Hospitalist Collaboration

Coordinating Care in Hospitalist Medicine

Hospitalist Executive Leadership Summit

December 2, 2010

Michael Wagner, MD FACPChief, Internal Medicine and Adult Primary Care

Michael Wagner MD FACP December 2010

Michael Wagner, MD FACP

Positions• Chief, Internal Medicine and Adult Primary Care, Tufts Medical Center 2008‐

present• Chief Executive Officer, EmCare Inpatient Services 2003‐8• Chief, General Internal Medicine, Tufts‐New England Medical Center 1999‐2003• Regional Medical Director, Cove Healthcare 1998‐1999• Internal Medicine Residency Program Director and Director of Medical Education,

St. Mary’s Hospital and University of Rochester 1992‐1997• Internist, New England Medical Center 1990‐1992• Chief Resident, Dartmouth‐Hitchcock Medical Center 1989‐1990• MD Georgetown University School of Medicine, 1986Current Roles• Associate Professor of Medicine, Tufts University School of Medicine• Vice Chair, institutional Review Board, Tufts Medical Center and Tufts University

Health Sciences • Physician Advisor, Information Technology Tufts Medical Center• Chair, Managed Care and Quality Committee, Tufts Medical Center Physician

Organization

Disclosures• None 2


Collaboration – Goals of presentation

• Discuss broad concept of collaboration in hospitalist medicine

• Segment collaboration into functional assessment categories

• Discuss specific areas for collaboration and coordination• Discuss specific strategies to enhance and hardwire

collaboration and coordination of care into a hospitalist program


Provisos

• Focus – Day/rounding hospitalist• Non-teaching environment


Hospitalist as a member of the team

Hospitalist

Program CoordinatorProgram Coordinator

Patient and FamilyPatient and Family

NursingNursing

Care managementCare management

Ancillary servicesPharmacyRadiology

Laboratory Respiratory

Ancillary servicesPharmacyRadiology

Laboratory Respiratory

Primary Care PhysicianPrimary Care Physician

Specialist PhysicianSpecialist Physician

Home Care ServicesHome Care ServicesRehab/LT care facilityRehab/LT care facility

Emergency MedicineEmergency Medicine


Collaboration – Case

• Dr. Smith is a new graduate from a local residency program who recently joined your hospitalist service. He came with excellent references and interviewed very well when he was recruited.

• After 3 months into working, you (as the medical director of the program) perform a focused professional practice evaluation (FPPE). You perform a chart review and review the metrics that have been collected so far. He seems to be doing well and his documentation is complete and medically appropriate. Feedback from nursing is not negative.

• When you ask around most of the staff have met him but they say they don’t know him very well.


Episode of care

Collaboration – 1st order

1st order collaboration – Interactions and work involving direct care for a specific patient

ED

Inpatient units

Post Hospital

ED MD ED RN

Primary RN Case Management

PCP PCP RN

Ancillary Consultants


Collaboration – Case continued

•When you begin your block of shifts you pick up Dr. Smith’s patients. In the process of finishing several discharges you find several inconsistencies in the medication lists between admission and the planned dc med list you have from his last note.•This prompts you to talk to the patient’s primary nurse.

“I was hoping to talk with one of you hospitalist about this patient’s med list. Dr. Smith wasn’t available and I never had the chance to talk with him the case. In fact sometimes I don’t even see him. I have to page him several times in the morning just to clarify orders he has written.”


Collaboration - Engagement

Actively disengaged

Disengaged

Engagable

Actively Engaged


Collaboration – 2nd order

• Floor nursing• Case management• Specialty physicians• ED physicians

2nd order collaboration – Interactions and relationships that are created and exist between the hospitalist and other care givers


Inpatient complexity

1500 patients

15 patients5 doctorswith busy outside practices

2000 patients

2500 patients

1800 patients


Reducing inpatient complexity

Hospitalist

Reducing complexity of the inpatient enterprise• Smaller number of “attendings”• Higher volume/attending• Lower ratio of attendings:nurse

15 patients5 doctorswith busy outside practices

15 patients1 doctor with NO outside practice



• You go and seek out Dr. Smith the next time he is on and ask him to recount his typical day:

“I usual start in the office and start my progress notes there. Igather the vital signs and labs that have returned so far. I then go to the floor and see my patients. You know there really isn’t a good place to think or write my notes so I go back to the office and finish my notes. You know it is really annoying that the nursing staff keep paging me, I think my orders are pretty clear. You know thenursing staff isn’t very good here.”

• You get the sense he is not very happy in his new role and you are not happy with his attitude.


Collaboration – 3rd order

• Emergency Department• Nurse managers• Case management department• Primary care practices

3rd order collaboration – Interactions and relationships that are created and exist between the hospitalist program and the other clinical departments and outside referring physicians.


ED physician

PATIENT

Hospitalist

• Condition• Emergent treatment• Triage

• Disease• Work up completed• Treatment initiation

InterestsPosition

• Move the patient out of the ED

• Am I the best next physician?



• The hospital administrator calls you to complain about the delays in transfers from the ED to the floors. He has gotten feedback from the ED that the hospitalists are taking forever to call back and get down to the ED for new admissions. He also states at the last FLOW committee the assigned hospitalist did not show up.


Collaboration – Best practices

• Recruit relaters• Primary nurse face to face communication• Organized daily multi-disciplinary rounds• Deal with the ED conflict issue• Virtually integrate with your referring PCPs• Develop care expectations• Leadership


Develop care expectations

• Traditional– Pneumonia– CHF– Chest pain

• Service standards– Time to see patients– Communication

• Special populations– Frail elderly– Warfarin– Poly-pharmacy– Frequent re-admissions


Collaboration – Hospital based physicians

• 1st order– Verbal communication about why you want the consult or

procedure done– Make a point to touch base if you see consultant and discuss case

face to face

• 2nd order– Introduce yourself– Interact in MD lounge – Eat lunch with someone new

• 3rd order– Participate in medical staff committees– Go to medical staff meetings– Discuss sources of frustrations with medical director


Collaboration – Power of relating

0

10

20

30

40

50

60

70

80

1 2 3 4 5 6 7 8 9 10 11 12

Dr. Specialist newOld specialist 3Old specialist 2Old specialist 1

Quarters

Num

ber o

f con

sults


Collaboration – PCPs

• 1st order– Make an attempt to call and discuss case with PCP on admission– Call PCP at time of DC– Write a concise and accurate discharge summary

• 2nd order – Go to mixers for PCP staff

• 3rd order– Get involved in IDN/ACO committees – there will be PCPs driving

this process and discussion


Collaboration – Case conclusion

• Dr. Smith is very appreciative of your feedback and specific suggestions on rounding with the primary nurse. The number of pages has decreased and he is feeling more comfortable. He agrees to participate in the Flow committee as well.


The hospitalist’s dilemma

“Bummer of a birthmark, Dr. Hal.”

Documents

Hospitalist Collaboration