Want to showcase your new FHM or SFHM certificate in a snazzy frame? Need to stay hydrated at work? Or maybe the hospital hallways are too chilly?

SHM’s eStore has you covered with brand new merchandise, including certificate frames, branded water bottles, and zip-up hoodies with the SHM logo on the front. To browse SHM merchandise, click on “eStore”.

Want to showcase your new FHM or SFHM certificate in a snazzy frame? Need to stay hydrated at work? Or maybe the hospital hallways are too chilly?

SHM’s eStore has you covered with brand new merchandise, including certificate frames, branded water bottles, and zip-up hoodies with the SHM logo on the front. To browse SHM merchandise, click on “eStore”.

Want to showcase your new FHM or SFHM certificate in a snazzy frame? Need to stay hydrated at work? Or maybe the hospital hallways are too chilly?

SHM’s eStore has you covered with brand new merchandise, including certificate frames, branded water bottles, and zip-up hoodies with the SHM logo on the front. To browse SHM merchandise, click on “eStore”.

Jasen Gundersen, MD, MBA, CPE, SFHM, didn’t take the straightest path to HM. First, as he entered University of Connecticut School of Medicine in Farmington, he thought he’d be an emergency medicine physician. Then he thought about being a rural primary care physician. To that end, he did his residency in family medicine at UMass Memorial Medical Center in Worcester.

And yet, somehow, he became a hospitalist.

“I found that I liked spending all my time in the hospital. I could spend all my time with patients and deal with higher-acuity issues,” says Dr. Gundersen, president of TeamHealth Hospital Medicine in Fort Lauderdale, Fla. “I found that I’d rather deal with acute and more complicated [cases] in the hospital setting than work in an office setting. I like the pace of working in an acute care setting.”

The move to HM, and later to an administrative role, shocked some of his friends and colleagues. But in medical school, the nature of emergency room crises became clear: For a cardiac case, the cardiologist would take over. For a surgical issue, surgeons rolled in.

“I found that if I was going to be doing primary care for folks, which is what happens in a lot of emergency rooms, I didn’t want to do it in a quick, in-and-out setting, where you don’t really get to know the patient,” he says.

Now, Dr. Gundersen is bringing his off-the-beaten path career insights to Team Hospitalist. He’s one of six new members of the volunteer editorial advisory board of The Hospitalist.

Question: Was there a mentor who pushed you to HM?

Answer: It just kind of happened. I liked working in the hospital. I was really excited about my weeks in the hospital and when I was in the office, I was thinking about working in the hospital.

Q: How did HM help prepare you for your current position, in terms of growing and building a business?

A: It’s a rapidly growing field. The timing was perfect for me to be in the field and have a background in hospital medicine and grow in a leadership role. I think my background of knowing hospitals made it easier to be a HM leader, but along the way I had hospital leadership roles. The experience working in the hospital, as a hospitalist, touching all aspects of patient care, really set me up well for a leadership role in a hospital. That was a springboard for me, managing doctors, to step into the role I have now with TeamHealth.

Q: What do you miss most about clinical work, given that you spend most of your time now in business development?

A: The simplicity of it, compared to the complicated aspects of running a huge company. It’s nice to be able to just go in and be a doctor sometimes. You know, talk to patients about their illness, work through the systems, and just be a doc. Not thinking about fixing something and managing people.

Q: What is the best advice you’ve ever received?

A: Be honest. Always be honest. That’s be honest with yourself about what your abilities are, where your limitations are, and what your goals are and why you have them. And then be honest with all the people you work with about what you can do and can’t do. That is probably the most important thing. If you are a hospitalist and want to be a leader, be honest with yourself [about] why you want to do it. Is it because you enjoy it? Is it because you think you are going to have more time or make more money? Are you capable of handling the stress of being a leader?

Q: What is the worst piece of advice you’ve ever received?

A: I don’t know, probably because I just ignored it.

Q: Where do you see the field in five to 10 years?

A: I think the field of hospital medicine needs to be cautious of the pace [at which] we are growing, and some of the limitations and demands we have been trying to put on it. I think we need to embrace the growth and embrace what people are asking us to do. I think the role of hospitalists will get bigger and bigger. I think what has really happened is that we have transitioned into two types of physicians in general, and I think that is because of the hospitalist movement. Medical staffs will be made up of outpatient physicians and inpatient physicians.

Q: Any concerns about that growth?

A: I think we need to be cautious as we grow that we don’t overspecialize the hospital and that we realize that what has allowed us to grow is our flexibility. The ‘scope creep’ of what we cover and what we do is going to continue, and we’re going to have to work with it and seize that opportunity.

Richard Quinn is a freelance writer in New Jersey.

Jasen Gundersen, MD, MBA, CPE, SFHM, didn’t take the straightest path to HM. First, as he entered University of Connecticut School of Medicine in Farmington, he thought he’d be an emergency medicine physician. Then he thought about being a rural primary care physician. To that end, he did his residency in family medicine at UMass Memorial Medical Center in Worcester.

And yet, somehow, he became a hospitalist.

“I found that I liked spending all my time in the hospital. I could spend all my time with patients and deal with higher-acuity issues,” says Dr. Gundersen, president of TeamHealth Hospital Medicine in Fort Lauderdale, Fla. “I found that I’d rather deal with acute and more complicated [cases] in the hospital setting than work in an office setting. I like the pace of working in an acute care setting.”

The move to HM, and later to an administrative role, shocked some of his friends and colleagues. But in medical school, the nature of emergency room crises became clear: For a cardiac case, the cardiologist would take over. For a surgical issue, surgeons rolled in.

“I found that if I was going to be doing primary care for folks, which is what happens in a lot of emergency rooms, I didn’t want to do it in a quick, in-and-out setting, where you don’t really get to know the patient,” he says.

Now, Dr. Gundersen is bringing his off-the-beaten path career insights to Team Hospitalist. He’s one of six new members of the volunteer editorial advisory board of The Hospitalist.

Question: Was there a mentor who pushed you to HM?

Answer: It just kind of happened. I liked working in the hospital. I was really excited about my weeks in the hospital and when I was in the office, I was thinking about working in the hospital.

Q: How did HM help prepare you for your current position, in terms of growing and building a business?

A: It’s a rapidly growing field. The timing was perfect for me to be in the field and have a background in hospital medicine and grow in a leadership role. I think my background of knowing hospitals made it easier to be a HM leader, but along the way I had hospital leadership roles. The experience working in the hospital, as a hospitalist, touching all aspects of patient care, really set me up well for a leadership role in a hospital. That was a springboard for me, managing doctors, to step into the role I have now with TeamHealth.

Q: What do you miss most about clinical work, given that you spend most of your time now in business development?

A: The simplicity of it, compared to the complicated aspects of running a huge company. It’s nice to be able to just go in and be a doctor sometimes. You know, talk to patients about their illness, work through the systems, and just be a doc. Not thinking about fixing something and managing people.

Q: What is the best advice you’ve ever received?

A: Be honest. Always be honest. That’s be honest with yourself about what your abilities are, where your limitations are, and what your goals are and why you have them. And then be honest with all the people you work with about what you can do and can’t do. That is probably the most important thing. If you are a hospitalist and want to be a leader, be honest with yourself [about] why you want to do it. Is it because you enjoy it? Is it because you think you are going to have more time or make more money? Are you capable of handling the stress of being a leader?

Q: What is the worst piece of advice you’ve ever received?

A: I don’t know, probably because I just ignored it.

Q: Where do you see the field in five to 10 years?

A: I think the field of hospital medicine needs to be cautious of the pace [at which] we are growing, and some of the limitations and demands we have been trying to put on it. I think we need to embrace the growth and embrace what people are asking us to do. I think the role of hospitalists will get bigger and bigger. I think what has really happened is that we have transitioned into two types of physicians in general, and I think that is because of the hospitalist movement. Medical staffs will be made up of outpatient physicians and inpatient physicians.

Q: Any concerns about that growth?

A: I think we need to be cautious as we grow that we don’t overspecialize the hospital and that we realize that what has allowed us to grow is our flexibility. The ‘scope creep’ of what we cover and what we do is going to continue, and we’re going to have to work with it and seize that opportunity.

Richard Quinn is a freelance writer in New Jersey.

Jasen Gundersen, MD, MBA, CPE, SFHM, didn’t take the straightest path to HM. First, as he entered University of Connecticut School of Medicine in Farmington, he thought he’d be an emergency medicine physician. Then he thought about being a rural primary care physician. To that end, he did his residency in family medicine at UMass Memorial Medical Center in Worcester.

And yet, somehow, he became a hospitalist.

“I found that I liked spending all my time in the hospital. I could spend all my time with patients and deal with higher-acuity issues,” says Dr. Gundersen, president of TeamHealth Hospital Medicine in Fort Lauderdale, Fla. “I found that I’d rather deal with acute and more complicated [cases] in the hospital setting than work in an office setting. I like the pace of working in an acute care setting.”

The move to HM, and later to an administrative role, shocked some of his friends and colleagues. But in medical school, the nature of emergency room crises became clear: For a cardiac case, the cardiologist would take over. For a surgical issue, surgeons rolled in.

“I found that if I was going to be doing primary care for folks, which is what happens in a lot of emergency rooms, I didn’t want to do it in a quick, in-and-out setting, where you don’t really get to know the patient,” he says.

Now, Dr. Gundersen is bringing his off-the-beaten path career insights to Team Hospitalist. He’s one of six new members of the volunteer editorial advisory board of The Hospitalist.

Question: Was there a mentor who pushed you to HM?

Answer: It just kind of happened. I liked working in the hospital. I was really excited about my weeks in the hospital and when I was in the office, I was thinking about working in the hospital.

Q: How did HM help prepare you for your current position, in terms of growing and building a business?

A: It’s a rapidly growing field. The timing was perfect for me to be in the field and have a background in hospital medicine and grow in a leadership role. I think my background of knowing hospitals made it easier to be a HM leader, but along the way I had hospital leadership roles. The experience working in the hospital, as a hospitalist, touching all aspects of patient care, really set me up well for a leadership role in a hospital. That was a springboard for me, managing doctors, to step into the role I have now with TeamHealth.

Q: What do you miss most about clinical work, given that you spend most of your time now in business development?

A: The simplicity of it, compared to the complicated aspects of running a huge company. It’s nice to be able to just go in and be a doctor sometimes. You know, talk to patients about their illness, work through the systems, and just be a doc. Not thinking about fixing something and managing people.

Q: What is the best advice you’ve ever received?

A: Be honest. Always be honest. That’s be honest with yourself about what your abilities are, where your limitations are, and what your goals are and why you have them. And then be honest with all the people you work with about what you can do and can’t do. That is probably the most important thing. If you are a hospitalist and want to be a leader, be honest with yourself [about] why you want to do it. Is it because you enjoy it? Is it because you think you are going to have more time or make more money? Are you capable of handling the stress of being a leader?

Q: What is the worst piece of advice you’ve ever received?

A: I don’t know, probably because I just ignored it.

Q: Where do you see the field in five to 10 years?

A: I think the field of hospital medicine needs to be cautious of the pace [at which] we are growing, and some of the limitations and demands we have been trying to put on it. I think we need to embrace the growth and embrace what people are asking us to do. I think the role of hospitalists will get bigger and bigger. I think what has really happened is that we have transitioned into two types of physicians in general, and I think that is because of the hospitalist movement. Medical staffs will be made up of outpatient physicians and inpatient physicians.

Q: Any concerns about that growth?

A: I think we need to be cautious as we grow that we don’t overspecialize the hospital and that we realize that what has allowed us to grow is our flexibility. The ‘scope creep’ of what we cover and what we do is going to continue, and we’re going to have to work with it and seize that opportunity.

Richard Quinn is a freelance writer in New Jersey.

A team that could respond quickly to social and behavioral concerns—and not medical issues per se—would have tremendous benefits for patients and caregivers.

I think there has been a steady increase, over the last 20 years or so, in the number of very unhappy, angry, or misbehaving patients (e.g. abusive/threatening to staff). In some cases, the hospital and caregivers have failed the patient. In other cases, their frustration arises out of things outside the hospital’s direct control, such as Medicare observation status, or perhaps the patient or family is just unreasonable or suffering from a psychiatric or substance abuse disorder.

I’m not talking about the common occurrence of a disappointed patient or family who might calmly complain about something. Instead, I want to focus on those patients who, whether we perceive them as justifiably unhappy or not, are so angry that they become very time consuming and distressing to deal with. Maybe they shout about how their lawyer will be suing us and the newspaper will be writing a story about how awful we are. Or they shout and throw things, and staff become afraid of them.

In my May 2013 column, I discussed care plans for patients like this who are admitted frequently, but such plans are not sufficient in every case.

A Haphazard Approach

Most hospitals have an informal process of dealing with these patients; it starts with the bedside nurse and/or doctor trying to apologize or make adjustments to satisfy and calm the patient. If that fails, then perhaps the manager of the nursing unit gets involved. Others may be recruited, such as someone from the hospital’s risk management or “patient advocate” departments and hospital executives such as the CNO, CMO, or CEO. Sometimes several of these people may meet as a group in an effort to come up with a plan to address the situation. But, most institutions do not have a clear and consistent approach to this important work, so the hospital personnel involved end up “reinventing the wheel” each time.

The growing awareness that hospital personnel don’t seem to have a robust and confident approach to addressing this type of situation can increase a patient’s distress, and it may embolden some to become even more demanding or threatening.

And all of this takes a significant toll on bedside caregivers, who often spend so much time dealing with the angry patient that they have less time to devote to other patients, who are in turn at least a little more likely to become unhappy or suffer as a result of a distressed and busy caregiver.

A Consistent Approach: RRT for Non-Medical Distress

I think the potential benefit for patients and caregivers is significant enough that hospitals should develop a standardized approach to managing such patients, and rapid response teams (RRTs) could serve as a model. To be clear, I’m not advocating that RRTs add management of very angry or distressed patients to their current role. Let’s call it an “RRT for non-medical distress.” And, while I think it is a worthwhile idea, and I am in the early steps of trying to develop it at “my” hospital, I’m not aware of any such team in place anywhere now.

To make it practical, I think this team should be available only during weekday business hours and would comprise something like six to 10 people with clinical backgrounds who do mostly administrative work. For example, the team members could include two nursing unit directors, a risk manager, a patient advocate (or patient satisfaction “czar”), a psychiatrist, the hospitalist medical director, the chief medical officer, and a few other individuals selected for their communication skills.

One of the team members would be on call for a day or week at a time and would carry the team’s pager during business hours. Any hospital caregiver could send a page requesting the team’s assistance, and the on-call team member would respond immediately by phone or, if possible, in person. After the on-call team member’s initial assessment, the whole team would meet later the same day or early the next day. On most days, a few members of the team would be off and unable to attend the meeting. So, if the team has eight members, each meeting of the team might average about five participants.

Non-Medical Distress RRT Processes

When meeting to establish a plan for addressing an extraordinarily distressed patient/family, the team should follow a standardized written approach. A designated person should lead the conversation—perhaps the on-call team member who responded first—and another should take notes. Using a form developed for this purpose, the note-taker would capture a standardized data set that is likely to be useful in determining a course of action, as well as valuable in helping the team fine-tune its approach by reviewing trends in aggregate data. The form might include things like patient demographics; the patient’s complaints and demands; potential complicating patient issues such as substance abuse, psychoactive drugs, or psychiatric history; location in the hospital; and names of bedside caregivers. Every effort should be made to keep the meetings efficient and as brief as practical—typically 30-60 minutes.

I’m convinced that when deciding how to respond to the situation, the team should try to limit itself to choosing one or more of eight to 10 standard interventions, rather than aiming for an entirely customized response in every case. Among the standardized interventions:

• Service recovery tools, such as a handwritten apology letter;
• A meeting between the patient/family and the hospital CEO or CMO;
• Security guard(s) at the door, on “high alert” to help if called; or
• A behavioral contract specifying the expectations for both patient and hospital staff behavior.

You might think of additional “tools” this team could have in their standardized response set.

Why limit the team as much as possible to a small set of standardized interventions? Developing customized responses in each situation is time consuming and, arguably, has a higher risk of failure, since it will be difficult to ensure that all staff caring for the patient can understand and execute them effectively. And the small set of interventions will make it easier to track their effectiveness over multiple patients so that the whole process can be improved over time.

Set a High Bar

The team should not be activated for every unhappy or difficult patient; that would be overkill and would result in many activations requiring dedicated staff with no other duties to serve on the team each day. Instead, I think the team should be activated only for the most difficult and distressing cases, at least for the first few years. In a 300-bed hospital, this would be approximately one to 1.5 activations per week.

Bedside caregivers would likely feel some reassurance knowing that they can reliably get help managing the most difficult patients, and, if the plan is executed well, these patients may get care that is safer for both themselves and staff. Who knows, medical outcomes might be improved for these patients also.

A team that could respond quickly to social and behavioral concerns—and not medical issues per se—would have tremendous benefits for patients and caregivers.

I think there has been a steady increase, over the last 20 years or so, in the number of very unhappy, angry, or misbehaving patients (e.g. abusive/threatening to staff). In some cases, the hospital and caregivers have failed the patient. In other cases, their frustration arises out of things outside the hospital’s direct control, such as Medicare observation status, or perhaps the patient or family is just unreasonable or suffering from a psychiatric or substance abuse disorder.

I’m not talking about the common occurrence of a disappointed patient or family who might calmly complain about something. Instead, I want to focus on those patients who, whether we perceive them as justifiably unhappy or not, are so angry that they become very time consuming and distressing to deal with. Maybe they shout about how their lawyer will be suing us and the newspaper will be writing a story about how awful we are. Or they shout and throw things, and staff become afraid of them.

In my May 2013 column, I discussed care plans for patients like this who are admitted frequently, but such plans are not sufficient in every case.

A Haphazard Approach

Most hospitals have an informal process of dealing with these patients; it starts with the bedside nurse and/or doctor trying to apologize or make adjustments to satisfy and calm the patient. If that fails, then perhaps the manager of the nursing unit gets involved. Others may be recruited, such as someone from the hospital’s risk management or “patient advocate” departments and hospital executives such as the CNO, CMO, or CEO. Sometimes several of these people may meet as a group in an effort to come up with a plan to address the situation. But, most institutions do not have a clear and consistent approach to this important work, so the hospital personnel involved end up “reinventing the wheel” each time.

The growing awareness that hospital personnel don’t seem to have a robust and confident approach to addressing this type of situation can increase a patient’s distress, and it may embolden some to become even more demanding or threatening.

And all of this takes a significant toll on bedside caregivers, who often spend so much time dealing with the angry patient that they have less time to devote to other patients, who are in turn at least a little more likely to become unhappy or suffer as a result of a distressed and busy caregiver.

A Consistent Approach: RRT for Non-Medical Distress

I think the potential benefit for patients and caregivers is significant enough that hospitals should develop a standardized approach to managing such patients, and rapid response teams (RRTs) could serve as a model. To be clear, I’m not advocating that RRTs add management of very angry or distressed patients to their current role. Let’s call it an “RRT for non-medical distress.” And, while I think it is a worthwhile idea, and I am in the early steps of trying to develop it at “my” hospital, I’m not aware of any such team in place anywhere now.

To make it practical, I think this team should be available only during weekday business hours and would comprise something like six to 10 people with clinical backgrounds who do mostly administrative work. For example, the team members could include two nursing unit directors, a risk manager, a patient advocate (or patient satisfaction “czar”), a psychiatrist, the hospitalist medical director, the chief medical officer, and a few other individuals selected for their communication skills.

One of the team members would be on call for a day or week at a time and would carry the team’s pager during business hours. Any hospital caregiver could send a page requesting the team’s assistance, and the on-call team member would respond immediately by phone or, if possible, in person. After the on-call team member’s initial assessment, the whole team would meet later the same day or early the next day. On most days, a few members of the team would be off and unable to attend the meeting. So, if the team has eight members, each meeting of the team might average about five participants.

Non-Medical Distress RRT Processes

When meeting to establish a plan for addressing an extraordinarily distressed patient/family, the team should follow a standardized written approach. A designated person should lead the conversation—perhaps the on-call team member who responded first—and another should take notes. Using a form developed for this purpose, the note-taker would capture a standardized data set that is likely to be useful in determining a course of action, as well as valuable in helping the team fine-tune its approach by reviewing trends in aggregate data. The form might include things like patient demographics; the patient’s complaints and demands; potential complicating patient issues such as substance abuse, psychoactive drugs, or psychiatric history; location in the hospital; and names of bedside caregivers. Every effort should be made to keep the meetings efficient and as brief as practical—typically 30-60 minutes.

I’m convinced that when deciding how to respond to the situation, the team should try to limit itself to choosing one or more of eight to 10 standard interventions, rather than aiming for an entirely customized response in every case. Among the standardized interventions:

• Service recovery tools, such as a handwritten apology letter;
• A meeting between the patient/family and the hospital CEO or CMO;
• Security guard(s) at the door, on “high alert” to help if called; or
• A behavioral contract specifying the expectations for both patient and hospital staff behavior.

You might think of additional “tools” this team could have in their standardized response set.

Why limit the team as much as possible to a small set of standardized interventions? Developing customized responses in each situation is time consuming and, arguably, has a higher risk of failure, since it will be difficult to ensure that all staff caring for the patient can understand and execute them effectively. And the small set of interventions will make it easier to track their effectiveness over multiple patients so that the whole process can be improved over time.

Set a High Bar

The team should not be activated for every unhappy or difficult patient; that would be overkill and would result in many activations requiring dedicated staff with no other duties to serve on the team each day. Instead, I think the team should be activated only for the most difficult and distressing cases, at least for the first few years. In a 300-bed hospital, this would be approximately one to 1.5 activations per week.

Bedside caregivers would likely feel some reassurance knowing that they can reliably get help managing the most difficult patients, and, if the plan is executed well, these patients may get care that is safer for both themselves and staff. Who knows, medical outcomes might be improved for these patients also.

A team that could respond quickly to social and behavioral concerns—and not medical issues per se—would have tremendous benefits for patients and caregivers.

I think there has been a steady increase, over the last 20 years or so, in the number of very unhappy, angry, or misbehaving patients (e.g. abusive/threatening to staff). In some cases, the hospital and caregivers have failed the patient. In other cases, their frustration arises out of things outside the hospital’s direct control, such as Medicare observation status, or perhaps the patient or family is just unreasonable or suffering from a psychiatric or substance abuse disorder.

I’m not talking about the common occurrence of a disappointed patient or family who might calmly complain about something. Instead, I want to focus on those patients who, whether we perceive them as justifiably unhappy or not, are so angry that they become very time consuming and distressing to deal with. Maybe they shout about how their lawyer will be suing us and the newspaper will be writing a story about how awful we are. Or they shout and throw things, and staff become afraid of them.

In my May 2013 column, I discussed care plans for patients like this who are admitted frequently, but such plans are not sufficient in every case.

A Haphazard Approach

Most hospitals have an informal process of dealing with these patients; it starts with the bedside nurse and/or doctor trying to apologize or make adjustments to satisfy and calm the patient. If that fails, then perhaps the manager of the nursing unit gets involved. Others may be recruited, such as someone from the hospital’s risk management or “patient advocate” departments and hospital executives such as the CNO, CMO, or CEO. Sometimes several of these people may meet as a group in an effort to come up with a plan to address the situation. But, most institutions do not have a clear and consistent approach to this important work, so the hospital personnel involved end up “reinventing the wheel” each time.

The growing awareness that hospital personnel don’t seem to have a robust and confident approach to addressing this type of situation can increase a patient’s distress, and it may embolden some to become even more demanding or threatening.

And all of this takes a significant toll on bedside caregivers, who often spend so much time dealing with the angry patient that they have less time to devote to other patients, who are in turn at least a little more likely to become unhappy or suffer as a result of a distressed and busy caregiver.

A Consistent Approach: RRT for Non-Medical Distress

I think the potential benefit for patients and caregivers is significant enough that hospitals should develop a standardized approach to managing such patients, and rapid response teams (RRTs) could serve as a model. To be clear, I’m not advocating that RRTs add management of very angry or distressed patients to their current role. Let’s call it an “RRT for non-medical distress.” And, while I think it is a worthwhile idea, and I am in the early steps of trying to develop it at “my” hospital, I’m not aware of any such team in place anywhere now.

To make it practical, I think this team should be available only during weekday business hours and would comprise something like six to 10 people with clinical backgrounds who do mostly administrative work. For example, the team members could include two nursing unit directors, a risk manager, a patient advocate (or patient satisfaction “czar”), a psychiatrist, the hospitalist medical director, the chief medical officer, and a few other individuals selected for their communication skills.

One of the team members would be on call for a day or week at a time and would carry the team’s pager during business hours. Any hospital caregiver could send a page requesting the team’s assistance, and the on-call team member would respond immediately by phone or, if possible, in person. After the on-call team member’s initial assessment, the whole team would meet later the same day or early the next day. On most days, a few members of the team would be off and unable to attend the meeting. So, if the team has eight members, each meeting of the team might average about five participants.

Non-Medical Distress RRT Processes

When meeting to establish a plan for addressing an extraordinarily distressed patient/family, the team should follow a standardized written approach. A designated person should lead the conversation—perhaps the on-call team member who responded first—and another should take notes. Using a form developed for this purpose, the note-taker would capture a standardized data set that is likely to be useful in determining a course of action, as well as valuable in helping the team fine-tune its approach by reviewing trends in aggregate data. The form might include things like patient demographics; the patient’s complaints and demands; potential complicating patient issues such as substance abuse, psychoactive drugs, or psychiatric history; location in the hospital; and names of bedside caregivers. Every effort should be made to keep the meetings efficient and as brief as practical—typically 30-60 minutes.

I’m convinced that when deciding how to respond to the situation, the team should try to limit itself to choosing one or more of eight to 10 standard interventions, rather than aiming for an entirely customized response in every case. Among the standardized interventions:

• Service recovery tools, such as a handwritten apology letter;
• A meeting between the patient/family and the hospital CEO or CMO;
• Security guard(s) at the door, on “high alert” to help if called; or
• A behavioral contract specifying the expectations for both patient and hospital staff behavior.

You might think of additional “tools” this team could have in their standardized response set.

Why limit the team as much as possible to a small set of standardized interventions? Developing customized responses in each situation is time consuming and, arguably, has a higher risk of failure, since it will be difficult to ensure that all staff caring for the patient can understand and execute them effectively. And the small set of interventions will make it easier to track their effectiveness over multiple patients so that the whole process can be improved over time.

Set a High Bar

The team should not be activated for every unhappy or difficult patient; that would be overkill and would result in many activations requiring dedicated staff with no other duties to serve on the team each day. Instead, I think the team should be activated only for the most difficult and distressing cases, at least for the first few years. In a 300-bed hospital, this would be approximately one to 1.5 activations per week.

Bedside caregivers would likely feel some reassurance knowing that they can reliably get help managing the most difficult patients, and, if the plan is executed well, these patients may get care that is safer for both themselves and staff. Who knows, medical outcomes might be improved for these patients also.

Phuoc Le, MD, MPH, was born a year after the Vietnam War ended and was five when he and his family fled Vietnam by boat to seek asylum in Hong Kong. At a refugee camp there, he had his first contact with a functional public health system and, within days, was cured of the parasitic disease that had made him ill since he was a toddler. Later, as an undergraduate at Dartmouth College in Hanover, N.H., he realized he had been one of the health disparity victims described by medical anthropologist Paul E. Farmer, PhD, MD, in his books.

“For the vast majority of people, it doesn’t turn out the way it did for me,” says Dr. Le. “As much as I’ve been blessed with, what I expect of myself is to focus on health disparities and have it be my life’s work.”

Dr. Le’s personal mission led him to co-found the Global Health Core within the division of hospital medicine at the University of California San Francisco, which aims to train hospitalists to work in resource-poor settings. The program recently was honored with the 2015 SHM Award for Excellence in Humanitarian Service.

Dr. Le, assistant professor of medicine and pediatrics at the University of California San Francisco (UCSF), where he co-directs the Global Health-Hospital Medicine Fellowship, recently spoke with The Hospitalist about his work.

Question: What was your first trip as a physician abroad like?

Answer: I was a resident at Harvard [University in Cambridge, Mass.] in 2007 when I went to Haiti with Paul Farmer and a few other residents involved in the [nonprofit] Partners in Health. I’ll never forget that the trip from Port-au-Prince to the hospital was only about 120 miles, and it took eight hours in a four-wheel drive vehicle to get there. They didn’t want us residents to suffer that trip, so they got a bunch of volunteer pilots to fly us in a single-engine plane, which took about 20 minutes.

We got there, had lunch and dinner, and it was during dinner that the group coming by vehicle finally arrived. It just dawned on me. These are things you don’t have a visceral feeling for until you see them. These people were tired because they had driven all day. What if I had been a patient and had to travel 120 miles and was sick? Would I have lasted eight hours to go that small distance?

This is just one example of many structural problems that need to be addressed. The same conditions are impeding the progress in [controlling] Ebola in West Africa. I was there in November. The problems that led to [the] Ebola [outbreak] were absolutely predictable and avoidable if the global community had paid more attention to this injustice before Ebola started—or responded much earlier. It could have saved lives [and] money, and we probably wouldn’t have had the huge scare in the U.S. that we did.

Q: What compelled you to go to Liberia just as the Ebola outbreak began?

A: To me, there was no question in my mind that I needed to go. It was a situation where I had the expertise. I’m a physician, a public health expert, [I’ve] worked in places with tropical diseases and have experience responding to emergencies like the cholera epidemic in Haiti and the Haiti earthquake. We also had a relationship with an NGO [non-governmental organization] in Liberia for several years. My colleagues and I at UCSF started the nation’s first global health hospital medicine fellowship, and our fellows had been going to Liberia for the last three years. For us, it was a matter of solidarity.

Q: You trained at the CDC prior to your trip. How did that training prepare you?

A: During those three days at the CDC, we were taught how to put on and take off personal protective equipment every day, and so we understood how difficult it was, especially in searing heat. It is very challenging, and we were able to teach those skills in Liberia.

Q: In a paper recently published in the Journal of Hospital Medicine, you call on hospitalists to join the ranks of global health hospitalists. Can you explain?

A: Whether it’s Navajo Nation in Arizona or rural Haiti, the healthcare needs of the poor are very similar. Global health hospitalists play an important role in capacity building, running a health system, improving quality while reducing costs, working in teams to provide holistic care for the inpatient, and improving transitions to the outpatient setting.

Q: How do the skills learned in resource-poor settings apply back home?

A: Let’s say you have a patient with tuberculosis, which is very common in places like Liberia, and you suspect fluid in the lungs. [In Liberia], you would insert a needle and remove the fluid. In the U.S., a lot of providers would not be able to remove the fluid without getting an ultrasound and multiple other studies. Those costs add up. Global health hospitalists are very well versed in the skills of ultrasonography because there are no ultrasonographers in the field working with us.

Q: You said it was in Haiti where you began to notice volunteers arriving with good intentions but without needed skills. What exactly did you learn?

A: I spent a lot of time there, responding to the earthquake and also the cholera epidemic in 2010. I came across dozens of healthcare volunteers who had passion and commitment but really came ill prepared, not through any fault of their own, but because they never had an opportunity to learn the skills needed to be effective in the field. For example, take a nurse from an ivory tower hospital and suddenly put her where she doesn’t have IVs to work with or the right type of fluids or tubing. Well, suddenly she feels like her efficacy has gone way down. That could easily lead to a lot of frustration and potential burnout.

Stephanie Mackiewicz is a freelance writer in Los Angeles.

Phuoc Le, MD, MPH, was born a year after the Vietnam War ended and was five when he and his family fled Vietnam by boat to seek asylum in Hong Kong. At a refugee camp there, he had his first contact with a functional public health system and, within days, was cured of the parasitic disease that had made him ill since he was a toddler. Later, as an undergraduate at Dartmouth College in Hanover, N.H., he realized he had been one of the health disparity victims described by medical anthropologist Paul E. Farmer, PhD, MD, in his books.

“For the vast majority of people, it doesn’t turn out the way it did for me,” says Dr. Le. “As much as I’ve been blessed with, what I expect of myself is to focus on health disparities and have it be my life’s work.”

Dr. Le’s personal mission led him to co-found the Global Health Core within the division of hospital medicine at the University of California San Francisco, which aims to train hospitalists to work in resource-poor settings. The program recently was honored with the 2015 SHM Award for Excellence in Humanitarian Service.

Dr. Le, assistant professor of medicine and pediatrics at the University of California San Francisco (UCSF), where he co-directs the Global Health-Hospital Medicine Fellowship, recently spoke with The Hospitalist about his work.

Question: What was your first trip as a physician abroad like?

Answer: I was a resident at Harvard [University in Cambridge, Mass.] in 2007 when I went to Haiti with Paul Farmer and a few other residents involved in the [nonprofit] Partners in Health. I’ll never forget that the trip from Port-au-Prince to the hospital was only about 120 miles, and it took eight hours in a four-wheel drive vehicle to get there. They didn’t want us residents to suffer that trip, so they got a bunch of volunteer pilots to fly us in a single-engine plane, which took about 20 minutes.

We got there, had lunch and dinner, and it was during dinner that the group coming by vehicle finally arrived. It just dawned on me. These are things you don’t have a visceral feeling for until you see them. These people were tired because they had driven all day. What if I had been a patient and had to travel 120 miles and was sick? Would I have lasted eight hours to go that small distance?

This is just one example of many structural problems that need to be addressed. The same conditions are impeding the progress in [controlling] Ebola in West Africa. I was there in November. The problems that led to [the] Ebola [outbreak] were absolutely predictable and avoidable if the global community had paid more attention to this injustice before Ebola started—or responded much earlier. It could have saved lives [and] money, and we probably wouldn’t have had the huge scare in the U.S. that we did.

Q: What compelled you to go to Liberia just as the Ebola outbreak began?

A: To me, there was no question in my mind that I needed to go. It was a situation where I had the expertise. I’m a physician, a public health expert, [I’ve] worked in places with tropical diseases and have experience responding to emergencies like the cholera epidemic in Haiti and the Haiti earthquake. We also had a relationship with an NGO [non-governmental organization] in Liberia for several years. My colleagues and I at UCSF started the nation’s first global health hospital medicine fellowship, and our fellows had been going to Liberia for the last three years. For us, it was a matter of solidarity.

Q: You trained at the CDC prior to your trip. How did that training prepare you?

A: During those three days at the CDC, we were taught how to put on and take off personal protective equipment every day, and so we understood how difficult it was, especially in searing heat. It is very challenging, and we were able to teach those skills in Liberia.

Q: In a paper recently published in the Journal of Hospital Medicine, you call on hospitalists to join the ranks of global health hospitalists. Can you explain?

A: Whether it’s Navajo Nation in Arizona or rural Haiti, the healthcare needs of the poor are very similar. Global health hospitalists play an important role in capacity building, running a health system, improving quality while reducing costs, working in teams to provide holistic care for the inpatient, and improving transitions to the outpatient setting.

Q: How do the skills learned in resource-poor settings apply back home?

A: Let’s say you have a patient with tuberculosis, which is very common in places like Liberia, and you suspect fluid in the lungs. [In Liberia], you would insert a needle and remove the fluid. In the U.S., a lot of providers would not be able to remove the fluid without getting an ultrasound and multiple other studies. Those costs add up. Global health hospitalists are very well versed in the skills of ultrasonography because there are no ultrasonographers in the field working with us.

Q: You said it was in Haiti where you began to notice volunteers arriving with good intentions but without needed skills. What exactly did you learn?

A: I spent a lot of time there, responding to the earthquake and also the cholera epidemic in 2010. I came across dozens of healthcare volunteers who had passion and commitment but really came ill prepared, not through any fault of their own, but because they never had an opportunity to learn the skills needed to be effective in the field. For example, take a nurse from an ivory tower hospital and suddenly put her where she doesn’t have IVs to work with or the right type of fluids or tubing. Well, suddenly she feels like her efficacy has gone way down. That could easily lead to a lot of frustration and potential burnout.

Stephanie Mackiewicz is a freelance writer in Los Angeles.

Phuoc Le, MD, MPH, was born a year after the Vietnam War ended and was five when he and his family fled Vietnam by boat to seek asylum in Hong Kong. At a refugee camp there, he had his first contact with a functional public health system and, within days, was cured of the parasitic disease that had made him ill since he was a toddler. Later, as an undergraduate at Dartmouth College in Hanover, N.H., he realized he had been one of the health disparity victims described by medical anthropologist Paul E. Farmer, PhD, MD, in his books.

“For the vast majority of people, it doesn’t turn out the way it did for me,” says Dr. Le. “As much as I’ve been blessed with, what I expect of myself is to focus on health disparities and have it be my life’s work.”

Dr. Le’s personal mission led him to co-found the Global Health Core within the division of hospital medicine at the University of California San Francisco, which aims to train hospitalists to work in resource-poor settings. The program recently was honored with the 2015 SHM Award for Excellence in Humanitarian Service.

Dr. Le, assistant professor of medicine and pediatrics at the University of California San Francisco (UCSF), where he co-directs the Global Health-Hospital Medicine Fellowship, recently spoke with The Hospitalist about his work.

Question: What was your first trip as a physician abroad like?

Answer: I was a resident at Harvard [University in Cambridge, Mass.] in 2007 when I went to Haiti with Paul Farmer and a few other residents involved in the [nonprofit] Partners in Health. I’ll never forget that the trip from Port-au-Prince to the hospital was only about 120 miles, and it took eight hours in a four-wheel drive vehicle to get there. They didn’t want us residents to suffer that trip, so they got a bunch of volunteer pilots to fly us in a single-engine plane, which took about 20 minutes.

We got there, had lunch and dinner, and it was during dinner that the group coming by vehicle finally arrived. It just dawned on me. These are things you don’t have a visceral feeling for until you see them. These people were tired because they had driven all day. What if I had been a patient and had to travel 120 miles and was sick? Would I have lasted eight hours to go that small distance?

This is just one example of many structural problems that need to be addressed. The same conditions are impeding the progress in [controlling] Ebola in West Africa. I was there in November. The problems that led to [the] Ebola [outbreak] were absolutely predictable and avoidable if the global community had paid more attention to this injustice before Ebola started—or responded much earlier. It could have saved lives [and] money, and we probably wouldn’t have had the huge scare in the U.S. that we did.

Q: What compelled you to go to Liberia just as the Ebola outbreak began?

A: To me, there was no question in my mind that I needed to go. It was a situation where I had the expertise. I’m a physician, a public health expert, [I’ve] worked in places with tropical diseases and have experience responding to emergencies like the cholera epidemic in Haiti and the Haiti earthquake. We also had a relationship with an NGO [non-governmental organization] in Liberia for several years. My colleagues and I at UCSF started the nation’s first global health hospital medicine fellowship, and our fellows had been going to Liberia for the last three years. For us, it was a matter of solidarity.

Q: You trained at the CDC prior to your trip. How did that training prepare you?

A: During those three days at the CDC, we were taught how to put on and take off personal protective equipment every day, and so we understood how difficult it was, especially in searing heat. It is very challenging, and we were able to teach those skills in Liberia.

Q: In a paper recently published in the Journal of Hospital Medicine, you call on hospitalists to join the ranks of global health hospitalists. Can you explain?

A: Whether it’s Navajo Nation in Arizona or rural Haiti, the healthcare needs of the poor are very similar. Global health hospitalists play an important role in capacity building, running a health system, improving quality while reducing costs, working in teams to provide holistic care for the inpatient, and improving transitions to the outpatient setting.

Q: How do the skills learned in resource-poor settings apply back home?

A: Let’s say you have a patient with tuberculosis, which is very common in places like Liberia, and you suspect fluid in the lungs. [In Liberia], you would insert a needle and remove the fluid. In the U.S., a lot of providers would not be able to remove the fluid without getting an ultrasound and multiple other studies. Those costs add up. Global health hospitalists are very well versed in the skills of ultrasonography because there are no ultrasonographers in the field working with us.

Q: You said it was in Haiti where you began to notice volunteers arriving with good intentions but without needed skills. What exactly did you learn?

A: I spent a lot of time there, responding to the earthquake and also the cholera epidemic in 2010. I came across dozens of healthcare volunteers who had passion and commitment but really came ill prepared, not through any fault of their own, but because they never had an opportunity to learn the skills needed to be effective in the field. For example, take a nurse from an ivory tower hospital and suddenly put her where she doesn’t have IVs to work with or the right type of fluids or tubing. Well, suddenly she feels like her efficacy has gone way down. That could easily lead to a lot of frustration and potential burnout.

Stephanie Mackiewicz is a freelance writer in Los Angeles.

Hospital medicine leaders have long acknowledged the disconnects in medical care that occur at discharge. The demand for greater efficiency in hospital-based care is what has driven the hospitalist movement and its inexorable growth the past two decades.

Efforts to overcome discontinuity of care have included more timely discharge summaries, phone calls to primary care physicians (PCPs) and specialists at the time of discharge, and hospitalist-staffed post-discharge clinics. In a 2002 article, Robert Wachter, MD, MHM, and Steven Pantilat, MD, SFHM, of the University of California San Francisco (UCSF), suggested that PCPs make continuity visits to the hospital once or twice to maintain their involvement and help coordinate the care of their patients.¹

A new “Perspectives” piece in The New England Journal of Medicine proposes that PCPs act as medical consultants to the hospitalist team while their patients are in the hospital, making a consulting visit “within 12 to 18 hours after admission to provide support and continuity to them and their families.”² Authors Allan Goroll, MD, MACP, and Daniel Hunt, MD, propose that the PCP be asked to write a succinct consultation note in the hospital chart, highlighting key elements of the patient’s history and recent tests—with the goal of complementing and informing the hospitalist’s admission workup and care plan—while being paid as a consultant.

“It’s a fairly straightforward proposal,” says Dr. Hunt, chief of the hospital medicine unit at Massachusetts General Hospital (MGH) in Boston. “We’re not looking for PCPs to take care of every aspect of inpatient care. It’s really just to bring in the PCP’s expertise and nuanced understanding of the patient at a vulnerable time for the patient.”

The idea might seem a little ironic given the fact that hospitalists were created in part to relieve busy PCPs from having to visit the hospital. But some see it as a way forward.

“I wouldn’t call it a step backward,” says Joseph Ming Wah Li, MD, SFHM, FACP, director of the hospital medicine program at Beth Israel Deaconess Medical Center (BIDMC) in Boston and a former SHM president. “Is it feasible? Realistically, in most settings today, I don’t think it is. But I would love it. I don’t really know enough about the patients I take care of in the hospital.”

The Barrier of “Not Enough Time”

Dr. Hunt says the biggest barrier to this proposal is the time that PCPs would have to carve out to make physical trips to the hospital.

“That ultimately comes down to reimbursement,” he says.

MGH, which is well situated with medical practices in or near the main hospital building, has piloted an approach similar to the NEJM proposal with a primary care group that comes in to see its patients in the first day or two after admission and then again on the day before discharge.

“We made a commitment, as hospitalists, to communicate directly by phone with the PCPs. That commitment lasted about a week, and then we quickly converted to a daily e-mail. That works, because both parties are communicating substantial information in these e-mails.”–Dr. Hunt

“But they are essentially doing it out of the goodness of their hearts,” Dr. Hunt explains. “What we’ve seen from this experiment are much better transitions of care and much better decision making around big decisions, such as end-of-life care or surgical interventions.”

Hospitalists at MGH and the PCPs spent a year and a half talking through the specifics of how their arrangement would work.

“We made a commitment, as hospitalists, to communicate directly by phone with the PCPs,” he says. “That commitment lasted about a week, and then we quickly converted to a daily e-mail. That works, because both parties are communicating substantial information in these e-mails.”

Dr. Hunt says the key is recognizing the “huge” value PCPs bring to an inpatient stay. And, while physical trips to the hospital or e-mails might not work for every hospitalist or PCP, the connecting of information and insight is often worth the investment.

“There are other ways [to communicate], such as video conferencing and Skype, where doctors could participate more efficiently in the care of their hospitalized patients,” he says, adding that hospitalists should reach out to PCPs, both when a patient enters the hospital and as part of a larger discussion about how to improve communication and continuity of care.

The PCP Perspective

Boston internist Gila Kriegel, MD, might seem like a throwback. She says she wants to visit her patients when they are in the hospital, if at all possible. In fact, hospitalists in Boston say Dr. Kriegel allows them to take care of her patients “almost begrudgingly.”

“She is so involved in their care,” Dr. Li says. “She tells me everything I need to know about them. She’d be here every day if she weren’t juggling other responsibilities.”

A PCP since 1986, Dr. Kriegel’s story illustrates the complexities of an evolving healthcare system. She’s based in an academic setting, which she calls a “kind of ivory tower.”

“But I was fortunate in 1989, after my first son was born and I went part-time, to have a colleague who offered to see my inpatients on the days I wasn’t working,” she explains. “Then a woman colleague of mine also went part-time, and we agreed to cross-cover for each other.”

Eventually, Dr. Kriegel was approached by Dr. Li’s hospitalist group, which offered to manage her hospitalized patients.

“For the first six months to a year, I’d go see my patients in the hospital on a social visit. I’d even write notes in the chart, until they told me, ‘You are not responsible for the care in the hospital. The hospitalist is,’” she recalls. “For me, it was a big loss to stop going to the hospital. Most PCPs I know like seeing their patients through the course of the illness.”

Then again, she also admits how difficult it is to see her patients in the hospital.

Still, she managed to stay connected. “When I stopped going to see my patients, I asked the hospital staff to give me the patient’s bedside phone number, and I’d call them in the hospital to let them know I was up on what was happening,” she says.

Technology, coincidentally, inserted a barrier: She wasn’t able to access hospitalists’ daily notes in the BIDMC electronic health records. That’s when Dr. Kriegel began e-mailing the hospitalists. In the end, even that form of communication wasn’t fully satisfying.

“The current system requires me to do the outreach,” she explains. “If you ask hospitalists about communication, they’d say they’re already doing it. But a discharge summary isn’t the same as knowing in real time what’s happening with my patients.”

“I’d love to make virtual visits to the patient in the hospital, by phone or computer link—even more so if I could get paid for my time. But I want to stay involved.”

Ripe for Innovation

Dr. Wachter, chief of hospital medicine at UCSF, who writes an HM-focused blog [wachtersworld.com], says the continuity visit is a good idea but also understands the difficulties in the new healthcare paradigm.

“It’s not easy to work out the logistics, and it depends on the geography,” he says. “We also need to be considering telemedicine. But something to enhance continuity is ripe for innovation.”

He says consultation or continuity visits offer ways to improve care with a relatively small expenditure.

“We still see a few PCPs come in when their patients are hospitalized. It’s very reassuring to their patients,” he says. “For the complicated cases where an ongoing relationship matters, those encounters are fabulous.”

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Goroll AH, Hunt DP. Bridging the hospitalist-primary care divide through collaborative care. New Engl J Med. 2015;372(4):308-309.
2. Wachter RM, Pantilat SZ. The “continuity visit” and the hospitalist model of care. Dis Mon. 2002;48(4):267-272.

Hospital medicine leaders have long acknowledged the disconnects in medical care that occur at discharge. The demand for greater efficiency in hospital-based care is what has driven the hospitalist movement and its inexorable growth the past two decades.

Efforts to overcome discontinuity of care have included more timely discharge summaries, phone calls to primary care physicians (PCPs) and specialists at the time of discharge, and hospitalist-staffed post-discharge clinics. In a 2002 article, Robert Wachter, MD, MHM, and Steven Pantilat, MD, SFHM, of the University of California San Francisco (UCSF), suggested that PCPs make continuity visits to the hospital once or twice to maintain their involvement and help coordinate the care of their patients.¹

A new “Perspectives” piece in The New England Journal of Medicine proposes that PCPs act as medical consultants to the hospitalist team while their patients are in the hospital, making a consulting visit “within 12 to 18 hours after admission to provide support and continuity to them and their families.”² Authors Allan Goroll, MD, MACP, and Daniel Hunt, MD, propose that the PCP be asked to write a succinct consultation note in the hospital chart, highlighting key elements of the patient’s history and recent tests—with the goal of complementing and informing the hospitalist’s admission workup and care plan—while being paid as a consultant.

“It’s a fairly straightforward proposal,” says Dr. Hunt, chief of the hospital medicine unit at Massachusetts General Hospital (MGH) in Boston. “We’re not looking for PCPs to take care of every aspect of inpatient care. It’s really just to bring in the PCP’s expertise and nuanced understanding of the patient at a vulnerable time for the patient.”

The idea might seem a little ironic given the fact that hospitalists were created in part to relieve busy PCPs from having to visit the hospital. But some see it as a way forward.

“I wouldn’t call it a step backward,” says Joseph Ming Wah Li, MD, SFHM, FACP, director of the hospital medicine program at Beth Israel Deaconess Medical Center (BIDMC) in Boston and a former SHM president. “Is it feasible? Realistically, in most settings today, I don’t think it is. But I would love it. I don’t really know enough about the patients I take care of in the hospital.”

The Barrier of “Not Enough Time”

Dr. Hunt says the biggest barrier to this proposal is the time that PCPs would have to carve out to make physical trips to the hospital.

“That ultimately comes down to reimbursement,” he says.

MGH, which is well situated with medical practices in or near the main hospital building, has piloted an approach similar to the NEJM proposal with a primary care group that comes in to see its patients in the first day or two after admission and then again on the day before discharge.

“We made a commitment, as hospitalists, to communicate directly by phone with the PCPs. That commitment lasted about a week, and then we quickly converted to a daily e-mail. That works, because both parties are communicating substantial information in these e-mails.”–Dr. Hunt

“But they are essentially doing it out of the goodness of their hearts,” Dr. Hunt explains. “What we’ve seen from this experiment are much better transitions of care and much better decision making around big decisions, such as end-of-life care or surgical interventions.”

Hospitalists at MGH and the PCPs spent a year and a half talking through the specifics of how their arrangement would work.

“We made a commitment, as hospitalists, to communicate directly by phone with the PCPs,” he says. “That commitment lasted about a week, and then we quickly converted to a daily e-mail. That works, because both parties are communicating substantial information in these e-mails.”

Dr. Hunt says the key is recognizing the “huge” value PCPs bring to an inpatient stay. And, while physical trips to the hospital or e-mails might not work for every hospitalist or PCP, the connecting of information and insight is often worth the investment.

“There are other ways [to communicate], such as video conferencing and Skype, where doctors could participate more efficiently in the care of their hospitalized patients,” he says, adding that hospitalists should reach out to PCPs, both when a patient enters the hospital and as part of a larger discussion about how to improve communication and continuity of care.

The PCP Perspective

Boston internist Gila Kriegel, MD, might seem like a throwback. She says she wants to visit her patients when they are in the hospital, if at all possible. In fact, hospitalists in Boston say Dr. Kriegel allows them to take care of her patients “almost begrudgingly.”

“She is so involved in their care,” Dr. Li says. “She tells me everything I need to know about them. She’d be here every day if she weren’t juggling other responsibilities.”

A PCP since 1986, Dr. Kriegel’s story illustrates the complexities of an evolving healthcare system. She’s based in an academic setting, which she calls a “kind of ivory tower.”

“But I was fortunate in 1989, after my first son was born and I went part-time, to have a colleague who offered to see my inpatients on the days I wasn’t working,” she explains. “Then a woman colleague of mine also went part-time, and we agreed to cross-cover for each other.”

Eventually, Dr. Kriegel was approached by Dr. Li’s hospitalist group, which offered to manage her hospitalized patients.

“For the first six months to a year, I’d go see my patients in the hospital on a social visit. I’d even write notes in the chart, until they told me, ‘You are not responsible for the care in the hospital. The hospitalist is,’” she recalls. “For me, it was a big loss to stop going to the hospital. Most PCPs I know like seeing their patients through the course of the illness.”

Then again, she also admits how difficult it is to see her patients in the hospital.

Still, she managed to stay connected. “When I stopped going to see my patients, I asked the hospital staff to give me the patient’s bedside phone number, and I’d call them in the hospital to let them know I was up on what was happening,” she says.

Technology, coincidentally, inserted a barrier: She wasn’t able to access hospitalists’ daily notes in the BIDMC electronic health records. That’s when Dr. Kriegel began e-mailing the hospitalists. In the end, even that form of communication wasn’t fully satisfying.

“The current system requires me to do the outreach,” she explains. “If you ask hospitalists about communication, they’d say they’re already doing it. But a discharge summary isn’t the same as knowing in real time what’s happening with my patients.”

“I’d love to make virtual visits to the patient in the hospital, by phone or computer link—even more so if I could get paid for my time. But I want to stay involved.”

Ripe for Innovation

Dr. Wachter, chief of hospital medicine at UCSF, who writes an HM-focused blog [wachtersworld.com], says the continuity visit is a good idea but also understands the difficulties in the new healthcare paradigm.

“It’s not easy to work out the logistics, and it depends on the geography,” he says. “We also need to be considering telemedicine. But something to enhance continuity is ripe for innovation.”

He says consultation or continuity visits offer ways to improve care with a relatively small expenditure.

“We still see a few PCPs come in when their patients are hospitalized. It’s very reassuring to their patients,” he says. “For the complicated cases where an ongoing relationship matters, those encounters are fabulous.”

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Goroll AH, Hunt DP. Bridging the hospitalist-primary care divide through collaborative care. New Engl J Med. 2015;372(4):308-309.
2. Wachter RM, Pantilat SZ. The “continuity visit” and the hospitalist model of care. Dis Mon. 2002;48(4):267-272.

Hospital medicine leaders have long acknowledged the disconnects in medical care that occur at discharge. The demand for greater efficiency in hospital-based care is what has driven the hospitalist movement and its inexorable growth the past two decades.

Efforts to overcome discontinuity of care have included more timely discharge summaries, phone calls to primary care physicians (PCPs) and specialists at the time of discharge, and hospitalist-staffed post-discharge clinics. In a 2002 article, Robert Wachter, MD, MHM, and Steven Pantilat, MD, SFHM, of the University of California San Francisco (UCSF), suggested that PCPs make continuity visits to the hospital once or twice to maintain their involvement and help coordinate the care of their patients.¹

A new “Perspectives” piece in The New England Journal of Medicine proposes that PCPs act as medical consultants to the hospitalist team while their patients are in the hospital, making a consulting visit “within 12 to 18 hours after admission to provide support and continuity to them and their families.”² Authors Allan Goroll, MD, MACP, and Daniel Hunt, MD, propose that the PCP be asked to write a succinct consultation note in the hospital chart, highlighting key elements of the patient’s history and recent tests—with the goal of complementing and informing the hospitalist’s admission workup and care plan—while being paid as a consultant.

“It’s a fairly straightforward proposal,” says Dr. Hunt, chief of the hospital medicine unit at Massachusetts General Hospital (MGH) in Boston. “We’re not looking for PCPs to take care of every aspect of inpatient care. It’s really just to bring in the PCP’s expertise and nuanced understanding of the patient at a vulnerable time for the patient.”

The idea might seem a little ironic given the fact that hospitalists were created in part to relieve busy PCPs from having to visit the hospital. But some see it as a way forward.

“I wouldn’t call it a step backward,” says Joseph Ming Wah Li, MD, SFHM, FACP, director of the hospital medicine program at Beth Israel Deaconess Medical Center (BIDMC) in Boston and a former SHM president. “Is it feasible? Realistically, in most settings today, I don’t think it is. But I would love it. I don’t really know enough about the patients I take care of in the hospital.”

The Barrier of “Not Enough Time”

Dr. Hunt says the biggest barrier to this proposal is the time that PCPs would have to carve out to make physical trips to the hospital.

“That ultimately comes down to reimbursement,” he says.

MGH, which is well situated with medical practices in or near the main hospital building, has piloted an approach similar to the NEJM proposal with a primary care group that comes in to see its patients in the first day or two after admission and then again on the day before discharge.

“We made a commitment, as hospitalists, to communicate directly by phone with the PCPs. That commitment lasted about a week, and then we quickly converted to a daily e-mail. That works, because both parties are communicating substantial information in these e-mails.”–Dr. Hunt

“But they are essentially doing it out of the goodness of their hearts,” Dr. Hunt explains. “What we’ve seen from this experiment are much better transitions of care and much better decision making around big decisions, such as end-of-life care or surgical interventions.”

Hospitalists at MGH and the PCPs spent a year and a half talking through the specifics of how their arrangement would work.

“We made a commitment, as hospitalists, to communicate directly by phone with the PCPs,” he says. “That commitment lasted about a week, and then we quickly converted to a daily e-mail. That works, because both parties are communicating substantial information in these e-mails.”

Dr. Hunt says the key is recognizing the “huge” value PCPs bring to an inpatient stay. And, while physical trips to the hospital or e-mails might not work for every hospitalist or PCP, the connecting of information and insight is often worth the investment.

“There are other ways [to communicate], such as video conferencing and Skype, where doctors could participate more efficiently in the care of their hospitalized patients,” he says, adding that hospitalists should reach out to PCPs, both when a patient enters the hospital and as part of a larger discussion about how to improve communication and continuity of care.

The PCP Perspective

Boston internist Gila Kriegel, MD, might seem like a throwback. She says she wants to visit her patients when they are in the hospital, if at all possible. In fact, hospitalists in Boston say Dr. Kriegel allows them to take care of her patients “almost begrudgingly.”

“She is so involved in their care,” Dr. Li says. “She tells me everything I need to know about them. She’d be here every day if she weren’t juggling other responsibilities.”

A PCP since 1986, Dr. Kriegel’s story illustrates the complexities of an evolving healthcare system. She’s based in an academic setting, which she calls a “kind of ivory tower.”

“But I was fortunate in 1989, after my first son was born and I went part-time, to have a colleague who offered to see my inpatients on the days I wasn’t working,” she explains. “Then a woman colleague of mine also went part-time, and we agreed to cross-cover for each other.”

Eventually, Dr. Kriegel was approached by Dr. Li’s hospitalist group, which offered to manage her hospitalized patients.

“For the first six months to a year, I’d go see my patients in the hospital on a social visit. I’d even write notes in the chart, until they told me, ‘You are not responsible for the care in the hospital. The hospitalist is,’” she recalls. “For me, it was a big loss to stop going to the hospital. Most PCPs I know like seeing their patients through the course of the illness.”

Then again, she also admits how difficult it is to see her patients in the hospital.

Still, she managed to stay connected. “When I stopped going to see my patients, I asked the hospital staff to give me the patient’s bedside phone number, and I’d call them in the hospital to let them know I was up on what was happening,” she says.

Technology, coincidentally, inserted a barrier: She wasn’t able to access hospitalists’ daily notes in the BIDMC electronic health records. That’s when Dr. Kriegel began e-mailing the hospitalists. In the end, even that form of communication wasn’t fully satisfying.

“The current system requires me to do the outreach,” she explains. “If you ask hospitalists about communication, they’d say they’re already doing it. But a discharge summary isn’t the same as knowing in real time what’s happening with my patients.”

“I’d love to make virtual visits to the patient in the hospital, by phone or computer link—even more so if I could get paid for my time. But I want to stay involved.”

Ripe for Innovation

Dr. Wachter, chief of hospital medicine at UCSF, who writes an HM-focused blog [wachtersworld.com], says the continuity visit is a good idea but also understands the difficulties in the new healthcare paradigm.

“It’s not easy to work out the logistics, and it depends on the geography,” he says. “We also need to be considering telemedicine. But something to enhance continuity is ripe for innovation.”

He says consultation or continuity visits offer ways to improve care with a relatively small expenditure.

“We still see a few PCPs come in when their patients are hospitalized. It’s very reassuring to their patients,” he says. “For the complicated cases where an ongoing relationship matters, those encounters are fabulous.”

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Goroll AH, Hunt DP. Bridging the hospitalist-primary care divide through collaborative care. New Engl J Med. 2015;372(4):308-309.
2. Wachter RM, Pantilat SZ. The “continuity visit” and the hospitalist model of care. Dis Mon. 2002;48(4):267-272.

In late January, the Centers for Medicare and Medicaid Services (CMS) released the early results of two multi-year innovation projects focused on the creation of patient-centered medical homes (PCMHs).

Although PCMH models have been lauded as a way to achieve CMS’ triple aim —better quality patient care and improved health at a lower cost—little evidence currently backs up this claim. The latest reports show that PCMH interventions hold promise, but the jury is still out.

“I think, two to three years from now, we will be in a totally different position, in terms of a sound evidence base for policy,” says Mark Friedberg, MD, MPP, a practicing general internist and senior natural scientist for the RAND Corporation. “We know these very large CMS demonstrations are just starting to trickle in with year one results.”

Both the Comprehensive Primary Care (CPC) Initiative and the Multi-payer Advanced Primary Care Practice (MAPCP) are large, multi-year CMS demonstrations launched in 2012 and 2011, respectively, and the reports cover just their first 12 months. Although different in numerous ways, both projects aim to create better coordinated care that will in turn lower hospital admissions and ED visits, reduce duplications, enhance patient health through prevention, improve chronic disease management, and move away from a fee-for-service approach. They are just two of many experiments supported by the 10-year, $10 billion CMS Innovation Center.

In its first 12 months, the CPC focused on improving the care of high-risk patients in four states plus three separate regions of the U.S. It served 345,000 Medicare beneficiaries and roughly 2.5 million patients overall among nearly 500 primary care practices identified as likely to achieve meaningful results.

The evaluation, performed by policy research firm Mathematica, found that CPC cut hospital admissions by 2% and saw a 3% reduction in ED visits relative to similar practices not participating in the initiative, contributing to an overall $168 savings per Medicare beneficiary. It generated more than $70,000 in additional revenue per median practice clinician.¹

However, the Department of Health and Human Services (HHS) paid practices $240 per patient to cover the costs of establishing the medical home, including hiring nurses, improving electronic health records, and setting up 24-hour call lines. Thus, the initiative failed to offset its costs. Even so, Mathematica called the findings “promising” and “more favorable” than expected for the first year of the initiative, though it advised caution in interpreting the findings at this stage.

The MAPCP involved primary care initiatives in eight states, encompassing 3,800 providers across 700 practices; it touched 400,000 Medicare beneficiaries in its first year (today, it serves practices in just six states). Private payers and Medicaid also took part, leading to an estimated savings of $4.2 million, according to the initiative’s evaluators, RTI International and The Urban Institute.²

The demonstration realized a reduction in fee-for-service Medicare growth in Vermont and Michigan, largely resulting from lower inpatient expenditures, but did little to reduce hospitalizations, readmissions, or ED visits. Data collection and utilization were recurring challenges.

Dr. Friedberg says these first reports are akin to seeing the first few ships of the armada break the horizon. Last year, he was first author of a Journal of the American Medical Association study of a three-year PCMH intervention in Pennsylvania, Southeastern Pennsylvania’s Chronic Care Initiative, which also showed mixed results.³ He currently is part of a team evaluating the CMS Federally Qualified Health Center Advanced Primary Care Practice Demonstration, which concluded last October.

Although he has not yet seen an evaluation of a PCMH intervention involving hospitalists, Dr. Friedberg says it would be interesting to see the results of a rigorously studied pilot that involves such an evaluation. A 2012 article in The Hospitalist highlighted one project in Wisconsin and laid out ways in which hospitalists could be involved in PCMH initiatives—among them, being part of hospital admissions decision making and maintaining open lines of communication.⁴ Leaders of that project declined to comment at this time.

“The patient-centered medical home really is an outpatient strategy more than it is an inpatient strategy,” says Robert Centor, MD, MACP, an academic hospitalist at the University of Alabama Huntsville and chair of the Board of Regents of the American College of Physicians, yet he sees a role for hospitalists.

“If we start getting good results with patient-centered medical homes and more people go to the model, a relationship between the PCMH on the outpatient side and a cadre of people who know how to work the inpatient side is going to be critical to success,” Dr. Centor says.

Indeed, Dr. Friedberg says hospitalists’ involvement could be one of the “missing ingredients” that might contribute to the success of any given PCMH intervention, and he’s careful to emphasize there is no such thing as “the medical home.” Rather, there are “many medical homes,” he says.

Dr. Centor says hospitalists could serve as conduits between care inside the hospital and follow-up care, which could reduce length of stay for some patients and smooth the transition from discharge to primary care. A well-versed hospitalist with the PCMH might also assist in reducing repeat tests and procedures.

“I think it comes down to relationships more than anything else,” Dr. Centor says. “The challenge is, given all of the busyness of outpatient practice and inpatient care, how do we best communicate?”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Mathematica Policy Research. Evaluation of the Comprehensive Primary Care Initiative: first annual report. Reference number 40102.R14. Available at: http://innovation.cms.gov/Files/reports/CPCI-EvalRpt1.pdf. Accessed March 4, 2015.
2. RTI International. Evaluation of the multi-payer advanced primary care practice (MAPCP) demonstration: first annual report. RTI Project Number 0212790.005.001.001. Available at: http://innovation.cms.gov/Files/reports/MAPCP-EvalRpt1.pdf. Accessed March 4, 2015.
3. Friedberg MW, Schneider EC, Rosenthal MB, Volpp KG, Werner RM. Association between participation in a multipayer medical home intervention and changes in quality, utilization, and costs of care. JAMA. 2014;311(8):815-825.
4. Collins T. Patients should prepare for the patient-centered medical home. The Hospitalist. July 3, 2012. Available at: http://www.the-hospitalist.org/article/hospitalists-should-prepare-for-the-patient-centered-medical-home/. Accessed March 4, 2015.

In late January, the Centers for Medicare and Medicaid Services (CMS) released the early results of two multi-year innovation projects focused on the creation of patient-centered medical homes (PCMHs).

Although PCMH models have been lauded as a way to achieve CMS’ triple aim —better quality patient care and improved health at a lower cost—little evidence currently backs up this claim. The latest reports show that PCMH interventions hold promise, but the jury is still out.

“I think, two to three years from now, we will be in a totally different position, in terms of a sound evidence base for policy,” says Mark Friedberg, MD, MPP, a practicing general internist and senior natural scientist for the RAND Corporation. “We know these very large CMS demonstrations are just starting to trickle in with year one results.”

Both the Comprehensive Primary Care (CPC) Initiative and the Multi-payer Advanced Primary Care Practice (MAPCP) are large, multi-year CMS demonstrations launched in 2012 and 2011, respectively, and the reports cover just their first 12 months. Although different in numerous ways, both projects aim to create better coordinated care that will in turn lower hospital admissions and ED visits, reduce duplications, enhance patient health through prevention, improve chronic disease management, and move away from a fee-for-service approach. They are just two of many experiments supported by the 10-year, $10 billion CMS Innovation Center.

In its first 12 months, the CPC focused on improving the care of high-risk patients in four states plus three separate regions of the U.S. It served 345,000 Medicare beneficiaries and roughly 2.5 million patients overall among nearly 500 primary care practices identified as likely to achieve meaningful results.

The evaluation, performed by policy research firm Mathematica, found that CPC cut hospital admissions by 2% and saw a 3% reduction in ED visits relative to similar practices not participating in the initiative, contributing to an overall $168 savings per Medicare beneficiary. It generated more than $70,000 in additional revenue per median practice clinician.¹

However, the Department of Health and Human Services (HHS) paid practices $240 per patient to cover the costs of establishing the medical home, including hiring nurses, improving electronic health records, and setting up 24-hour call lines. Thus, the initiative failed to offset its costs. Even so, Mathematica called the findings “promising” and “more favorable” than expected for the first year of the initiative, though it advised caution in interpreting the findings at this stage.

The MAPCP involved primary care initiatives in eight states, encompassing 3,800 providers across 700 practices; it touched 400,000 Medicare beneficiaries in its first year (today, it serves practices in just six states). Private payers and Medicaid also took part, leading to an estimated savings of $4.2 million, according to the initiative’s evaluators, RTI International and The Urban Institute.²

The demonstration realized a reduction in fee-for-service Medicare growth in Vermont and Michigan, largely resulting from lower inpatient expenditures, but did little to reduce hospitalizations, readmissions, or ED visits. Data collection and utilization were recurring challenges.

Dr. Friedberg says these first reports are akin to seeing the first few ships of the armada break the horizon. Last year, he was first author of a Journal of the American Medical Association study of a three-year PCMH intervention in Pennsylvania, Southeastern Pennsylvania’s Chronic Care Initiative, which also showed mixed results.³ He currently is part of a team evaluating the CMS Federally Qualified Health Center Advanced Primary Care Practice Demonstration, which concluded last October.

Although he has not yet seen an evaluation of a PCMH intervention involving hospitalists, Dr. Friedberg says it would be interesting to see the results of a rigorously studied pilot that involves such an evaluation. A 2012 article in The Hospitalist highlighted one project in Wisconsin and laid out ways in which hospitalists could be involved in PCMH initiatives—among them, being part of hospital admissions decision making and maintaining open lines of communication.⁴ Leaders of that project declined to comment at this time.

“The patient-centered medical home really is an outpatient strategy more than it is an inpatient strategy,” says Robert Centor, MD, MACP, an academic hospitalist at the University of Alabama Huntsville and chair of the Board of Regents of the American College of Physicians, yet he sees a role for hospitalists.

“If we start getting good results with patient-centered medical homes and more people go to the model, a relationship between the PCMH on the outpatient side and a cadre of people who know how to work the inpatient side is going to be critical to success,” Dr. Centor says.

Indeed, Dr. Friedberg says hospitalists’ involvement could be one of the “missing ingredients” that might contribute to the success of any given PCMH intervention, and he’s careful to emphasize there is no such thing as “the medical home.” Rather, there are “many medical homes,” he says.

Dr. Centor says hospitalists could serve as conduits between care inside the hospital and follow-up care, which could reduce length of stay for some patients and smooth the transition from discharge to primary care. A well-versed hospitalist with the PCMH might also assist in reducing repeat tests and procedures.

“I think it comes down to relationships more than anything else,” Dr. Centor says. “The challenge is, given all of the busyness of outpatient practice and inpatient care, how do we best communicate?”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Mathematica Policy Research. Evaluation of the Comprehensive Primary Care Initiative: first annual report. Reference number 40102.R14. Available at: http://innovation.cms.gov/Files/reports/CPCI-EvalRpt1.pdf. Accessed March 4, 2015.
2. RTI International. Evaluation of the multi-payer advanced primary care practice (MAPCP) demonstration: first annual report. RTI Project Number 0212790.005.001.001. Available at: http://innovation.cms.gov/Files/reports/MAPCP-EvalRpt1.pdf. Accessed March 4, 2015.
3. Friedberg MW, Schneider EC, Rosenthal MB, Volpp KG, Werner RM. Association between participation in a multipayer medical home intervention and changes in quality, utilization, and costs of care. JAMA. 2014;311(8):815-825.
4. Collins T. Patients should prepare for the patient-centered medical home. The Hospitalist. July 3, 2012. Available at: http://www.the-hospitalist.org/article/hospitalists-should-prepare-for-the-patient-centered-medical-home/. Accessed March 4, 2015.

In late January, the Centers for Medicare and Medicaid Services (CMS) released the early results of two multi-year innovation projects focused on the creation of patient-centered medical homes (PCMHs).

Although PCMH models have been lauded as a way to achieve CMS’ triple aim —better quality patient care and improved health at a lower cost—little evidence currently backs up this claim. The latest reports show that PCMH interventions hold promise, but the jury is still out.

“I think, two to three years from now, we will be in a totally different position, in terms of a sound evidence base for policy,” says Mark Friedberg, MD, MPP, a practicing general internist and senior natural scientist for the RAND Corporation. “We know these very large CMS demonstrations are just starting to trickle in with year one results.”

Both the Comprehensive Primary Care (CPC) Initiative and the Multi-payer Advanced Primary Care Practice (MAPCP) are large, multi-year CMS demonstrations launched in 2012 and 2011, respectively, and the reports cover just their first 12 months. Although different in numerous ways, both projects aim to create better coordinated care that will in turn lower hospital admissions and ED visits, reduce duplications, enhance patient health through prevention, improve chronic disease management, and move away from a fee-for-service approach. They are just two of many experiments supported by the 10-year, $10 billion CMS Innovation Center.

In its first 12 months, the CPC focused on improving the care of high-risk patients in four states plus three separate regions of the U.S. It served 345,000 Medicare beneficiaries and roughly 2.5 million patients overall among nearly 500 primary care practices identified as likely to achieve meaningful results.

The evaluation, performed by policy research firm Mathematica, found that CPC cut hospital admissions by 2% and saw a 3% reduction in ED visits relative to similar practices not participating in the initiative, contributing to an overall $168 savings per Medicare beneficiary. It generated more than $70,000 in additional revenue per median practice clinician.¹

However, the Department of Health and Human Services (HHS) paid practices $240 per patient to cover the costs of establishing the medical home, including hiring nurses, improving electronic health records, and setting up 24-hour call lines. Thus, the initiative failed to offset its costs. Even so, Mathematica called the findings “promising” and “more favorable” than expected for the first year of the initiative, though it advised caution in interpreting the findings at this stage.

The MAPCP involved primary care initiatives in eight states, encompassing 3,800 providers across 700 practices; it touched 400,000 Medicare beneficiaries in its first year (today, it serves practices in just six states). Private payers and Medicaid also took part, leading to an estimated savings of $4.2 million, according to the initiative’s evaluators, RTI International and The Urban Institute.²

The demonstration realized a reduction in fee-for-service Medicare growth in Vermont and Michigan, largely resulting from lower inpatient expenditures, but did little to reduce hospitalizations, readmissions, or ED visits. Data collection and utilization were recurring challenges.

Dr. Friedberg says these first reports are akin to seeing the first few ships of the armada break the horizon. Last year, he was first author of a Journal of the American Medical Association study of a three-year PCMH intervention in Pennsylvania, Southeastern Pennsylvania’s Chronic Care Initiative, which also showed mixed results.³ He currently is part of a team evaluating the CMS Federally Qualified Health Center Advanced Primary Care Practice Demonstration, which concluded last October.

Although he has not yet seen an evaluation of a PCMH intervention involving hospitalists, Dr. Friedberg says it would be interesting to see the results of a rigorously studied pilot that involves such an evaluation. A 2012 article in The Hospitalist highlighted one project in Wisconsin and laid out ways in which hospitalists could be involved in PCMH initiatives—among them, being part of hospital admissions decision making and maintaining open lines of communication.⁴ Leaders of that project declined to comment at this time.

“The patient-centered medical home really is an outpatient strategy more than it is an inpatient strategy,” says Robert Centor, MD, MACP, an academic hospitalist at the University of Alabama Huntsville and chair of the Board of Regents of the American College of Physicians, yet he sees a role for hospitalists.

“If we start getting good results with patient-centered medical homes and more people go to the model, a relationship between the PCMH on the outpatient side and a cadre of people who know how to work the inpatient side is going to be critical to success,” Dr. Centor says.

Indeed, Dr. Friedberg says hospitalists’ involvement could be one of the “missing ingredients” that might contribute to the success of any given PCMH intervention, and he’s careful to emphasize there is no such thing as “the medical home.” Rather, there are “many medical homes,” he says.

Dr. Centor says hospitalists could serve as conduits between care inside the hospital and follow-up care, which could reduce length of stay for some patients and smooth the transition from discharge to primary care. A well-versed hospitalist with the PCMH might also assist in reducing repeat tests and procedures.

“I think it comes down to relationships more than anything else,” Dr. Centor says. “The challenge is, given all of the busyness of outpatient practice and inpatient care, how do we best communicate?”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Mathematica Policy Research. Evaluation of the Comprehensive Primary Care Initiative: first annual report. Reference number 40102.R14. Available at: http://innovation.cms.gov/Files/reports/CPCI-EvalRpt1.pdf. Accessed March 4, 2015.
2. RTI International. Evaluation of the multi-payer advanced primary care practice (MAPCP) demonstration: first annual report. RTI Project Number 0212790.005.001.001. Available at: http://innovation.cms.gov/Files/reports/MAPCP-EvalRpt1.pdf. Accessed March 4, 2015.
3. Friedberg MW, Schneider EC, Rosenthal MB, Volpp KG, Werner RM. Association between participation in a multipayer medical home intervention and changes in quality, utilization, and costs of care. JAMA. 2014;311(8):815-825.
4. Collins T. Patients should prepare for the patient-centered medical home. The Hospitalist. July 3, 2012. Available at: http://www.the-hospitalist.org/article/hospitalists-should-prepare-for-the-patient-centered-medical-home/. Accessed March 4, 2015.

Editor’s note: first published online at shmcareercenter.org

There are many practical skills you should hone if you are interested in becoming a team leader in your hospital medicine group—among them the ability to engage others, to effectively conduct an efficient meeting, and to meet project deadlines. But more basic than that, says Jasen Gundersen, MD, MBA, CPE, SFHM, president of the Acute Care Services Division for TeamHealth in the Miami/Fort Lauderdale area, is to first ask yourself, “Why do I want to be a leader? What is it about being a leader that draws me in?”

Early career hospitalists may think leadership roles automatically yield more money and free time, Dr. Gundersen says. Actually, being a leader requires stamina and the ability to weather the ups and downs that come with the leadership role. For example, will you be able to handle situations in which your decisions make others unhappy?

Honest self-assessment is one of the most critical elements in becoming a leader, agrees Steven Deitelzweig, MD, MMM, FACP, FSVMB, RVT, VPMA, system chairman of hospital medicine and medical director of regional business development for Ochsner Health System in the greater New Orleans area. In addition to having good interpersonal skills, showing enthusiasm, and promoting your organization sincerely—what Dr. Deitelzweig labels “emotional intelligence”—prospective leaders need to be cognizant of delivering on promises.

“This is something I call a high ‘say/do’ ratio,” he explains, “and, simply put, it means that you accomplish what you say you will. At the end of the day, the only way anybody moves up is by being good at achieving results.”

If you start missing deadlines, you communicate that you are not reliable. Not all project implementation goes according to plan, of course, so when you encounter difficulties, early communication about obstacles is also key, he says.

Through SHM’s Leadership Academy, hospitalists can be trained in team management and other key leadership skills. An October 2015 session is scheduled in Austin.

Having trusted mentors is crucial, agreed both physicians, so that you can keep polishing your skill set and obtain honest feedback. These mentors should not be people to whom you directly report, and they need not be in the healthcare industry.

In fact, Dr. Gundersen says he’s known mentors for years “who have not been in the same specialty or even the same field, but who give me guidance and have helped make me into the leader I am.”

How do you assert your desire to be a leader? Dr. Deitelzweig suggests making your aspirations clear to your own group leaders. The annual review is an excellent juncture at which to discuss this, he says.

If you do not yet have project management or communications experience, ask your leaders whether they are familiar with training to help you develop those skills. In the current healthcare environment, the Affordable Care Act and reimbursement regulations mean that change will continue to be part of the leadership challenge.

“If you really want to be a leader,” Dr. Deitelzweig says, “you cannot be a naysayer. Make change work for you, look at it as an opportunity for you to innovate, and then show how valuable you can be.”

Gretchen Henkel is a freelance writer in California.

Editor’s note: first published online at shmcareercenter.org

There are many practical skills you should hone if you are interested in becoming a team leader in your hospital medicine group—among them the ability to engage others, to effectively conduct an efficient meeting, and to meet project deadlines. But more basic than that, says Jasen Gundersen, MD, MBA, CPE, SFHM, president of the Acute Care Services Division for TeamHealth in the Miami/Fort Lauderdale area, is to first ask yourself, “Why do I want to be a leader? What is it about being a leader that draws me in?”

Early career hospitalists may think leadership roles automatically yield more money and free time, Dr. Gundersen says. Actually, being a leader requires stamina and the ability to weather the ups and downs that come with the leadership role. For example, will you be able to handle situations in which your decisions make others unhappy?

Honest self-assessment is one of the most critical elements in becoming a leader, agrees Steven Deitelzweig, MD, MMM, FACP, FSVMB, RVT, VPMA, system chairman of hospital medicine and medical director of regional business development for Ochsner Health System in the greater New Orleans area. In addition to having good interpersonal skills, showing enthusiasm, and promoting your organization sincerely—what Dr. Deitelzweig labels “emotional intelligence”—prospective leaders need to be cognizant of delivering on promises.

“This is something I call a high ‘say/do’ ratio,” he explains, “and, simply put, it means that you accomplish what you say you will. At the end of the day, the only way anybody moves up is by being good at achieving results.”

If you start missing deadlines, you communicate that you are not reliable. Not all project implementation goes according to plan, of course, so when you encounter difficulties, early communication about obstacles is also key, he says.

Through SHM’s Leadership Academy, hospitalists can be trained in team management and other key leadership skills. An October 2015 session is scheduled in Austin.

Having trusted mentors is crucial, agreed both physicians, so that you can keep polishing your skill set and obtain honest feedback. These mentors should not be people to whom you directly report, and they need not be in the healthcare industry.

In fact, Dr. Gundersen says he’s known mentors for years “who have not been in the same specialty or even the same field, but who give me guidance and have helped make me into the leader I am.”

How do you assert your desire to be a leader? Dr. Deitelzweig suggests making your aspirations clear to your own group leaders. The annual review is an excellent juncture at which to discuss this, he says.

If you do not yet have project management or communications experience, ask your leaders whether they are familiar with training to help you develop those skills. In the current healthcare environment, the Affordable Care Act and reimbursement regulations mean that change will continue to be part of the leadership challenge.

“If you really want to be a leader,” Dr. Deitelzweig says, “you cannot be a naysayer. Make change work for you, look at it as an opportunity for you to innovate, and then show how valuable you can be.”

Gretchen Henkel is a freelance writer in California.

Editor’s note: first published online at shmcareercenter.org

There are many practical skills you should hone if you are interested in becoming a team leader in your hospital medicine group—among them the ability to engage others, to effectively conduct an efficient meeting, and to meet project deadlines. But more basic than that, says Jasen Gundersen, MD, MBA, CPE, SFHM, president of the Acute Care Services Division for TeamHealth in the Miami/Fort Lauderdale area, is to first ask yourself, “Why do I want to be a leader? What is it about being a leader that draws me in?”

Early career hospitalists may think leadership roles automatically yield more money and free time, Dr. Gundersen says. Actually, being a leader requires stamina and the ability to weather the ups and downs that come with the leadership role. For example, will you be able to handle situations in which your decisions make others unhappy?

Honest self-assessment is one of the most critical elements in becoming a leader, agrees Steven Deitelzweig, MD, MMM, FACP, FSVMB, RVT, VPMA, system chairman of hospital medicine and medical director of regional business development for Ochsner Health System in the greater New Orleans area. In addition to having good interpersonal skills, showing enthusiasm, and promoting your organization sincerely—what Dr. Deitelzweig labels “emotional intelligence”—prospective leaders need to be cognizant of delivering on promises.

“This is something I call a high ‘say/do’ ratio,” he explains, “and, simply put, it means that you accomplish what you say you will. At the end of the day, the only way anybody moves up is by being good at achieving results.”

If you start missing deadlines, you communicate that you are not reliable. Not all project implementation goes according to plan, of course, so when you encounter difficulties, early communication about obstacles is also key, he says.

Through SHM’s Leadership Academy, hospitalists can be trained in team management and other key leadership skills. An October 2015 session is scheduled in Austin.

Having trusted mentors is crucial, agreed both physicians, so that you can keep polishing your skill set and obtain honest feedback. These mentors should not be people to whom you directly report, and they need not be in the healthcare industry.

In fact, Dr. Gundersen says he’s known mentors for years “who have not been in the same specialty or even the same field, but who give me guidance and have helped make me into the leader I am.”

How do you assert your desire to be a leader? Dr. Deitelzweig suggests making your aspirations clear to your own group leaders. The annual review is an excellent juncture at which to discuss this, he says.

If you do not yet have project management or communications experience, ask your leaders whether they are familiar with training to help you develop those skills. In the current healthcare environment, the Affordable Care Act and reimbursement regulations mean that change will continue to be part of the leadership challenge.

“If you really want to be a leader,” Dr. Deitelzweig says, “you cannot be a naysayer. Make change work for you, look at it as an opportunity for you to innovate, and then show how valuable you can be.”

Gretchen Henkel is a freelance writer in California.

Hospitalists often are tasked with coordinating and overseeing patient care throughout a hospitalization. Depending on the care model and the availability of varying specialists, a patient could see several specialists throughout the stay, and even during a single day. A recurring issue for many hospitalists is justifying the medical necessity of their services, because payers do not want to reimburse overlapping care (i.e., multiple providers caring for the same patient problem) when more than one physician provides care on the same service date.

Payers often consider two key principles before reimbursing multiple visits on the same date:¹

• Does the patient’s condition warrant the services of more than one physician?
• Are the individual services provided by each physician reasonable and necessary?

Consider the following example: A 65-year-old female patient is admitted with a hip fracture (820.8) after slipping on the ice outside her home. The patient also has hypertension (401.1) and type II diabetes (250.00). The surgeon manages the patient’s peri-operative course for the fracture, while the hospitalist manages the patient’s medical issues.

Payers must be sure that the services of one physician do not duplicate those provided by another.1 For the above scenario, it is imperative that the hospitalist understand which services are considered the surgeon’s responsibility. The global surgical package includes payment for the surgical procedure and the completion of its corresponding facility-required paperwork (e.g. pre-operative history and physical exam, operative consent forms, pre-operative orders), in addition to the following services:²

• Pre-operative visits after making the decision for surgery beginning one day prior to surgery;
• All additional post-operative medical or surgical services provided by the surgeon related to complications but not requiring additional trips to the operating room;
• Post-operative visits by the surgeon related to recovery from surgery, including but not limited to dressing changes, local incisional care, removal of cutaneous sutures and staples, line removals, changes and removal of tracheostomy tubes, and discharge services; and
• Post-operative pain management provided by the surgeon.

Another physician who performs any component of the global package will not receive separate payment unless the surgeon is willing to forego a portion of the payment. For example, a hospitalist admits a patient who has no other identifiable medical conditions aside from the problem prompting surgery. The hospitalist’s role may be dictated by facility policy—quality of care or risk reduction, for example—and administrative requirements (history and physical exam, discharge services, coordination of care) rather than what a payer would perceive as necessary “medical” management. Similarly, if the hospitalist’s post-op care is limited to ordering routine post-op labs or maintaining appropriate pain management, the hospitalist’s service will likely be denied as incidental to the surgical package.

Remember, if the hospitalist’s claim is submitted and paid, it doesn’t mean that the payer won’t retract the payment upon review if an erroneous payment is suspected. A payer review may be triggered when the diagnosis listed on the hospitalist’s claim matches the diagnosis listed on the surgeon’s claim (e.g. 820.8). If too many claims are considered “not medically necessary” due to overlapping care, hospitalists may need to negotiate other terms of payment with the facility to recoup unpaid time and effort when involved in this type of care.

When more than one medical condition exists and several physicians participate in the patient’s care, medical necessity is easily established for each physician. Each physician manages the condition related to his/her expertise. In the above example, the surgeon cares for the patient’s fracture, while the hospitalist oversees diabetes and hypertension management. Service distinction is crucial during the claim submission process. The hospitalist should report a subsequent hospital care code (99231-99233) with a primary diagnosis corresponding to his/her specialty-related care (i.e., 9923x with 250.00, 401.1).³

When more specialists are involved, claim submission becomes more complex. A cardiologist who was also involved in patient management would report his or her service using 401.1. When a different primary diagnosis is assigned to the visit code to indicate the reason for each physician’s involvement, all claims are more likely to be paid.⁴ As long as the hospitalist maintains care over one of the patients’ conditions, concurrent care is justified.

Because these physicians are in different specialties and different provider groups, most payers do not require the modifier 25 (separately identifiable evaluation/management [E/M] service on the same day as a procedure or other service) with the visit code; however, some managed care payers may have a general claim edit that pays the first claim and denies the second unless modifier 25 is appended to the concurrent E/M visit code (i.e., 99232-25) as an attestation that the service is distinct from any other provider’s service that day, despite claim submission under different tax identification numbers. This may not be identified until the claim is rejected or denied. If appropriate modifier use does not yield payment, appeal the denied concurrent care claims with supporting documentation from each physician visit, if possible. This demonstrates each physician’s contribution to care.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual: Chapter 15—Covered Medical and Other Health Services. Section 30.E. Available at: www.cms.gov/manuals/Downloads/bp102c15.pdf. Accessed March 5, 2015.
2. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12—Physicians/Nonphysician Practitioners. Section 40.A. Available at: www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed March 5, 2015.
3. American Medical Association. Current Procedural Terminology 2015 Professional Edition. Chicago: American Medical Association Press; 2014.
4. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12—Physicians/Nonphysician Practitioners. Section 30.6.9.C. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed March 5, 2015.
5. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12—Physicians/Nonphysician Practitioners. Section 30.6.5. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed March 5, 2015.
6. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 26—Completing and Processing Form CMS-1500 Data Set. Section 10.8.2. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf. Accessed March 5, 2015.

Hospitalists often are tasked with coordinating and overseeing patient care throughout a hospitalization. Depending on the care model and the availability of varying specialists, a patient could see several specialists throughout the stay, and even during a single day. A recurring issue for many hospitalists is justifying the medical necessity of their services, because payers do not want to reimburse overlapping care (i.e., multiple providers caring for the same patient problem) when more than one physician provides care on the same service date.

Payers often consider two key principles before reimbursing multiple visits on the same date:¹

• Does the patient’s condition warrant the services of more than one physician?
• Are the individual services provided by each physician reasonable and necessary?

Consider the following example: A 65-year-old female patient is admitted with a hip fracture (820.8) after slipping on the ice outside her home. The patient also has hypertension (401.1) and type II diabetes (250.00). The surgeon manages the patient’s peri-operative course for the fracture, while the hospitalist manages the patient’s medical issues.

Payers must be sure that the services of one physician do not duplicate those provided by another.1 For the above scenario, it is imperative that the hospitalist understand which services are considered the surgeon’s responsibility. The global surgical package includes payment for the surgical procedure and the completion of its corresponding facility-required paperwork (e.g. pre-operative history and physical exam, operative consent forms, pre-operative orders), in addition to the following services:²

• Pre-operative visits after making the decision for surgery beginning one day prior to surgery;
• All additional post-operative medical or surgical services provided by the surgeon related to complications but not requiring additional trips to the operating room;
• Post-operative visits by the surgeon related to recovery from surgery, including but not limited to dressing changes, local incisional care, removal of cutaneous sutures and staples, line removals, changes and removal of tracheostomy tubes, and discharge services; and
• Post-operative pain management provided by the surgeon.

Another physician who performs any component of the global package will not receive separate payment unless the surgeon is willing to forego a portion of the payment. For example, a hospitalist admits a patient who has no other identifiable medical conditions aside from the problem prompting surgery. The hospitalist’s role may be dictated by facility policy—quality of care or risk reduction, for example—and administrative requirements (history and physical exam, discharge services, coordination of care) rather than what a payer would perceive as necessary “medical” management. Similarly, if the hospitalist’s post-op care is limited to ordering routine post-op labs or maintaining appropriate pain management, the hospitalist’s service will likely be denied as incidental to the surgical package.

Remember, if the hospitalist’s claim is submitted and paid, it doesn’t mean that the payer won’t retract the payment upon review if an erroneous payment is suspected. A payer review may be triggered when the diagnosis listed on the hospitalist’s claim matches the diagnosis listed on the surgeon’s claim (e.g. 820.8). If too many claims are considered “not medically necessary” due to overlapping care, hospitalists may need to negotiate other terms of payment with the facility to recoup unpaid time and effort when involved in this type of care.

When more than one medical condition exists and several physicians participate in the patient’s care, medical necessity is easily established for each physician. Each physician manages the condition related to his/her expertise. In the above example, the surgeon cares for the patient’s fracture, while the hospitalist oversees diabetes and hypertension management. Service distinction is crucial during the claim submission process. The hospitalist should report a subsequent hospital care code (99231-99233) with a primary diagnosis corresponding to his/her specialty-related care (i.e., 9923x with 250.00, 401.1).³

When more specialists are involved, claim submission becomes more complex. A cardiologist who was also involved in patient management would report his or her service using 401.1. When a different primary diagnosis is assigned to the visit code to indicate the reason for each physician’s involvement, all claims are more likely to be paid.⁴ As long as the hospitalist maintains care over one of the patients’ conditions, concurrent care is justified.

Because these physicians are in different specialties and different provider groups, most payers do not require the modifier 25 (separately identifiable evaluation/management [E/M] service on the same day as a procedure or other service) with the visit code; however, some managed care payers may have a general claim edit that pays the first claim and denies the second unless modifier 25 is appended to the concurrent E/M visit code (i.e., 99232-25) as an attestation that the service is distinct from any other provider’s service that day, despite claim submission under different tax identification numbers. This may not be identified until the claim is rejected or denied. If appropriate modifier use does not yield payment, appeal the denied concurrent care claims with supporting documentation from each physician visit, if possible. This demonstrates each physician’s contribution to care.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual: Chapter 15—Covered Medical and Other Health Services. Section 30.E. Available at: www.cms.gov/manuals/Downloads/bp102c15.pdf. Accessed March 5, 2015.
2. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12—Physicians/Nonphysician Practitioners. Section 40.A. Available at: www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed March 5, 2015.
3. American Medical Association. Current Procedural Terminology 2015 Professional Edition. Chicago: American Medical Association Press; 2014.
4. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12—Physicians/Nonphysician Practitioners. Section 30.6.9.C. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed March 5, 2015.
5. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12—Physicians/Nonphysician Practitioners. Section 30.6.5. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed March 5, 2015.
6. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 26—Completing and Processing Form CMS-1500 Data Set. Section 10.8.2. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf. Accessed March 5, 2015.

Hospitalists often are tasked with coordinating and overseeing patient care throughout a hospitalization. Depending on the care model and the availability of varying specialists, a patient could see several specialists throughout the stay, and even during a single day. A recurring issue for many hospitalists is justifying the medical necessity of their services, because payers do not want to reimburse overlapping care (i.e., multiple providers caring for the same patient problem) when more than one physician provides care on the same service date.

Payers often consider two key principles before reimbursing multiple visits on the same date:¹

• Does the patient’s condition warrant the services of more than one physician?
• Are the individual services provided by each physician reasonable and necessary?

Consider the following example: A 65-year-old female patient is admitted with a hip fracture (820.8) after slipping on the ice outside her home. The patient also has hypertension (401.1) and type II diabetes (250.00). The surgeon manages the patient’s peri-operative course for the fracture, while the hospitalist manages the patient’s medical issues.

Payers must be sure that the services of one physician do not duplicate those provided by another.1 For the above scenario, it is imperative that the hospitalist understand which services are considered the surgeon’s responsibility. The global surgical package includes payment for the surgical procedure and the completion of its corresponding facility-required paperwork (e.g. pre-operative history and physical exam, operative consent forms, pre-operative orders), in addition to the following services:²

• Pre-operative visits after making the decision for surgery beginning one day prior to surgery;
• All additional post-operative medical or surgical services provided by the surgeon related to complications but not requiring additional trips to the operating room;
• Post-operative visits by the surgeon related to recovery from surgery, including but not limited to dressing changes, local incisional care, removal of cutaneous sutures and staples, line removals, changes and removal of tracheostomy tubes, and discharge services; and
• Post-operative pain management provided by the surgeon.

Another physician who performs any component of the global package will not receive separate payment unless the surgeon is willing to forego a portion of the payment. For example, a hospitalist admits a patient who has no other identifiable medical conditions aside from the problem prompting surgery. The hospitalist’s role may be dictated by facility policy—quality of care or risk reduction, for example—and administrative requirements (history and physical exam, discharge services, coordination of care) rather than what a payer would perceive as necessary “medical” management. Similarly, if the hospitalist’s post-op care is limited to ordering routine post-op labs or maintaining appropriate pain management, the hospitalist’s service will likely be denied as incidental to the surgical package.

Remember, if the hospitalist’s claim is submitted and paid, it doesn’t mean that the payer won’t retract the payment upon review if an erroneous payment is suspected. A payer review may be triggered when the diagnosis listed on the hospitalist’s claim matches the diagnosis listed on the surgeon’s claim (e.g. 820.8). If too many claims are considered “not medically necessary” due to overlapping care, hospitalists may need to negotiate other terms of payment with the facility to recoup unpaid time and effort when involved in this type of care.

When more than one medical condition exists and several physicians participate in the patient’s care, medical necessity is easily established for each physician. Each physician manages the condition related to his/her expertise. In the above example, the surgeon cares for the patient’s fracture, while the hospitalist oversees diabetes and hypertension management. Service distinction is crucial during the claim submission process. The hospitalist should report a subsequent hospital care code (99231-99233) with a primary diagnosis corresponding to his/her specialty-related care (i.e., 9923x with 250.00, 401.1).³

When more specialists are involved, claim submission becomes more complex. A cardiologist who was also involved in patient management would report his or her service using 401.1. When a different primary diagnosis is assigned to the visit code to indicate the reason for each physician’s involvement, all claims are more likely to be paid.⁴ As long as the hospitalist maintains care over one of the patients’ conditions, concurrent care is justified.

Because these physicians are in different specialties and different provider groups, most payers do not require the modifier 25 (separately identifiable evaluation/management [E/M] service on the same day as a procedure or other service) with the visit code; however, some managed care payers may have a general claim edit that pays the first claim and denies the second unless modifier 25 is appended to the concurrent E/M visit code (i.e., 99232-25) as an attestation that the service is distinct from any other provider’s service that day, despite claim submission under different tax identification numbers. This may not be identified until the claim is rejected or denied. If appropriate modifier use does not yield payment, appeal the denied concurrent care claims with supporting documentation from each physician visit, if possible. This demonstrates each physician’s contribution to care.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual: Chapter 15—Covered Medical and Other Health Services. Section 30.E. Available at: www.cms.gov/manuals/Downloads/bp102c15.pdf. Accessed March 5, 2015.
2. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12—Physicians/Nonphysician Practitioners. Section 40.A. Available at: www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed March 5, 2015.
3. American Medical Association. Current Procedural Terminology 2015 Professional Edition. Chicago: American Medical Association Press; 2014.
4. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12—Physicians/Nonphysician Practitioners. Section 30.6.9.C. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed March 5, 2015.
5. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12—Physicians/Nonphysician Practitioners. Section 30.6.5. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed March 5, 2015.
6. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 26—Completing and Processing Form CMS-1500 Data Set. Section 10.8.2. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf. Accessed March 5, 2015.

Clinical question: Is fondaparinux as safe and effective as argatroban and danaparoid in treating heparin-induced thrombocytopenia (HIT)?

Background: Guidelines for the treatment of HIT recommend using danaparoid (factor Xa inhibitor), argatroban, or lepirudin (both direct thrombin inhibitors). Reduced availability, cost, and complexity of administration limit these options, and fondaparinux is often used off label in the treatment of HIT.

Study design: Retrospective cohort study.

Setting: London Health Sciences Centre, Ontario, Canada.

Synopsis: Investigators analyzed 133 patients receiving fondaparinux for HIT against unmatched (n=106) and matched (n=60) cohorts receiving either argatroban or danaparoid. Using a composite of new thrombotic events, amputation, gangrene, thrombosis-related death, or death in which thrombosis cannot be excluded as the primary outcome, there was no difference between fondaparinux (16.5%) and the unmatched (19.8%) or matched (16.5%) cohorts of argatroban/danaparoid.

There also was no difference in major bleeding events between fondaparinux (21.1%) and the unmatched (25.5%) and matched (20.0%) argatroban/danaparoid cohorts, though major bleeding rates in this group were higher than in other studies, possibly reflecting a greater proportion of patients with renal dysfunction.

The single-site study was underpowered, and generalizability is limited, as the authors could not review all potential patient files. The risk of confounding effects is increased in the absence of randomization and universal gold standard confirmatory testing among the cohort. Prospective trials are needed to establish the safety and efficacy of treating HIT with fondaparinux.

Bottom line: In this underpowered and retrospective cohort study, fondaparinux was as effective in treating HIT as argatroban and danaparoid, with a similar safety profile.

Citation: Kang M, Alahmadi M, Sawh S, Kovacs MJ, Lazo-Langner A. Fondaparinux for the treatment of suspected heparin-induced thrombocytopenia: a propensity score-matched study. Blood. 2015;125(6):924-929.

Clinical question: Is fondaparinux as safe and effective as argatroban and danaparoid in treating heparin-induced thrombocytopenia (HIT)?

Background: Guidelines for the treatment of HIT recommend using danaparoid (factor Xa inhibitor), argatroban, or lepirudin (both direct thrombin inhibitors). Reduced availability, cost, and complexity of administration limit these options, and fondaparinux is often used off label in the treatment of HIT.

Study design: Retrospective cohort study.

Setting: London Health Sciences Centre, Ontario, Canada.

Synopsis: Investigators analyzed 133 patients receiving fondaparinux for HIT against unmatched (n=106) and matched (n=60) cohorts receiving either argatroban or danaparoid. Using a composite of new thrombotic events, amputation, gangrene, thrombosis-related death, or death in which thrombosis cannot be excluded as the primary outcome, there was no difference between fondaparinux (16.5%) and the unmatched (19.8%) or matched (16.5%) cohorts of argatroban/danaparoid.

There also was no difference in major bleeding events between fondaparinux (21.1%) and the unmatched (25.5%) and matched (20.0%) argatroban/danaparoid cohorts, though major bleeding rates in this group were higher than in other studies, possibly reflecting a greater proportion of patients with renal dysfunction.

The single-site study was underpowered, and generalizability is limited, as the authors could not review all potential patient files. The risk of confounding effects is increased in the absence of randomization and universal gold standard confirmatory testing among the cohort. Prospective trials are needed to establish the safety and efficacy of treating HIT with fondaparinux.

Bottom line: In this underpowered and retrospective cohort study, fondaparinux was as effective in treating HIT as argatroban and danaparoid, with a similar safety profile.

Citation: Kang M, Alahmadi M, Sawh S, Kovacs MJ, Lazo-Langner A. Fondaparinux for the treatment of suspected heparin-induced thrombocytopenia: a propensity score-matched study. Blood. 2015;125(6):924-929.

Clinical question: Is fondaparinux as safe and effective as argatroban and danaparoid in treating heparin-induced thrombocytopenia (HIT)?

Background: Guidelines for the treatment of HIT recommend using danaparoid (factor Xa inhibitor), argatroban, or lepirudin (both direct thrombin inhibitors). Reduced availability, cost, and complexity of administration limit these options, and fondaparinux is often used off label in the treatment of HIT.

Study design: Retrospective cohort study.

Setting: London Health Sciences Centre, Ontario, Canada.

Synopsis: Investigators analyzed 133 patients receiving fondaparinux for HIT against unmatched (n=106) and matched (n=60) cohorts receiving either argatroban or danaparoid. Using a composite of new thrombotic events, amputation, gangrene, thrombosis-related death, or death in which thrombosis cannot be excluded as the primary outcome, there was no difference between fondaparinux (16.5%) and the unmatched (19.8%) or matched (16.5%) cohorts of argatroban/danaparoid.

There also was no difference in major bleeding events between fondaparinux (21.1%) and the unmatched (25.5%) and matched (20.0%) argatroban/danaparoid cohorts, though major bleeding rates in this group were higher than in other studies, possibly reflecting a greater proportion of patients with renal dysfunction.

The single-site study was underpowered, and generalizability is limited, as the authors could not review all potential patient files. The risk of confounding effects is increased in the absence of randomization and universal gold standard confirmatory testing among the cohort. Prospective trials are needed to establish the safety and efficacy of treating HIT with fondaparinux.

Bottom line: In this underpowered and retrospective cohort study, fondaparinux was as effective in treating HIT as argatroban and danaparoid, with a similar safety profile.

Citation: Kang M, Alahmadi M, Sawh S, Kovacs MJ, Lazo-Langner A. Fondaparinux for the treatment of suspected heparin-induced thrombocytopenia: a propensity score-matched study. Blood. 2015;125(6):924-929.

Clinical question: Does the presence of a rapid response team (RRT) affect the perception of resident education and autonomy?

Background: Studies on the perception of RRTs, which can generally be activated by any concerned staff member, have been primarily limited to nurses. No studies to date have evaluated resident perception of the effects of RRTs on education or autonomy.

Study design: Survey study measure on a five-point Likert scale.

Setting: Moffitt-Long Hospital, a 600-bed acute care hospital and tertiary academic medical center of the University of California San Francisco.

Synopsis: Among 342 potential respondents, 246 surveys were completed, 10 of which were excluded due a lack of experience with RRTs. Overall, 78% of respondents felt that working with RRTs creates a valuable educational experience, though this was seen more commonly in the responses of medical residents (83.2%) than in those of surgical residents (70.4%). There was no significant difference between interns (82.9%) and upper-level residents (77.3%).

Additionally, 75.8% of respondents did not feel that the presence of an RRT decreased resident autonomy, and there was no statistically significant difference between the responses of interns (77.8%) and upper-level residents (76.8%), or between those of medical (79.9%) and surgical (71.2%) residents.

The survey design increases the risk of response bias, and the single-site nature limits generalizability. Additionally, no objective measurements of education or autonomy were evaluated.

Bottom line: The presence of RRTs is perceived as having educational value and is not perceived by residents as reducing resident autonomy.

Citation: Butcher BW, Quist CE, Harrison JD, Ranji SR. The effect of a rapid response team on resident perceptions of education and autonomy. J Hosp Med. 2015;10(1):8-12.

Clinical question: Does the presence of a rapid response team (RRT) affect the perception of resident education and autonomy?

Background: Studies on the perception of RRTs, which can generally be activated by any concerned staff member, have been primarily limited to nurses. No studies to date have evaluated resident perception of the effects of RRTs on education or autonomy.

Study design: Survey study measure on a five-point Likert scale.

Setting: Moffitt-Long Hospital, a 600-bed acute care hospital and tertiary academic medical center of the University of California San Francisco.

Synopsis: Among 342 potential respondents, 246 surveys were completed, 10 of which were excluded due a lack of experience with RRTs. Overall, 78% of respondents felt that working with RRTs creates a valuable educational experience, though this was seen more commonly in the responses of medical residents (83.2%) than in those of surgical residents (70.4%). There was no significant difference between interns (82.9%) and upper-level residents (77.3%).

Additionally, 75.8% of respondents did not feel that the presence of an RRT decreased resident autonomy, and there was no statistically significant difference between the responses of interns (77.8%) and upper-level residents (76.8%), or between those of medical (79.9%) and surgical (71.2%) residents.

The survey design increases the risk of response bias, and the single-site nature limits generalizability. Additionally, no objective measurements of education or autonomy were evaluated.

Bottom line: The presence of RRTs is perceived as having educational value and is not perceived by residents as reducing resident autonomy.

Citation: Butcher BW, Quist CE, Harrison JD, Ranji SR. The effect of a rapid response team on resident perceptions of education and autonomy. J Hosp Med. 2015;10(1):8-12.

Clinical question: Does the presence of a rapid response team (RRT) affect the perception of resident education and autonomy?

Background: Studies on the perception of RRTs, which can generally be activated by any concerned staff member, have been primarily limited to nurses. No studies to date have evaluated resident perception of the effects of RRTs on education or autonomy.

Study design: Survey study measure on a five-point Likert scale.

Setting: Moffitt-Long Hospital, a 600-bed acute care hospital and tertiary academic medical center of the University of California San Francisco.

Synopsis: Among 342 potential respondents, 246 surveys were completed, 10 of which were excluded due a lack of experience with RRTs. Overall, 78% of respondents felt that working with RRTs creates a valuable educational experience, though this was seen more commonly in the responses of medical residents (83.2%) than in those of surgical residents (70.4%). There was no significant difference between interns (82.9%) and upper-level residents (77.3%).

Additionally, 75.8% of respondents did not feel that the presence of an RRT decreased resident autonomy, and there was no statistically significant difference between the responses of interns (77.8%) and upper-level residents (76.8%), or between those of medical (79.9%) and surgical (71.2%) residents.

The survey design increases the risk of response bias, and the single-site nature limits generalizability. Additionally, no objective measurements of education or autonomy were evaluated.

Bottom line: The presence of RRTs is perceived as having educational value and is not perceived by residents as reducing resident autonomy.

Citation: Butcher BW, Quist CE, Harrison JD, Ranji SR. The effect of a rapid response team on resident perceptions of education and autonomy. J Hosp Med. 2015;10(1):8-12.