Hospitalists are physicians primarily responsible for the care of “orphaned” patients (patients unattached to a family or general practitioner with hospital admitting privileges) admitted to hospital. The hospitalist, who is contracted by the hospital, not only provides care for these patients, but also coordinates care throughout the patients’ hospital stay. Hospitalists work with the patient, the family, nurses, diagnostic staff, and specialists to provide timely, appropriate care. A pilot project for the hospitalist program began on 15 January 2001 at Burnaby Hospital in the former Simon Fraser Health Region. Since then, it has been implemented at seven sites in the Fraser Health Authority. Anecdotally, initial success of the program was evident from the informal feedback from patients, doctors, nurses, and other hospital staff. A more formal quality survey 1 year into the Burnaby program confirmed a high level of acceptance of the program from patients, their families, allied health providers, administrators, and hospitalists. Physician colleagues were independently surveyed and echoed near universal support for the program.
With the doctor-of-the-day system increasingly difficult to staff and an ever-growing population of “orphaned” patients, Burnaby Hospital had a problem. Their hospitalist program, now in its sixth year, seems to be the solution.
Prior to the hospitalist program implementation, hospitals in the former Simon Fraser Health Region (SFHR) found the doctor-of-the-day system increasingly difficult to staff. Concern grew among family physicians with hospital privileges, as they were caring for an ever-increasing number of “orphaned” patients, that is, patients unattached to a family or general practitioner with hospital admitting privileges.
The number of orphaned patients is rising because of a number of factors, including a limited supply of family physicians, an increasing reliance on walk-in clinics, and an increasing number of family practitioners dropping hospital privileges.
Burnaby Family Practice brought concerns to the attention of the SFHR Board in May 1999, prompting an investigation into possible alternatives. Medical representatives from each of the acute care sites in the region participated in researching possibilities, and the hospitalist solution surfaced.
Insight into an active hospitalist program was gained from a visit to Calgary’s Foothills, Peter Lougheed, and Rocky View hospitals. Information gained from this visit was valuable in developing a framework for the SFHR program.
Program goals and objectives, the framework, and costs were presented to the health board, and with subsequent approval, a pilot project began at Burnaby Hospital on 15 January 2001.
The key objectives of the hospitalist program are to:
• Provide for the medical needs of orphaned patients in the hospital.
• Improve continuity of medical care with 24-hour medical coverage.
• Provide support for consultants.
• Develop the expertise required for improved efficiency through safe, earlier discharge.
Guiding principles developed for the hospitalist program include absorption of these programs into the Department of Family Practice, development of a chief hospitalist at each site to coordinate the program and report to the medical director, and job equity between sites (hours of coverage, patient loads, and compensation will be similar for core job duties). It was also determined that the programs would be monitored using the same key indicators and that communication with all concerned parties would be done on a timely basis. Assignment of hospital privileges continues as per the medical staff bylaws. Improved medical quality is a cornerstone value of all programs and the foundation of the group practice.
While parameters were set, it was clearly determined that the program would be designed specifically for each acute care site—tailored to meet the individual needs of each site and of the communities they serve.
The hospitalist provides high-quality inpatient clinical services, including admission and ongoing care for patients who don’t have a family physician with admitting privileges. In the coordination role, the hospitalist liaises with necessary specialists and participates in the transfer of care and ongoing care from other services for orphaned patients.
Other primary responsibilities include:
• Notifying the patient’s primary physician within 24 hours of admission.
• Monitoring admissions and discharges to promote optimal bed use.
• Providing concise, clearly legible documentation of patient progress and plans, including a plan of care upon admission.
• Participating in program quality improvement, utilization management, and the establishment of benchmarks and measurement mechanisms in accordance with the departmental quality assurance framework.
Benefits of the hospitalist program are many. For the patient, there is coordinated care and more comprehensive and reliable around-the-clock access to a physician. Patients are discharged with a handwritten copy of their discharge summary/medications. A copy is also faxed to their family physician by the next day and the full transcribed dictation follows. For patients with no family physician, a list of doctors accepting patients is given to them at discharge. (More than 94% of the patients have an identified community-based family physician.)
For the hospitalist, there is an opportunity to develop expertise in the care of common inpatient disorders. With the increasing acuity of patients being admitted from the emergency department, this expertise is invaluable to providing the best possible care. There is no office overhead and a flexible schedule allows for a better work and personal life.
For primary care physicians who struggle to juggle heavy workloads in their offices and hospital, there is the opportunity to direct energies solely to their main professional focus. This translates into improved lifestyle for community-based family physicians with a reduction in less productive time.
The main benefits for the hospital are decreased resource utilization, increased communication with nurses, allied health professionals, and other hospital physicians. Because the hospitalist is on site, patients’ length of stay is reduced because they are assessed more quickly and the diagnostic workup is begun sooner.
As a result of the Burnaby hospitalist program, on average there are 15 fewer patients hospitalized at any given time. This represents 6.5% overall reduction in the bed base, or 11% of the medical/surgical beds. The reality is that 15 beds are no longer required or staffed, which translates into more than $1 million potential cost savings.
A 3-month evaluation of the Burnaby pilot captured evidence that the program was achieving the projected and desired outcomes. Although preliminary, the results indicated success. Specifically:
• The program accepted 38.3% of family practice patients, slightly higher than the predicted 34%.
• The majority of the patients (96%) entered via the emergency department.
• The program exceeded the projected decrease in length of stay of 16%, with a 27.6% reduction against the control group.
• The Alternate Level of Care (ALC) rate for the hospitalist program was significantly lower than comparison groups.
• The documentation requirements were met (99.8%), with information given to the primary care physician within 24 hours of admission and discharge.
Further analysis of the program for the period April to mid-September 2002 revealed:
• The average age of hospitalist patients was 64.5 compared with family physician patients at 72.3.
• During the period studied, hospitalists cared for 1028 patients while family physicians managed 551 cases.
• The hospitalists’ patients used 10 288 hospital days (average length of stay: 10.1 days) whereas the family physician patients used 11 118 days (average length of stay: 20.2 days).
• When long-stay patients (greater than 30 days) were removed from the data sets, the hospitalists’ patients’ average length of stay was 6.55 days, while the family physicians’ patients averaged 8.9 days.
• These rough data reveal a 50% reduction in overall length-of-stay in the entire cohort and a greater than 25% reduction when longer-stay patients are removed from the data set.
Other performance indicators reveal a dramatic change in patient flow throughout the hospital within 1 year of the program start, with discharges occurring evenly throughout the week. In the 2 years prior, weekend discharges accounted for 16% of total discharges. This rose to over 24% with the hospitalist program in place.
More recently, 7-day recidivism rates were compared and the hospitalist group patients were half as likely to be readmitted (4% versus 8%).
Since the advent of the program there have been fewer than five complaints from patients or their families about not having their usual family physician care for them.
Hospitalists are contracted to the facility and paid for hours worked. The health authority submits fee-for-service billing and payment is assigned to the health authority. Fee-for-service covers a portion of the costs (55% to 65%) and Fraser Health contributes the balance. Alternate methods of payment are being explored through ongoing discussions with the Ministry of Health, with the expectation that the hospitalist program will become an alternate payment program.
Hospitalist programs are evolving in response to the multiple pressures of our society, which increasingly operates on a 24-hours-a-day, 7-days-a-week basis. The main driver is the need for hospitals to provide physician coverage for unattached patients. Canada is fortunate to have well-trained family physicians who are well suited to undertake this demanding work. All have experienced a steep learning curve with ongoing educational and learning experiences that are further defining the scope and skill set of their new specialty.
There are significant issues that need to be resolved in every community as these programs evolve.
The 24 or more inpatients seen by a hospitalist in an average workday can potentially save 12 to 20 family physicians an hour or more time, allowing them to see more community-based patients. This has a beneficial effect as we are facing increasing physician resource problems.
The Burnaby Emergency Department has experienced a drop from nearly 60 000 to 50 000 visits during the last few years. Much of this reduction is attributable to walk-in clinics, but no new walk-in clinics have been opened in that period. At the same time, more than 80% of the family physicians are no longer caring for hospital inpatients. Hospitalists now manage more than 80% of the Burnaby Hospital patient load in 65% of the total bed base. As a group, each day they average 120 to 130 patients and have four 10-hour shifts for ward rounds, admissions, and discharges. There is a 12-hour overnight shift that is primarily provided to assure seamless, timely coverage for admissions and crisis intervention for any patient in the hospital. The hospitalist on duty also attends cardiac arrests with the emergency physician to provide an invaluable extra set of hands for these often difficult cases.
In conversation: Hospitalist Gordon Doyle
After dedicating 18 years to a family practice in Squamish, Dr Gordon Doyle recently switched gears to take on the role of chief hospitalist at Burnaby Hospital. Like many family physicians, he was looking for a change, but still wanted to practise hospital-based medicine. Taking charge of the 24/7, 365-days-a-year hospitalist program seemed a perfect fit.
“The hospitalist program comes at a time when specialty and family physicians, already in short supply, have clearly demonstrated that they are not willing to participate in a 70- to 80-hour workweek any more,” says Dr Doyle.
“It’s difficult to be in two places at once, and that in essence is what the family physicians have been doing in serving patients in their office and those in hospital, whose condition may change quickly and need urgent attention,” he says.
“More and more, doctors are looking for more defined work hours, activity, and incomes, and are less likely to open themselves up to open-ended demands.
For community physicians, the hospitalist program offers relief from hospital burdens, while providing a safety net for their patients, and consequently a measure of comfort for physicians that their patients are in very capable hands,” he adds.
“It frees up doctors to concentrate on family practice duties, and gives them a greater opportunity to find a balance between professional and personal lives. Further evidence for needed change is the increasing difficulty being experienced in finding locums who will cover family practice as well as hospital care.”
In the Year 1 satisfaction survey results, two nurses said it is the single most positive thing that Burnaby Hospital has done since they started their careers in 1990, mostly because the 24-hour-a-day availability and bedside presence of a physician had improved their job satisfaction immeasurably. In most dimensions the satisfaction survey results consistently had performance rated as good to excellent by over 90% of allied health staff.
The hospitalist is rewarded with the challenge of the patient acuity, the chance to develop expertise, and the opportunity for a better lifestyle. Nurses now have physicians readily available to respond to urgent calls to attend patients who experience a change in health status and require physician assessment and treatment.
As for the patients, there has been excellent overall satisfaction and acceptance. Dr Doyle pointed to initial concerns voiced by patients about not being cared for by their own doctor. However, he said, it is believed that the acceptance and trust came as the realization spread throughout the community that this is a new pattern of practice.
He believes patients and their families will continue to see the added benefits from the program, such as the 24-hour access to a physician and increased opportunities to speak to a physician face-to-face.
Brian McGowan, MD, and Marie Nightingale
Dr McGowan is the medical director of Burnaby Hospital. Ms Nightingale is a communications consultant with the Fraser Health Authority.
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