Disruption to Hospitalist Outpatient Care

Are we there yet? Perhaps not, but with Papa Larry (Larry Wellikson, CEO, Society of Hospital Medicine) at the driving seat, it sure seems to be full speed ahead. The vehicle is jam packed, with standing room only, and so far he has been navigating through choppy waters very efficiently. In figures from 2007, the hospitalist specialty was more than 20,000 strong and is continuing to grow. Hats off to you, Larry Wellikson.

What necessitated this innovation was the sorry state of outpatient care. Over-burdened primary care physicians were running around between hospital and office practice, tired and over-stretched. Somewhere in between were the fights with payers for prior authorization to render care to their patients, appealing denials, and submitting copies of progress notes to justify CPT codes, not to mention the almost predictable annual cuts in reimbursement. Just to maintain their income level, primary care physicians are forced to see more and more patients every year. Forget about any income increase, or even any adjustment for inflationary rates. A solitary internist or family practitioner in a small community is literally on call and available year round to the emergency room and for after hours calls from his patients. This leads to an increasing percentage of internal medicine residents opting for sub-specialty fellowships rather than following the primary care tract. Out of this misery was borne the hospitalist specialty. Its success lies in the fact that it has given freedom from night calls to primary care providers, a better income potential to internists who chose this specialty, a better life style, and less upfront investment- which is an integral part of opening an office practice.

Two major challenges hospitalists faced immediately were the disruption in the longitudinal continuity of care and transitioning care to incoming hospitalist shift. The first hurdle, caused because the primary care physicians were not available to provide valuable information about patients’ past history, medication history and other pertinent information, was soon overcome by adopting various efficient methods of communication with the patients’ primary care provider. Most of the hospitalist groups now do contact patients’ private physicians on admission, discharge and for any centennial events. The second major challenge, which still lacks satisfactory resolution, is signing out to an incoming shift. In programs where hospitalists are in house day and night, this is less of a challenge.

The outgoing physician sits down face to face with incoming physician and goes over the problem list. In programs where hospitalists are In house during the day time, typically a twelve hours shift, and on call at night, this face to face meeting does not happen. The night physician often does not need to come to the hospital, unless there is a particularly unstable patient. The physician completing his day shift leaves a written sign out, makes a phone call, or performs a hybrid or the two. Written sign outs can be done using hospital based health information systems, password protected emails, or leaving a list of patients’ names together with problems and issues in the office. The problem with the later methodology is that the night physician does not get to see this list until he comes to the hospital. In short, different methods are being tried, but they lack consistency and have the potential of falling through the cracks. With transition of care being identified as a point where patient safety and care can potentially suffer, hospitalists need to close this loop and find a consistent sign out methodology, particularly for programs where night coverage is from home.