Tuesday, March 15, 2011

How is organized hospital medicine coping with the problem of post hospital transitions? By gradually dismantling the hospitalist model!

Yes, I said it. It won't sound so absurd after you read this article in a recent issue of The Hospitalist, especially the concluding paragraph:

The blurring of lines between outpatient and inpatient providers has created questions for hospitalists, too. For example, at what point does a hospitalist working much of the time in an outpatient clinic or skilled nursing facility no longer fit the traditional definition of a hospitalist? Does that detract from the doctor’s hospital duties?

Wachter and Goldman in their classic NEJM paper in 1996 coined the term hospitalist to describe a new practice model which was springing up out of the economic necessities of managed care. Economic advantages continued even after the pressures of managed care waned as ambulatory providers realized the added efficiency of avoiding the competing demands of the hospital. Now there are new economic realities. Will the new pressures for accountability across the transition from hospital to ambulatory care make the hospitalist model obsolete? That increasingly seems to be the opinion of many hospitalist leaders. I was surprised at the degree to which this idea was promoted at HM 2010 and it seems to be gaining traction.

Discontinuity between the hospital and the ambulatory side has always been the principal weakness of the hospitalitst model. It's so inherent in the model (in fact Bob Wachter has often said that it was deliberately designed into it) that in the minds of some it can't be addressed without altering the model.

The idea of a post discharge clinic run by hospitalists never made sense to me. Having the hospitalist see the recently discharged patient in clinic for one or two visits will not eliminate the hand off. It will only delay it by those one or two visits. The patients who are at greatest risk for readmission are those who are on a continuous, long term trajectory with their complex medical illnesses. The need for intensive follow up is ongoing, and one or two post hospital visits will not address the problem. The real fix needs to be on the ambulatory side.

As pressure to address the problem of readmissions increases the leadership of the Society of Hospital Medicine will have to take a more definitive stand on this issue. Will they support the preservation of the hospitalist model or allow it to unravel?

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