Hospitalists take charge in the post-acute world
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.
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."
