Saturday, March 21, 2015

More tweaks proposed for the hospitalist model of care

The hospitalist model came into being with the hope that it would result in improved quality and cost efficiency. That hope did not withstand scientific scrutiny despite the persistent claims of some. While many hospitalists ascend a long and steep learning curve, thereby becoming quite skilled in the management of inpatients, that advantage may be outweighed by the discontinuity that is built into the system.

Concerns about this discontinuity prompted some leaders to propose modifications which would in effect dismantle the model. Some, for example, have suggested that hospitalists spend part of their time in the clinic. A few years ago AAFP promulgated guidelines calling for PCPs to collaborate with ER doctors before their patients are admitted to hospitalists, and to be involved in their patients' hospital stays. None of these ideas were widely adopted.

Now a Perspective piece in the New England Journal of Medicine proposes taking things a step further:

Under this voluntary system, PCPs would visit their hospitalized patients within 12 to 18 hours after admission to provide support and counseling to them and their families and consultation to the hospitalist team. The consultation would focus on the direction and scope of the patient's workup and care. The PCP would write a succinct consultation note, highlighting key elements of the patient's history (including pertinent family and psychosocial components), physical exam, and recent testing, and conclude with a prioritized differential diagnosis and recommendations for personalized inpatient evaluation and management. The hospitalist team would still retain full attending-physician responsibilities.

The initial consultation — contributing insights from an established doctor–patient relationship — would be designed to complement and help inform the hospitalist's admission workup and care plan, aiming to reduce hospitalist workload while increasing personalization of care. Subsequent to the admission consultative visit, the PCP would be available to meet with the patient, family, and hospitalist team on an as-needed basis, returning just before discharge to consult on the design of a coordinated posthospital program.

This means the PCP would round at least twice during the patient's hospital stay. Given a typical length of stay of about 4 days that means he or she would be rounding at least half the time. Although most hospitalists I know would be delighted to see the PCPs reaching inside the walls of hospitals this proposal would dismantle the hospitalist model as we now know it. It would take a radical payment shift to create enough incentive to bring something like this about and, despite the optimism in today's reform climate I don't see it happening any time soon.

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