclusively in the post-acute care setting, providing
coverage to these facilities anywhere from 3 to 7 days a week. Some of the physicians
working under this model are former hospitalists, but others are geriatricians, intensivists,
internists, and family physicians.
Dr. Jerome Wilborn
Nearly 27% of hospitalist medical groups provide services in either inpatient rehabilitation
facilities, psychiatric facilities, or long-term acute care hospitals. And nearly 10% provide
services in SNFs or extended-care facilities, according to the 2012 State of Hospital Medicine
survey released by the Society of Hospital Medicine (SHM).
One reason for the shift in care is that the old model isn’t working, said Dr. Jerome Wilborn,
the national medical director for post-acute care services at IPC The Hospitalist Company.
"Unfortunately, you look around the country, and doctors just don’t go to the nursing facility
setting often enough to make an impact," Dr. Wilborn said. "How do we know that? A quarter
of the patients who come here, bounce back to the hospital."
Beefing up the physician presence at SNFs and other post-acute care facilities has the
potential to bring down those hospital readmission numbers, Dr. Wilborn said. In the postacute care hospitalist programs that he oversees, the number of patient visits is driven by
clinical acuity.
For example, in the first week, when patients are most vulnerable to bouncing back to the
hospital, they may be seen by a physician three or four times. Some of that time is spent
counseling family members, working on reducing medications, and coordinating care with the
discharging physician, Dr. Wilborn said.
"It’s not so much the number of touches as it is the presence of the clinical team that’s there,"
Dr. Wilborn said. "You don’t know who you’re going to see, or who you should see, if you only
go once a week."
IPC The Hospitalist Company recently made a big entrance into the post-acute care market.
Over the past 4 years, they have begun practicing in about 650 post-acute care facilities. The
facilities are mostly SNFs, but also include long-term acute care hospitals, inpatient
rehabilitation facilities, assisted living facilities, and others, according to Todd Kislak, the vice
president of marketing for IPC. This is in addition to the traditional hospital practices that the
company has in about 350 acute care hospitals and long-term acute care hospitals around the
country.
The IPC executives saw the holes in care in the post-acute care setting and saw an
opportunity to use their experience with hospitalist programs, electronic health record
technology, and advanced communications systems to surge ahead in the market, Mr. Kislak
said. "IPC is playing an influential role in the organization and consolidation of these doctors in
the post-acute space," he said.
IPC and other acute care hospitalist groups follow a fee-for-service business model. But there
are other, more complex financial drivers that appear to be moving this model forward.
One driver is the Medicare 30-day readmission penalty, which went into effect on Oct. 1, 2012.
Under the new policy, the Centers for Medicare and Medicaid Services is cutting Medicare
payments to hospitals with excess readmissions in heart failure, pneumonia, and acute
myocardial infarction.
Courtesy Diane Williams
Dr. Sean Muldoon
The readmission policy incentivizes short-term acute care hospitals to use post-acute care
services efficiently, safely, and effectively, said Dr. Sean R. Muldoon, the senior vice president
and chief medical officer at Kindred Healthcare’s Hospital Division, which is a national network
of long-term acute care hospitals headquartered in Louisville, Ky.
"Managing the transition and assuring that the patients go into settings that are likely to
continue the patients’ improvement are in [the hospitals’] best patient, payment, and policy
interests," said Dr. Muldoon, who cochairs the SHM Post-Acute Care Task Force.
And the movement by Medicare toward bundling payments for an entire episode of care
means that hospitals will have another financial incentive to move patients into a less costly
setting, while also ensuring that the quality of care is maintained.
For SNFs and other post-acute care facilities, there’s a growing recognition that they need help
in managing the increasingly complex patients coming through their doors, he said.
"The post-acute care settings, particularly SNFs, have really asked physicians to be more
involved, more present, and more coordinating in their care plans," Dr. Muldoon said.
"Hospitalists have responded to that because those are core competencies that they have
developed very well in short-term hospitals and are largely transferrable to the post-acute
care setting."
As physicians take on a larger role in the post-acute care setting, the debate is growing over
what model is best.
Each of the current models has some advantages, said Dr. Heather Zinzella-Cox, the practice
group leader for the Delaware region for IPC and the cochair of the SHM Post-Acute Care Task
Force.
Dr. Heather Zinzella-Cox
The hybrid model offers continuity of care because the same physicians who are following
patients in the hospital are also involved in their post-acute care. At her IPC practice in
Delaware, the nursing facility contracts with some traditional hospitalists to serve as Medical
Director Consultants. Since these physicians have a foot in each setting, they are able to use
their post-acute knowledge to inform their work as hospitalists. For instance, many SNF
pharmacies may not have access to certain medications or may need 24 hours to provide
them. So the hospitalist needs to be aware of those challenges and take the necessary steps
to provide a safe and effective handoff to the facility, she said.
But the hybrid model also comes with the typical disadvantages of trying to do too many
different things at once.
"When a provider is stretched and has too many hats, something gives," Dr. Zinzella-Cox said.
"And it’s typically the post-acute care space."
The hybrid model is most successful, she said, if the post-acute care facility is attached to the
hospital or if the two facilities share an electronic health record system.
On the other hand, the dedicated model in the post-acute care setting keeps physicians from
being pulled back and forth between different settings. "It allows me to stay engaged in my
facility," she said.
Whatever model emerges, Dr. Zinzella-Cox predicted that the combination of Medicare
readmission penalties and other new payment initiatives will force traditional hospitalists to
pay closer attention to the post-acute care setting.
"Hospitalists will drive the care of their patients and, in combination with the social worker,
determine where their patients are going to go after discharge," she said.
Hospitalists’ habits: Standardizing post-acute care
Hospitalists who have moved to the post-acute world are bringing some of the hospital culture
with them.
Dr. Donald Quinn, who started three hospitalist groups in east Tennessee and is now the
practice group leader for the Tennessee region of IPC The Hospitalist Company, said
hospitalists bring a standardized approach to quality of care. One of the tools Dr. Quinn and
his colleagues are using in skilled nursing facilities is pathways and protocols that help
standardize the care provided for common clinical situations.
The use of clinical pathways has been especially helpful at night, when physicians aren’t on
site but are available by phone. Being able to instruct the nursing staff to begin a
preestablished clinical protocol can help keep patients out of the emergency department,
safely, Dr. Quinn said.
Post-acute care hospitalists aren’t just standardizing the care. They are also standardizing
their hours. Dr. Quinn said he and his IPC colleagues have set up regular visit schedules with
the post-acute facilities they work with so patients and staff there know when a physician will
be in the building. Typically, their post-acute care hospitalists visit two facilities per day,
where they see patients and coordinate care with nurse practitioners and physician assistants.
The group also cross-credentials its physicians so that when someone is sick or goes on
vacation, a doctor is still available at the facility at the scheduled time.
"Once you get these folks used to this quality and this intensity of care, it does make a
difference if no one shows up that day," Dr. Quinn said. "It’s a totally different practice."
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