The Revolution in Inpatient Care: Hospitalist Program

Mohammed Moizuddin, Quretul Quresh and Qasim Raza

Society of Hospital Medicine (SHM) defines 'Hospitalists' as physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to hospital medicine.

The term "hospitalist"¹was first introduced in 1996 by Robert M. Wachter and L Goldman to describe physicians who devote much of their professional time and focus to the care of hospitalized patients. In the most prevalent American model of hospitalist care, several doctors practice together as a group and work full-time caring for inpatients. Most of the (80%) of practicing hospitalists are board certified or eligible in internal medicine, and some (5%) have completed subspecialty fellowships. Although hospitalists first emerged in the care of adult inpatients, the field has grown rapidly in pediatrics, now accounting for nearly 10% of U.S. hospitalists². Hospitalists typically provide 24/7 inpatient coverage and thus are more readily available to a patient than a doctor who spends much of the day outside the hospital in an office or clinic setting.

Over the past decade, the United States has undergone a remarkable evolution in the way it delivers inpatient medical care. In the mid-1990s, much of American health care was dominated by a managed care paradigm, which gave incentives to control health care inflation³. Hospitalist model was uniquely well versed in evidence based practice and systems improvement. Their focus on providing clinically appropriate care, improving efficiency, reduce length of inpatient stay and helping to make the hospital system work better, without compromising patient satisfaction & outcome was big boon for its growth. Hospitalist field has now become the fastest growing specialty in the history of American medicine, approximately today close to 15,000 hospitalists practice in America, and the field is likely to grow to about 30,000 making it a larger specialty than cardiology⁴.

Hospitalist Program, St Joseph's Hospital/Marshfield Clinic

In keeping pace with nation wide trend, St. Joseph's Hospital (SJH) Marshfield Clinic, Marshfield was developed in 2000 by the General Internal Medicine Department at the request of clinic leadership. Hospitalst Program was formally launched in October 2001. SJH was pioneer and leader during the time in the Midwest. Dr Qasim Raza & Dr Mark Schwartz were instrumental in establishing a full fledged hospitalist program that has grown tremendously over the years. Dr Bill Yanke, then Chairman of Internal Medicine made into a full subdivision in October 2005 under the leadership of Dr Qasim Raza as Medical Director and Dr Mark Schwartz as Associate Program Director. Today there are 24 full-time hospitalists providing 24/7 hours inpatient medical services, including consultative services to all sub-specialists at Marshfield Center. Their job also includes surgical co-management of all orthopedic patients admitted to St. Josephs hospital.

Hospitalists typically work in shift system, and on any given day we have about 7 day time non-teaching, 2-3 academic teaching, 1 back-up, 2 evening and 1 night time hospitalist covering all medical inpatient services. St. Joseph's Hospital/Marshfield has always been able to recruit the top graduating residents from Internal Medicine Residency/Med-Peds Programs across United States as we believe this is the first step towards success of our program. Many of our hospitalists are actively involved in academic research & teaching and hold Clinical Assistant Professor rank with School of Medicine & Public Health, University of Wisconsin, Madison.

Andy Weir, Director Quality & Strategic Analysis, St. Joseph's hospital (SJH), Ministry Health places our program among the top 15 in the State of Wisconsin. SJH continues to have a lower Length of Stay (LOS) for the top 25 DRG (Diagnosis Related Group) that usually makes typical hospitalist patients. In FY 2007 we still held a 0.16 LOS advantage compared to other 14 hospitals that round up the top 15 hospitals of Wisconsin. This literally means thousands of dollars saved for the patients in todays world of skyrocketing health care costs. This was achieved without significant compromise on quality of care or patient satisfaction. We have far few readmits when compared to our peers in other hospitals of the state. This was only achieved with hard work and dedication of our hospitalist team under the able leadership of Dr Roderick Koehler, Chairman of Internal Medicine Department and full support of Marshfield Clinic Board of Directors.

Marshfield Clinic physicians work in four other hospitalist programs besides St Joseph's Hospital/Marshfield Center. Marshfield Clinic Euclaire, Minocqua & Wausau Centers have 4 full time hospitalists each. Marshfield Clinic Lake View Medical Center; Rice Lake has one full time hospitalist. This makes Marshfield Clinic almost the largest employer of Hospitalists (total of 37 today) in Wisconsin.

The Future : Hospitalists are here to stay

Proponents say Hospitalists fill a growing gap in continuity of patient care. Typically Physicians spend more time today in treating patients in their offices than at hospitals. Hospitals are traditionally getting sicker patients than ever before, and no primary are physicians are willing to take care of unassigned patients (patients with no primary care provider privileged to work in their hospital). Hospitalists are easily available 24 hours daily to take are of these acutely ill patients. Primary care physicians and sub-specialists are happy in that they can spend more time in their practices. There is no competition as Hospitalists have no out-patient practice and their patients return back for follow-up appointments. Its a win-win situation for patients and physicians. Medicare and more insurance companies have now tagged reimbursement with quality of care provided to patients. Research has proven that in-house physicians are good for hospitals goal to achieve these targets⁵.

Dr Robert Watcher in his landmark article in JAMA concluded that implementation of Hospitalist programs was associated significant reductions in resource use, usually measured as hospital costs (average decrease , 13.4%) or average LOS (average, 16.6%). All research till date has empirically proven that hospitalists improve in-patient efficiency without harmful effects on quality or patient satisfaction⁶.

Hospitalists come from diverse training backgrounds and hence SHM has started implementing a process to start early training programs for hospitalists, including residency track and fellowship programs. Current educational deficits include training in communication skills, end-of-life care, quality improvement and patient safety, medical economics, follow-up of acute post-op surgical patients. Hospitalists are slowly expanding into other roles beyond the traditional role of medical consultant ^{Table 1}.

Hospital Medicine : New Specialty

Specialists in medicine are traditionally defined by organ disease, example Cardiology; Gastroenterology, Nephrology, Radiology, Oncology, General Surgery etc. The hospitalist, on the other hand is a site defined generalist specialist similar to ER physicians. They care for acutely ill patients with wide array of organ derangements and ages in a given specific location⁷. Hospitalist co-ordinate and integrate patient care within the health delivery system and reduce the distance between office and hospital with their round of clock availability. Hospitalists already have their own Clinical Textbook⁸ and SHM is the fastest growing medical society in United States and soon plan to get credentials from ABME (American Board of Medical Specialties) to start an accredited fellowship program in Hospital Medicine.

Critical Issues Facing Hospitalists today

There is significant variation in hospitalists training level, and in the way hospitalists groups are managed. Starting a Hospitalist core curriculum in Residency Training program is the key step towards this goal. Marshfield Clinic Internal Medicine Residents already do Hospitalist Service elective rotation for one month during their post-graduate training period at SJH. Funding of hospitalist programs remains a challenge for hospital administrators. Stagnant Medicare reimbursement, rise in uninsured patients, more acutely ill patients are increasing costs, while their ability to support these costs from hospital budgets is decreasing. There is increasing diversity of hospitalists clinical and non-clinical duties, burn out myth due to ever increasing work-loads, rise in demand for hospitalists (1 available for 10 jobs!), perceived shortage may potentially compromising the efficiency and advantages of hospitalists⁹. Division between out-patient and inpatient practices continues to widen, hence it is vital to maintain connections between referring and primary care physicians. All of these may in-turn negatively impact hospiltalist and patient satisfaction¹⁰.

Respondents (patients and allied health care providers) have overwhelming positive impressions of hospitalist movement. In one survey over 76% believed that they improve Emergency Room efficiency, and 66% felt hospitalists lower costs. Interestingly majority 69% would prefer hospitalists have additional certification or training. In 2007 at least 59% and probably closer to 2/3 of California Hospitals have hospitalists. I believe its true for Wisconsin as well. Quality improvement, keeping patients satisfaction (health care customer), challenging all the above critical issues discussed will be the key to success of this hospitalist program at St. Josephs Hospital/Marshfield Clinic in future.

The impact of this revolution in Inpatient care is just beginning to be felt, and history will tell us if this is the best thing that has happened to medicine this decade. Nevertheless, hospital care will likely remain a highly pluralistic system in which organization of care is determined by efforts to improve the value of care in context to local demands and needs¹¹. I am sure everybody will agree that, method of care chosen should always be the one that promotes the best clinical outcomes and highest patient satisfaction at lowest costs. With these goals hospitalists will definitely have increasingly visible role in many institutions across the country in near future.

References

1. Watcher RM, Goldman L. The emerging role of "hospitalists" in the American health care system. N Engl J Med. 1996; 335:514-7.

2. Bellet PS and Watcher RM. The hospitalist movement and its implications for care of hospitalized children. Pediatrics 1999; 103:47377

3. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington DC: National Academy Press, 2001.

4. Niraj L Sehgal, RM Watcher The emerging role of "hospitalists" in the American health care system. Swiss Med Wkly 2006; 136:591-596

5. Hospitals & Health Network; June 2006, Vol. 80 Issue 6, p56-60, 3p

6. Watcher RM, Goldman L; JAMA January 23/30, 2002, Vol. 287, No.4

7. Watcher RM. An Introduction to the hospitalist model. Ann Intern Med. 1999-130:338-342

8. Watcher RM, Goldman L, Hollander H; Hospital Medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2^nd Edition 2005

9. Eduard E. Vasilevskis etal; California Health Foundation, July 2007 ISBN 1-933795-34-4

10. Berenson R.A., Ginsburg P.B. May J.H. Hospital-physician relations: Co-operation, competition, or separation? Health Affairs 2007; w31-w43

11. Watcher RM, Med Clin North American 86 (2002) 687-706

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