Association of decision support for hospital discharge disposition with outcomes

OBJECTIVES

To assess the association of a clinical decision support (CDS) algorithm for hospital discharge disposition with spending, readmissions, and postdischarge emergency department (ED) use.

STUDY DESIGN

A retrospective study in a cohort of fee-for-service Medicare patients 65 years or older linked to a database of patients receiving CDS.

METHODS

We evaluated (1) patients whose discharge disposition was concordant with the CDS recommendation versus those whose disposition was not and (2) patients receiving CDS for discharge disposition versus those not receiving CDS, regardless of concordance. Outcomes were spending over a 90-day episode, 90-day readmissions, and postdischarge ED utilization not associated with a readmission.

RESULTS

Analysis of concordant versus discordant cases showed decreased spending for concordant cases ($860 savings; 95% CI, $162-$1558; P = .016), a decrease in readmissions (adjusted odds ratio [OR], 0.920; 95% CI, 0.850-0.995; P = .038), and no change in rate of postdischarge ED use (adjusted OR, 0.990; 95% CI, 0.882-1.110; P = .858). Analysis of patients receiving CDS versus not receiving CDS showed no significant difference in spending ($221 savings; 95% CI, -$115 to $557; P = .198), ED use (adjusted OR, 0.959; 95% CI, 0.908-1.012; P = .128), or readmission rate (adjusted OR, 1.004; 95% CI, 0.966-1.043; P = .840).

CONCLUSIONS

Following the recommendation of a CDS algorithm for hospital discharge disposition was associated with lower spending, fewer readmissions, and no change in ED use over a 90-day episode of care.

Promoting high value inpatient care via a coaching model of structured, interdisciplinary team rounds

The professional development of early career hospital physicians may be improved by embedding an experienced physician in a coaching role during structured, interdisciplinary team rounds. This article gives a descriptive report of such a model and discusses how it may promote delivery of high-value care to adult inpatients.

The key principles and characteristics of an effective hospital medicine group: an assessment guide for hospitals and hospitalists

BACKGROUND

Despite the growth of hospital medicine, few guidelines exist to guide effective management of hospital medicine groups (HMGs).

METHODS

The Society of Hospital Medicine Board of Directors appointed a workgroup consisting of individuals who have experience with a wide array of HMG models. The workgroup developed an initial draft of characteristics, which then went through a multistep process of review and redrafting. In addition, the workgroup went through a 2-step Delphi process to consolidate characteristics and/or eliminate characteristics that were redundant or unnecessary. Over an 18-month period, a broad group of stakeholders in hospital medicine and the broader healthcare industry provided comments and feedback.

RESULTS

The final framework consists of 47 key characteristics of an effective HMG organized under 10 principles.

CONCLUSIONS

These principles and characteristics provide a framework for HMGs seeking to conduct self-assessments, outlining a pathway for improvement and better defining the central role of hospitalists in coordinating team-based, patient-centered care in the acute-care setting. They are designed to be aspirational, helping to raise the bar for the specialty of hospital medicine.

2011 John M. Eisenberg Patient Safety and Quality Awards. Mentored implementation: building leaders and achieving results through a collaborative improvement model. Innovation in patient safety and quality at the national level

BACKGROUND

The Society of Hospital Medicine (SHM) created "Mentored Implementation" (MI) programs with the dual aims of educating and mentoring hospitalists and their quality improvement (QI) teams and accelerating improvement in the inpatient setting in three signature programs: Venous Thromboembolism (VTE) Prevention, Glycemic Control, and Project BOOST (Better Outcomes for Older adults through Safe Transitions).

METHODS

More than 300 hospital improvement teams were enrolled in SHM MI programs in a series of cohorts. Hospitalist mentors worked with individual hospitals/health systems to guide local teams through the life cycle of a QI project. Implementation Guides and comprehensive Web-based "Resource Rooms," as well as the mentor's own experience, provided best-practice definitions, practical implementation tips, measurement strategies, and other tools. E-mail interactions and mentoring were augmented by regularly scheduled teleconferences; group webinars; and, in some instances, a site visit. Performance was tracked in a centralized data tracking center.

RESULTS

Preliminary data on all three MI programs show significant improvement in patient outcomes, as well as enhancements of communication and leadership skills of the hospitalists and their QI teams.

CONCLUSIONS

Although objective data on outcomes and process measures for the MI program's efficacy remain preliminary at this time, the maturing data tracking system, multiple awards, and early results indicate that the MI programs are successful in providing QI training and accelerating improvement efforts.

Organizing a hospitalist program: an overview of fundamental concepts

This article has discussed several fundamental concepts in the development and implementation of a hospitalist program. Perhaps the two most important barriers to the success of hospitalist practices are lack of buy-in from PCPs and other physicians (which is becoming much less common) and the inability to gain durable financial support from the hospital or other sponsoring entity. These issues always should be addressed before starting a program. Systems for adequate communication between hospitalists and community physicians will ensure buy-in is maintained. Unique challenges for those administering a hospitalist group include physician scheduling that balances continuity with a sustainable career track. Finally, providing leadership with a medical director increases the likelihood that operational problems are quickly managed, and that strategic planning takes place to ensure the future success of the program.

Passing the clinical baton: 6 principles to guide the hospitalist

Hospitalist systems make it increasingly common for responsibility for a patient to be passed from one physician to another. During such transfers, patients' outcomes and satisfaction can benefit from better communication between hospitalists and the primary care physicians whose patients they care for. We propose 6 principles to guide such communication, to ensure that critical information about patients is not lost and to optimize the quality of care. We also discuss special considerations for patients discharged to a skilled nursing facility or to home with home care.

Thriving and surviving in a new medical career: the case of hospitalist physicians

Managed care is cultivating a variety of new work careers within the medical profession, and it is worth asking whether they will function as long- or shorter-term career options for the individuals who participate in them. This paper uses the specific case of hospitalist physicians to explore how the surrounding social and economic work contexts contribute to two individual-level outcomes that inform the issue of career longevity: the concepts of burnout and intent to stay in the career. The findings of a national survey of hospitalists reveal that job burnout and intent to remain in the career are more meaningfully associated with favorable social relations involving colleagues, co-workers, and patients than with negative experiences related to the economically induced pressures of the job, such as reduced autonomy and the use of financial incentives. In addition, career longevity is enhanced by the extent to which individual physicians pursue intrinsic and extrinsic rewards through their choices to become hospitalists. These findings demonstrate that sociologists should pay greater attention to the career trajectories of contemporary doctors in order to understand larger scale professional stratification within medicine. They also offer empirical support for redirecting our focus towards the relational dynamics that shape these trajectories.

Passing the clinical baton: 6 principles to guide the hospitalist

Hospitalist systems make it increasingly common for responsibility for a patient to be passed from one physician to another. During such transfers, patients' outcomes and satisfaction can benefit from better communication between hospitalists and the primary care physicians whose patients they care for. We propose 6 principles to guide such communication, to ensure that critical information about patients is not lost and to optimize the quality of care. We also discuss special considerations for patients discharged to a skilled nursing facility or to home with home care.

Characteristics and work experiences of hospitalists in the United States

BACKGROUND

Little is known about the personal characteristics, work-related attitudes, or professional experiences of hospitalists. In considering the future of hospital medicine as a viable career choice for physicians (primarily, internists), these issues should be examined in a systematic fashion. Learning more about hospitalists and their work can enhance dialogue about the advantages and shortcomings of such a career from the perspective of the individual physician.

METHODS

A self-administered mail survey was sent to 820 hospitalists who are dues-paying members of the National Association of Inpatient Physicians and who spend 50% or more of their time doing clinical work, teaching, or research related to hospital medicine. Attitudes about topics such as job-related burnout and job satisfaction were tapped, as well as information about different professional and social experiences. The analyses were performed using descriptive statistics and analysis of variance techniques.

RESULTS

Analysis was based on 393 responses (48% response rate). Results show hospitalists to be a group of younger, mostly male, early-career individuals with high levels of job satisfaction and autonomy, low levels of burnout, and a long-term commitment to remaining in the role. Hospital medicine is a source of positive social and professional work experiences related to interactions with physician peers, patients and their families, and nonphysician hospital coworkers. Key components of hospitalists' jobs, practices, and workload are coalescing. However, certain developments, such as changing patterns of compensation and the enlisting of more general internists and women as hospitalists, merit further examination.

CONCLUSIONS

The results offer insight into the physicians who are becoming hospitalists, the jobs and settings in which they work, and how hospitalists experience their everyday work lives. Valuable baseline data are provided for assessment of attitudes, such as burnout, that should be examined regularly in this fledgling group. This study complements research looking at the performance-related outcomes of hospitalists, and it can be used by various stakeholders to better understand and assess the long-term potential of what is being proposed as a new career path.

Financial implications of implementing a hospitalist program

The use of hospitalists, who are physicians specializing in providing hospital inpatient care, has become increasingly popular. Preliminary data suggest that hospitalists can shorten inpatient lengths of stay and lower costs without compromising clinical outcomes or patient satisfaction. The role of hospitalists, their position in the organizational framework, and their contractual and financial relationships are influenced by the structure of the healthcare organization in which they work. Although hospitalist programs can benefit hospitals and medical groups financially, they rarely become self-supporting through professional fees alone. The long-term viability of hospitalist programs frequently will depend on the support the programs receive from whichever entity benefits from hospitalist-generated efficiencies.