PERSPECTIVE
B R ID G IN G
THE
H O S P IT A L IS T — PRI M A R Y
CARE
D IV ID E
Bridging the Hospitalist-Prim ary Care Divide through Collaborative Care Allan H. Goroll, M.D., and Daniel P. Hunt, M.D.
ne of the most notable changes in the delivery of medical care in the United States in the past quarter-century has been the near disappearance of primary care physicians (PCPs) from general medical inpatient care, replaced by a new breed of generalist: the hospitalist.1 There are many reasons for this shift, ranging from revenue-driven pres sures to increase office visits and minimize lengths of hospital stays to physicians’ desires for more manageable lifestyles as both outpatient and inpatient care become more intensive and de manding. Many young physi cians who aspire to be general ists — especially graduates of general internal medicine resi dencies — now choose hospital ist positions over office-based primary care opportunities.2 Hospitalist care is more effi cient than traditional models of inpatient care and, on average, appears to be of similar quality.3 Good communication among hospitalist team members and between hospitalists and PCPs can lead to seamless, efficient, well-coordinated care; however, shift-work schedules and suboptimal communication and passoffs can result in fragmented, impersonal care and excessive testing.4 Inpatients often ask, “Who is the doctor here?” and wonder, at moments of acute need, “Where is my own doc tor?” Hospitalists can become overwhelmed with the care of patients with complex conditions whom they’ve only just met; es pecially difficult are personal
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ized decisions about the appro priate intensity of care, especially near the end of life. PCPs may feel isolated from their patients and disconnected from decision making, which can compromise postdischarge management. These shortcomings suggest that the current dichotomous di vision of labor between hospital ists and PCPs warrants reconsid eration, though any alternative approach needs to respect the achievements of the current sys tem, which have included re duced lengths of stay, enhanced standards for inpatient care, the development of a new cadre of generalist clinician-educators in teaching hospitals, and the trans formation of primary care prac tices into medical homes. Past solutions to address issues of con tinuity of care and information transfer have included designat ing members of a primary care practice or group to serve, on a rotating basis, as the attending physicians for their patients. A re lated option is to assign a small number of hospitalists to a pri mary care group or to embed them within it. Logistic and pro fessional barriers such as equity in scheduling and payment, cross coverage needs, and the chal lenge of interfacing with unfa miliar and complex medical and system environments have limit ed the adoption of these models. Mindful of the forces that maintain the current division of labor, but taking into consider ation emerging reforms in pri mary care payment and practice, we have been exploring alterna
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tive strategies for bridging the chasm between inpatient and primary care. The endeavor is timely in an era of multidiscipli nary teams, patient-centered care, and enhanced payment for care management and coordination. In 2002, Wachter and Pantilat suggested that PCPs make a “con tinuity visit” when their patients were hospitalized, to maintain involvement and help coordinate their care.5 They envisioned a visit once or twice during a pa tient’s hospital stay that would involve a brief discussion with the patient, a focused exam, and documentation to assist the hos pitalist team, for which physi cians would receive a modest payment. Although PCPs do some times make such visits, our expe rience suggests that this practice never became widespread because of persisting financial and work pressures. With the advent of pri mary care practice transforma tion and increasing interest in payment reform, we believe it might be time to reconsider and revitalize this model. We propose a collaborative in patient care model that incorpo rates the PCP into the hospitalist team as a consultant. Under this voluntary system, PCPs would visit their hospitalized patients within 12 to 18 hours after ad mission to provide support and counseling to them and their families and consultation to the hospitalist team. The consultation would focus on the direction and scope of the patient’s workup and care. The PCP would write a succinct consultation note, high-
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lighting key elements of the pa tient’s history (including perti nent family and psychosocial components), physical exam, and recent testing, and conclude with a prioritized differential diagno sis and recommendations for per sonalized inpatient evaluation and management. The hospitalist team would still retain full attendingphysician responsibilities. The initial consultation — con tributing insights from an estab lished doctor-patient relationship — would be designed to comple ment and help inform the hospi talises admission workup and care plan, aiming to reduce hos pitalist workload while increasing personalization of care. Subse quent to the admission consulta tive visit, the PCP would be avail able to meet with the patient, family, and hospitalist team on an as-needed basis, returning just before discharge to consult on the design of a coordinated posthospital program. A key challenge to implement ing collaborative inpatient care will be ensuring that PCPs have time to fulfill this role, which can be especially daunting for those in solo or small-group prac tices that are still reimbursed un der traditional fee-for-service ar rangements. Many such practices cannot afford the often-recom mended multidisciplinary team structure that can shift PCP work load to more value-added activi ties such as care coordination and management. Having a well functioning primary care team is probably essential to PCP partici pation in collaborative inpatient care. Emerging electronic tech nologies could play an important facilitative role, making possible “virtual visits” when a live visit is not deemed necessary, freeing up time for essential live visits.
B R ID G IN G
THE
For collaborative care to suc ceed, the hospitalist workflow also needs adjustment to make best use of the PCP’s input. The inpatient team’s organization and communication protocols will need to be revised. Enhanced in formation flow (made possible by an interoperable electronic medi cal record) and timely collabora tion and consultative input from the PCP (some o f which might be virtual) should allow hospitalists to care for inpatients more ef ficiently and cost-effectively. Implementing collaborative in patient care would also require payment reform that removes in centives for maximizing the vol ume of office visits. Risk-adjust ed bundled and global payment models are one approach to pay ment reform; capitated care-man agement fees that supplement fee-for-service contracts are an other. Even a traditional fee-forservice payment system could support a collaborative inpatient care model if it were comple mented by a new set o f evalua tion and management codes for collaborative care, with appropri ate scores reflecting the total amount of time and effort that PCPs spend on inpatient consul tations and taking into account the complexity of the patient’s conditions and the value created by these visits. Budget-conscious observers may raise concern that payment to PCPs for inpatient work could in crease total costs. Savings should accrue, however, from improved diagnostic efficiency and accuracy; from reductions in lengths of stay, unnecessary testing, preventable readmissions, and inappropriate discharges; and from enhanced compliance, follow-up, and patient satisfaction — measurable param eters that can be used to evaluate
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the efficacy of the proposed re forms. We would expect savings to be realized in both inpatient and outpatient settings. Pilot stud ies of this proposed model could focus on overall cost, clinical out comes, operational metrics (e.g., length of stay, prenoon-discharge rates, 30-day readmissions), and patient satisfaction. The current hospitalist-ambulist division of general medical care has made important contri butions to patient care, but it leaves much to be desired, espe cially with regard to personaliza tion and continuity of care. A col laborative inpatient care model that incorporates the PCP into the hospitalist team as a consul tant has the potential to costeffectively improve the patient’s care experience and other impor tant outcomes, as well as en hance professional satisfaction at this critical time for both hospitalists and PCPs. Disclosure forms provided by the authors are available with the full text of this article at NEJM.org. F ro m th e D iv is io n o f G e n e ra l In te rn a l M e d ic in e ,
M a s s a c h u s e tts
G e n e ra l
H o s p ita l,
B o s to n .
1. K uo YF, S h a rm a G, Freem an JL, G o o d w in JS. G ro w th in th e care o f o ld e r p a tie n ts by h o s p ita lis ts in th e U n ite d S tate s. N Engl J M e d 2009;3 60:1 102 -12. 2 . W e s t CP, D u p ra s D M . G e n e ra l m e d ic in e vs s u b s p e c ia lty c a re e r p la n s a m o n g in te rn a l m e d ic in e re s id e n ts .J A M A 2012;308:2241-7. 3. W h ite H L , G la z ie r R H . D o h o s p ita lis t p h y s ic ia n s im p ro v e th e q u a lity o f in p a tie n t care d e live ry? A s y s te m a tic re v ie w o f p ro c e s s , e f fic ie n c y an d o u tc o m e m e a s u re s . B M C M e d 2011;9:58. 4 . T u rn e r J, H a n s e n L, H in a m i K, e t al. T h e im p a c t o f h o s p ita lis t d is c o n tin u ity o n h o s p i ta l c o s t, re a d m is s io n s , an d p a tie n t s a tis fa c tio n .J G en In te rn M e d 20 14;2 9:10 04-8. 5. W a c h te r R M , P a n tila t SZ. T h e " c o n tin u ity v is it " an d th e h o s p ita lis t m o d e l o f care. D is M o n 2002;48:26 7-7 2. D O I: 10.1056/NEJMpl411416 C opyright © 2015 Massachusetts M e d ical Society.
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Copyright © Massachusetts Medical Society 2015.
B R ID G IN G
THE
H O S P IT A L IS T — PRI M A R Y
CARE
D IV ID E
Bridging the Hospitalist-Prim ary Care Divide through Collaborative Care Allan H. Goroll, M.D., and Daniel P. Hunt, M.D.
ne of the most notable changes in the delivery of medical care in the United States in the past quarter-century has been the near disappearance of primary care physicians (PCPs) from general medical inpatient care, replaced by a new breed of generalist: the hospitalist.1 There are many reasons for this shift, ranging from revenue-driven pres sures to increase office visits and minimize lengths of hospital stays to physicians’ desires for more manageable lifestyles as both outpatient and inpatient care become more intensive and de manding. Many young physi cians who aspire to be general ists — especially graduates of general internal medicine resi dencies — now choose hospital ist positions over office-based primary care opportunities.2 Hospitalist care is more effi cient than traditional models of inpatient care and, on average, appears to be of similar quality.3 Good communication among hospitalist team members and between hospitalists and PCPs can lead to seamless, efficient, well-coordinated care; however, shift-work schedules and suboptimal communication and passoffs can result in fragmented, impersonal care and excessive testing.4 Inpatients often ask, “Who is the doctor here?” and wonder, at moments of acute need, “Where is my own doc tor?” Hospitalists can become overwhelmed with the care of patients with complex conditions whom they’ve only just met; es pecially difficult are personal
O
3 0 8
ized decisions about the appro priate intensity of care, especially near the end of life. PCPs may feel isolated from their patients and disconnected from decision making, which can compromise postdischarge management. These shortcomings suggest that the current dichotomous di vision of labor between hospital ists and PCPs warrants reconsid eration, though any alternative approach needs to respect the achievements of the current sys tem, which have included re duced lengths of stay, enhanced standards for inpatient care, the development of a new cadre of generalist clinician-educators in teaching hospitals, and the trans formation of primary care prac tices into medical homes. Past solutions to address issues of con tinuity of care and information transfer have included designat ing members of a primary care practice or group to serve, on a rotating basis, as the attending physicians for their patients. A re lated option is to assign a small number of hospitalists to a pri mary care group or to embed them within it. Logistic and pro fessional barriers such as equity in scheduling and payment, cross coverage needs, and the chal lenge of interfacing with unfa miliar and complex medical and system environments have limit ed the adoption of these models. Mindful of the forces that maintain the current division of labor, but taking into consider ation emerging reforms in pri mary care payment and practice, we have been exploring alterna
N E N G LJ M ED 37214
NEJM .O RG
tive strategies for bridging the chasm between inpatient and primary care. The endeavor is timely in an era of multidiscipli nary teams, patient-centered care, and enhanced payment for care management and coordination. In 2002, Wachter and Pantilat suggested that PCPs make a “con tinuity visit” when their patients were hospitalized, to maintain involvement and help coordinate their care.5 They envisioned a visit once or twice during a pa tient’s hospital stay that would involve a brief discussion with the patient, a focused exam, and documentation to assist the hos pitalist team, for which physi cians would receive a modest payment. Although PCPs do some times make such visits, our expe rience suggests that this practice never became widespread because of persisting financial and work pressures. With the advent of pri mary care practice transforma tion and increasing interest in payment reform, we believe it might be time to reconsider and revitalize this model. We propose a collaborative in patient care model that incorpo rates the PCP into the hospitalist team as a consultant. Under this voluntary system, PCPs would visit their hospitalized patients within 12 to 18 hours after ad mission to provide support and counseling to them and their families and consultation to the hospitalist team. The consultation would focus on the direction and scope of the patient’s workup and care. The PCP would write a succinct consultation note, high-
J AN UARY 2 2 , 2 0 1 5
PERSPECTIVE
lighting key elements of the pa tient’s history (including perti nent family and psychosocial components), physical exam, and recent testing, and conclude with a prioritized differential diagno sis and recommendations for per sonalized inpatient evaluation and management. The hospitalist team would still retain full attendingphysician responsibilities. The initial consultation — con tributing insights from an estab lished doctor-patient relationship — would be designed to comple ment and help inform the hospi talises admission workup and care plan, aiming to reduce hos pitalist workload while increasing personalization of care. Subse quent to the admission consulta tive visit, the PCP would be avail able to meet with the patient, family, and hospitalist team on an as-needed basis, returning just before discharge to consult on the design of a coordinated posthospital program. A key challenge to implement ing collaborative inpatient care will be ensuring that PCPs have time to fulfill this role, which can be especially daunting for those in solo or small-group prac tices that are still reimbursed un der traditional fee-for-service ar rangements. Many such practices cannot afford the often-recom mended multidisciplinary team structure that can shift PCP work load to more value-added activi ties such as care coordination and management. Having a well functioning primary care team is probably essential to PCP partici pation in collaborative inpatient care. Emerging electronic tech nologies could play an important facilitative role, making possible “virtual visits” when a live visit is not deemed necessary, freeing up time for essential live visits.
B R ID G IN G
THE
For collaborative care to suc ceed, the hospitalist workflow also needs adjustment to make best use of the PCP’s input. The inpatient team’s organization and communication protocols will need to be revised. Enhanced in formation flow (made possible by an interoperable electronic medi cal record) and timely collabora tion and consultative input from the PCP (some o f which might be virtual) should allow hospitalists to care for inpatients more ef ficiently and cost-effectively. Implementing collaborative in patient care would also require payment reform that removes in centives for maximizing the vol ume of office visits. Risk-adjust ed bundled and global payment models are one approach to pay ment reform; capitated care-man agement fees that supplement fee-for-service contracts are an other. Even a traditional fee-forservice payment system could support a collaborative inpatient care model if it were comple mented by a new set o f evalua tion and management codes for collaborative care, with appropri ate scores reflecting the total amount of time and effort that PCPs spend on inpatient consul tations and taking into account the complexity of the patient’s conditions and the value created by these visits. Budget-conscious observers may raise concern that payment to PCPs for inpatient work could in crease total costs. Savings should accrue, however, from improved diagnostic efficiency and accuracy; from reductions in lengths of stay, unnecessary testing, preventable readmissions, and inappropriate discharges; and from enhanced compliance, follow-up, and patient satisfaction — measurable param eters that can be used to evaluate
N ENG LJ
M ED 37214
N E J M .O R G
JA N U A R Y 22, 2 0 1
H OS P IT A L IS T -P R I M ARY CARE
D IV ID E
the efficacy of the proposed re forms. We would expect savings to be realized in both inpatient and outpatient settings. Pilot stud ies of this proposed model could focus on overall cost, clinical out comes, operational metrics (e.g., length of stay, prenoon-discharge rates, 30-day readmissions), and patient satisfaction. The current hospitalist-ambulist division of general medical care has made important contri butions to patient care, but it leaves much to be desired, espe cially with regard to personaliza tion and continuity of care. A col laborative inpatient care model that incorporates the PCP into the hospitalist team as a consul tant has the potential to costeffectively improve the patient’s care experience and other impor tant outcomes, as well as en hance professional satisfaction at this critical time for both hospitalists and PCPs. Disclosure forms provided by the authors are available with the full text of this article at NEJM.org. F ro m th e D iv is io n o f G e n e ra l In te rn a l M e d ic in e ,
M a s s a c h u s e tts
G e n e ra l
H o s p ita l,
B o s to n .
1. K uo YF, S h a rm a G, Freem an JL, G o o d w in JS. G ro w th in th e care o f o ld e r p a tie n ts by h o s p ita lis ts in th e U n ite d S tate s. N Engl J M e d 2009;3 60:1 102 -12. 2 . W e s t CP, D u p ra s D M . G e n e ra l m e d ic in e vs s u b s p e c ia lty c a re e r p la n s a m o n g in te rn a l m e d ic in e re s id e n ts .J A M A 2012;308:2241-7. 3. W h ite H L , G la z ie r R H . D o h o s p ita lis t p h y s ic ia n s im p ro v e th e q u a lity o f in p a tie n t care d e live ry? A s y s te m a tic re v ie w o f p ro c e s s , e f fic ie n c y an d o u tc o m e m e a s u re s . B M C M e d 2011;9:58. 4 . T u rn e r J, H a n s e n L, H in a m i K, e t al. T h e im p a c t o f h o s p ita lis t d is c o n tin u ity o n h o s p i ta l c o s t, re a d m is s io n s , an d p a tie n t s a tis fa c tio n .J G en In te rn M e d 20 14;2 9:10 04-8. 5. W a c h te r R M , P a n tila t SZ. T h e " c o n tin u ity v is it " an d th e h o s p ita lis t m o d e l o f care. D is M o n 2002;48:26 7-7 2. D O I: 10.1056/NEJMpl411416 C opyright © 2015 Massachusetts M e d ical Society.
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Copyright © Massachusetts Medical Society 2015.
