Clinical

In a poster presented at HM12, Kathryn Quinn, MPH, CPPS, FACHE, described how her quality team at the University of California at San Francisco (UCSF) developed a checklist to improve physician communication with patients, then taught it to the attending hospitalist faculty.¹ The project began with a list of 29 best practices for patient-physician interaction, as identified in medical literature. Hospitalists then voted for the elements they felt were most important to their practice, as well as those best able to be measured, and a top-10 list was created.

Quinn, the program manager for quality and safety in the division of hospital medicine at UCSF, says the communication best practices were “chosen by the people whose practices we are trying to change.”

The quality team presented the best practices in one-hour training sessions that included small-group role plays, explains co-investigator and UCSF hospitalist Diane Sliwka, MD. The training extended to outpatient physicians, medical specialists, and chief residents. Participants also were provided a laminated pocket card listing the interventions. They also received feedback from structured observations with patients on service.

Quinn says UCSF hospitalists have improved at knocking and asking permission to enter patient rooms, introducing themselves by name and role, and encouraging questions at the end of the interaction. They have been less successful at inquiring about the patient’s concerns early in the interview and at discussing duration of treatment and next steps.

“We learned that it takes more than just talk,” Quinn says. “Just telling physicians how to improve communication doesn’t mean it’s easy to do.”

Still to be determined is the project’s impact on patient satisfaction scores, although the hospitalists reported that they found the training and feedback helpful.

References

1. Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
2. Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
3. Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
4. JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
5. Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.

In a poster presented at HM12, Kathryn Quinn, MPH, CPPS, FACHE, described how her quality team at the University of California at San Francisco (UCSF) developed a checklist to improve physician communication with patients, then taught it to the attending hospitalist faculty.¹ The project began with a list of 29 best practices for patient-physician interaction, as identified in medical literature. Hospitalists then voted for the elements they felt were most important to their practice, as well as those best able to be measured, and a top-10 list was created.

Quinn, the program manager for quality and safety in the division of hospital medicine at UCSF, says the communication best practices were “chosen by the people whose practices we are trying to change.”

The quality team presented the best practices in one-hour training sessions that included small-group role plays, explains co-investigator and UCSF hospitalist Diane Sliwka, MD. The training extended to outpatient physicians, medical specialists, and chief residents. Participants also were provided a laminated pocket card listing the interventions. They also received feedback from structured observations with patients on service.

Quinn says UCSF hospitalists have improved at knocking and asking permission to enter patient rooms, introducing themselves by name and role, and encouraging questions at the end of the interaction. They have been less successful at inquiring about the patient’s concerns early in the interview and at discussing duration of treatment and next steps.

“We learned that it takes more than just talk,” Quinn says. “Just telling physicians how to improve communication doesn’t mean it’s easy to do.”

Still to be determined is the project’s impact on patient satisfaction scores, although the hospitalists reported that they found the training and feedback helpful.

References

1. Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
2. Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
3. Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
4. JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
5. Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.

In a poster presented at HM12, Kathryn Quinn, MPH, CPPS, FACHE, described how her quality team at the University of California at San Francisco (UCSF) developed a checklist to improve physician communication with patients, then taught it to the attending hospitalist faculty.¹ The project began with a list of 29 best practices for patient-physician interaction, as identified in medical literature. Hospitalists then voted for the elements they felt were most important to their practice, as well as those best able to be measured, and a top-10 list was created.

Quinn, the program manager for quality and safety in the division of hospital medicine at UCSF, says the communication best practices were “chosen by the people whose practices we are trying to change.”

The quality team presented the best practices in one-hour training sessions that included small-group role plays, explains co-investigator and UCSF hospitalist Diane Sliwka, MD. The training extended to outpatient physicians, medical specialists, and chief residents. Participants also were provided a laminated pocket card listing the interventions. They also received feedback from structured observations with patients on service.

Quinn says UCSF hospitalists have improved at knocking and asking permission to enter patient rooms, introducing themselves by name and role, and encouraging questions at the end of the interaction. They have been less successful at inquiring about the patient’s concerns early in the interview and at discussing duration of treatment and next steps.

“We learned that it takes more than just talk,” Quinn says. “Just telling physicians how to improve communication doesn’t mean it’s easy to do.”

Still to be determined is the project’s impact on patient satisfaction scores, although the hospitalists reported that they found the training and feedback helpful.

References

1. Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
2. Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
3. Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
4. JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
5. Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.

Johnbuck Creamer, MD

SHM added a new item to its 2012 State of Hospital Medicine report: the ratio of respondents’ observation admissions to inpatient admission encounters. This metric was added because observation encounters have been increasing, with financial effects on hospitals and patients. SHM survey respondents reported a 20% observation rate for both adult and pediatric practice groups (see Figure 1).

Johnbuck Creamer, MD

Under observation status, services that used to be billed as inpatient status (e.g. chest pain evaluation, treatment of asthma exacerbation) must be billed by the hospital at much lower outpatient rates. Some hospitals have responded to this financial pressure by creating observation units or making other operational adjustments. One recent analysis suggested that nationwide adoption of such efforts could save billions of dollars.¹

Becoming lean enough to do short work in short time, though, does not address all of the observation-related issues facing hospitals. When the Centers for Medicare & Medicaid Services’ (CMS) Recovery Audit Contractors (RACs) determine retrospectively that an inpatient admission should have been an observation encounter, the hospital’s payment is not downgraded but forfeited.² This development has prompted hospitals to preemptively opt for observation status for certain patients. Case managers and providers increasingly are spending time reviewing inpatient versus observation status throughout a patient’s stay. Many hospitals have turned to third-party contractors to help review observation status.

Observation status has financial implications for patients as well. In the past year, USA Today, The Wall Street Journal, and CNN Money all have reported on patients hit with unexpected out-of-pocket expenses related to observation care.^3,4,5 A common theme: Medicare patient hospitalized with an acute fracture, managed nonoperatively but requiring rehabilitation prior to returning home. These patients found out too late that observation, a status they were often unaware of, did not qualify for CMS’ three-day inpatient requirement to cover rehabilitation costs. Some patients were charged exorbitant prices for noncovered “outpatient” services, such as providing their routine medications.

Advocacy groups have joined the fray on patients’ behalf, and legal challenges have ensued. AARP and others are educating patients about observation status—and their right to challenge it. The Center for Medicare Advocacy (www.kslaw.com/Library/publication/HH111411_Bagnall.pdf) has filed a lawsuit against the U.S. Department of Health and Human Services on behalf of patients hit with uncovered rehabilitation costs, and the American Hospital Association has teamed with several hospitals to sue over funds forfeited in RAC audits (www.aha.org/content/12/121101-aha-hhs-medicare-com.pdf). Both houses of Congress have legislation (H.R. 1543 and S. 818) seeking to count observation days toward the Medicare three-day rule. For its part, CMS has promised to review observation status and, hopefully, clarify the rules.

Hospitalists, meanwhile, are gearing up for more observation care. The 2012 State of Hospital Medicine report shows that 37% of adult groups and 28% of pediatric groups reported having primary responsibility for observation or short-stay units. My own hospital runs both a clinical decision unit in the ED and a short-stay unit staffed by our hospitalist group. As SHM tracks observation status in future surveys, HM groups will be able to follow this phenomenon among their colleagues and benchmark their own rates of observation encounters.

Dr. Creamer is medical director of the short-stay unit at MetroHealth Medical Center in Cleveland and a member of SHM’s Practice Analysis Committee.

References

1. Feng Z, Wright DB, Mor V. Sharp rise in Medicare enrollees being held in hospitals for observation raises concerns about causes and consequences. Health Aff (Millwood). 2012;31(6):1251-1259.
2. Baugh CW, Venkatesh AK, Hilton JA, Samuel PA, Schuur JD, Bohan JS. Making greater use of dedicated hospital observation units for many short-stay patients could save $3.1 billion a year. Health Aff (Millwood). 2012;31(10):2314-2323.
3. Gengler A. The painful new trend in Medicare. CNN Money website. Available at: http://money.cnn.com/2012/08/07/pf/medicare-rehab-costs.moneymag/index.htm. Accessed March 6, 2013.
4. Jaffe S. Patients held for observation can face steep drug bills. USA Today website. Available at: http://usatoday30.usatoday.com/money/industries/health/drugs/story/2012-04-30/drugs-can-be-expensive-in-observation-care/54646378/1. Accessed March 6, 2013.
5. Landro L. Filling a gap between ERs and inpatient rooms. The Wall Street Journal website. Available at: http://online.wsj.com/article/SB10001424052970204349404578101060863887052.html. Accessed March 6, 2013.

Johnbuck Creamer, MD

SHM added a new item to its 2012 State of Hospital Medicine report: the ratio of respondents’ observation admissions to inpatient admission encounters. This metric was added because observation encounters have been increasing, with financial effects on hospitals and patients. SHM survey respondents reported a 20% observation rate for both adult and pediatric practice groups (see Figure 1).

Johnbuck Creamer, MD

Under observation status, services that used to be billed as inpatient status (e.g. chest pain evaluation, treatment of asthma exacerbation) must be billed by the hospital at much lower outpatient rates. Some hospitals have responded to this financial pressure by creating observation units or making other operational adjustments. One recent analysis suggested that nationwide adoption of such efforts could save billions of dollars.¹

Becoming lean enough to do short work in short time, though, does not address all of the observation-related issues facing hospitals. When the Centers for Medicare & Medicaid Services’ (CMS) Recovery Audit Contractors (RACs) determine retrospectively that an inpatient admission should have been an observation encounter, the hospital’s payment is not downgraded but forfeited.² This development has prompted hospitals to preemptively opt for observation status for certain patients. Case managers and providers increasingly are spending time reviewing inpatient versus observation status throughout a patient’s stay. Many hospitals have turned to third-party contractors to help review observation status.

Observation status has financial implications for patients as well. In the past year, USA Today, The Wall Street Journal, and CNN Money all have reported on patients hit with unexpected out-of-pocket expenses related to observation care.^3,4,5 A common theme: Medicare patient hospitalized with an acute fracture, managed nonoperatively but requiring rehabilitation prior to returning home. These patients found out too late that observation, a status they were often unaware of, did not qualify for CMS’ three-day inpatient requirement to cover rehabilitation costs. Some patients were charged exorbitant prices for noncovered “outpatient” services, such as providing their routine medications.

Advocacy groups have joined the fray on patients’ behalf, and legal challenges have ensued. AARP and others are educating patients about observation status—and their right to challenge it. The Center for Medicare Advocacy (www.kslaw.com/Library/publication/HH111411_Bagnall.pdf) has filed a lawsuit against the U.S. Department of Health and Human Services on behalf of patients hit with uncovered rehabilitation costs, and the American Hospital Association has teamed with several hospitals to sue over funds forfeited in RAC audits (www.aha.org/content/12/121101-aha-hhs-medicare-com.pdf). Both houses of Congress have legislation (H.R. 1543 and S. 818) seeking to count observation days toward the Medicare three-day rule. For its part, CMS has promised to review observation status and, hopefully, clarify the rules.

Hospitalists, meanwhile, are gearing up for more observation care. The 2012 State of Hospital Medicine report shows that 37% of adult groups and 28% of pediatric groups reported having primary responsibility for observation or short-stay units. My own hospital runs both a clinical decision unit in the ED and a short-stay unit staffed by our hospitalist group. As SHM tracks observation status in future surveys, HM groups will be able to follow this phenomenon among their colleagues and benchmark their own rates of observation encounters.

Dr. Creamer is medical director of the short-stay unit at MetroHealth Medical Center in Cleveland and a member of SHM’s Practice Analysis Committee.

References

1. Feng Z, Wright DB, Mor V. Sharp rise in Medicare enrollees being held in hospitals for observation raises concerns about causes and consequences. Health Aff (Millwood). 2012;31(6):1251-1259.
2. Baugh CW, Venkatesh AK, Hilton JA, Samuel PA, Schuur JD, Bohan JS. Making greater use of dedicated hospital observation units for many short-stay patients could save $3.1 billion a year. Health Aff (Millwood). 2012;31(10):2314-2323.
3. Gengler A. The painful new trend in Medicare. CNN Money website. Available at: http://money.cnn.com/2012/08/07/pf/medicare-rehab-costs.moneymag/index.htm. Accessed March 6, 2013.
4. Jaffe S. Patients held for observation can face steep drug bills. USA Today website. Available at: http://usatoday30.usatoday.com/money/industries/health/drugs/story/2012-04-30/drugs-can-be-expensive-in-observation-care/54646378/1. Accessed March 6, 2013.
5. Landro L. Filling a gap between ERs and inpatient rooms. The Wall Street Journal website. Available at: http://online.wsj.com/article/SB10001424052970204349404578101060863887052.html. Accessed March 6, 2013.

Johnbuck Creamer, MD

SHM added a new item to its 2012 State of Hospital Medicine report: the ratio of respondents’ observation admissions to inpatient admission encounters. This metric was added because observation encounters have been increasing, with financial effects on hospitals and patients. SHM survey respondents reported a 20% observation rate for both adult and pediatric practice groups (see Figure 1).

Johnbuck Creamer, MD

Under observation status, services that used to be billed as inpatient status (e.g. chest pain evaluation, treatment of asthma exacerbation) must be billed by the hospital at much lower outpatient rates. Some hospitals have responded to this financial pressure by creating observation units or making other operational adjustments. One recent analysis suggested that nationwide adoption of such efforts could save billions of dollars.¹

Becoming lean enough to do short work in short time, though, does not address all of the observation-related issues facing hospitals. When the Centers for Medicare & Medicaid Services’ (CMS) Recovery Audit Contractors (RACs) determine retrospectively that an inpatient admission should have been an observation encounter, the hospital’s payment is not downgraded but forfeited.² This development has prompted hospitals to preemptively opt for observation status for certain patients. Case managers and providers increasingly are spending time reviewing inpatient versus observation status throughout a patient’s stay. Many hospitals have turned to third-party contractors to help review observation status.

Observation status has financial implications for patients as well. In the past year, USA Today, The Wall Street Journal, and CNN Money all have reported on patients hit with unexpected out-of-pocket expenses related to observation care.^3,4,5 A common theme: Medicare patient hospitalized with an acute fracture, managed nonoperatively but requiring rehabilitation prior to returning home. These patients found out too late that observation, a status they were often unaware of, did not qualify for CMS’ three-day inpatient requirement to cover rehabilitation costs. Some patients were charged exorbitant prices for noncovered “outpatient” services, such as providing their routine medications.

Advocacy groups have joined the fray on patients’ behalf, and legal challenges have ensued. AARP and others are educating patients about observation status—and their right to challenge it. The Center for Medicare Advocacy (www.kslaw.com/Library/publication/HH111411_Bagnall.pdf) has filed a lawsuit against the U.S. Department of Health and Human Services on behalf of patients hit with uncovered rehabilitation costs, and the American Hospital Association has teamed with several hospitals to sue over funds forfeited in RAC audits (www.aha.org/content/12/121101-aha-hhs-medicare-com.pdf). Both houses of Congress have legislation (H.R. 1543 and S. 818) seeking to count observation days toward the Medicare three-day rule. For its part, CMS has promised to review observation status and, hopefully, clarify the rules.

Hospitalists, meanwhile, are gearing up for more observation care. The 2012 State of Hospital Medicine report shows that 37% of adult groups and 28% of pediatric groups reported having primary responsibility for observation or short-stay units. My own hospital runs both a clinical decision unit in the ED and a short-stay unit staffed by our hospitalist group. As SHM tracks observation status in future surveys, HM groups will be able to follow this phenomenon among their colleagues and benchmark their own rates of observation encounters.

Dr. Creamer is medical director of the short-stay unit at MetroHealth Medical Center in Cleveland and a member of SHM’s Practice Analysis Committee.

References

1. Feng Z, Wright DB, Mor V. Sharp rise in Medicare enrollees being held in hospitals for observation raises concerns about causes and consequences. Health Aff (Millwood). 2012;31(6):1251-1259.
2. Baugh CW, Venkatesh AK, Hilton JA, Samuel PA, Schuur JD, Bohan JS. Making greater use of dedicated hospital observation units for many short-stay patients could save $3.1 billion a year. Health Aff (Millwood). 2012;31(10):2314-2323.
3. Gengler A. The painful new trend in Medicare. CNN Money website. Available at: http://money.cnn.com/2012/08/07/pf/medicare-rehab-costs.moneymag/index.htm. Accessed March 6, 2013.
4. Jaffe S. Patients held for observation can face steep drug bills. USA Today website. Available at: http://usatoday30.usatoday.com/money/industries/health/drugs/story/2012-04-30/drugs-can-be-expensive-in-observation-care/54646378/1. Accessed March 6, 2013.
5. Landro L. Filling a gap between ERs and inpatient rooms. The Wall Street Journal website. Available at: http://online.wsj.com/article/SB10001424052970204349404578101060863887052.html. Accessed March 6, 2013.

2013 marks a turning point in the way hospitals are held accountable for the prevention of healthcare-associated infections (HAIs). It has been known for some time that HAIs are a serious cause of morbidity, with 1 in 20 hospital patients in the U.S. acquiring one. That represents 1.7 million Americans and accounts for about 100,000 lives lost each year. On a personal note, my father died of an HAI after surgery in 2000.

Now, with the Affordable Care Act coming into full swing, hospitals must get serious about preventing HAIs. This presents a major opportunity for hospitalists. There are three ways that hospitals will be affected:

• Since 2008, hospitals have not been reimbursed at a higher rate for vascular catheter-associated infections, catheter-associated urinary tract infections (UTIs), or surgical-site infections when acquired in the hospital.
• Over the next few years, Medicare’s Hospital Value-Based Purchasing (HVBP) program will begin to pay hospitals more or less, depending on how they perform, on six HAIs.
• Beginning in October 2014, in a roll-up measure for hospital-acquired conditions (which include infections), the worst-performing quartile of U.S. hospitals will be penalized 1% of their Medicare inpatient payments (see Table 1, below).

There are six HAIs that will be increasingly tied to hospital reimbursement. Each can be partially or completely prevented based on sets of practices, or care bundles, that require teamwork both in the planning stages and at the bedside. And, of course, the single most important way to reduce the spread of HAIs is to clean your hands before and after each patient encounter.

Clostridium-Difficile-Associated Disease (CDAD)

It is likely that your hospital has some type of CDAD prevention program. Here are a few things to keep in mind for CDAD prevention:

• Avoid alcohol-based hand rubs, because they do not kill C. diff spores. Vigorous hand washing with soap and water is the best approach.
• Use clindamycin, fluoroquinolones, and third-generation cephalosporins judiciously, as their restriction has been associated with reduced rates of CDAD.
• Place patients with suspected or proven C. diff infection on contact precautions, including gloves and gowns.

click for large version

Methicillin-Resistant Staphylococcus Aureus (MRSA)

This includes hospital-acquired MRSA bacteremia. This topic will be discussed in future columns. Approaches to prevention include hand hygiene, cohorting patients, effective environmental cleaning, and antibiotic stewardship.

Central-Line-Associated Bloodstream Infection (CLABSI)

Adherence to the central-line insertion bundle has been conclusively shown to prevent CLABSI. It will become a process measure for HVBP in the near future. Prevention measures include hand hygiene, maximal barrier precautions during insertion, skin antisepsis with chlorhexidine, avoidance of the femoral vein, and daily assessment for readiness to discontinue the central line (which should involve every hospitalist).

Catheter-Associated Urinary Tract Infection (CAUTI)

CAUTI has been mentioned frequently in this column, and for good reason: It is the most common HAI. Although the evidence supporting practices that prevent CAUTI is not as strong as for CLABSI, every institution should have a bundle of practices embedded in nurses’ and doctors’ workflow to prevent CAUTI (see “Quality Meets Finance,” January 2013, p. 31).

Surgical-Site Infection (SSI)

For the most part, SSI can be left to the surgeons and other operating room professionals. However, with increasing involvement of hospitalists in surgical cases, we must have an understanding of how SSIs are prevented. The World Health Organization surgical checklist (www.who.int/patientsafety/safesurgery) is a great starting point for any organization.

Ventilator-Associated Pneumonia (VAP)

For hospitalists who provide critical care, adherence to a VAP prevention bundle includes:

• Elevation of the head of the bed;
• Daily “sedation vacation” and readiness to extubate;
• Oral care with chlorhexidine; and
• Peptic ulcer disease and venous thromboembolism prophylaxis.

In 2009, the U.S. Department of Health and Human Services (HHS) launched an action plan to prevent HAIs. As part of this effort, the Agency for Health Research and Quality (AHRQ) created a comprehensive unit-based safety program (CUSP) aimed at preventing CLABSI and CAUTI. The effort also focuses on safety culture and teamwork. For those interested in participating, visit www.onthecuspstophai.org.

Another way to get involved is to work Partnership for Patients, a public-private partnership led by HHS (http://partnershipforpatients.cms.gov), if a team at your hospital is participating. The Partnership for Patients seeks to reduce harm, including HAIs, by 40% by the end of 2013 compared with a 2010 baseline.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at wfwhit@comcast.net.

The View from The Center

As many of you know, SHM recently submitted five recommendations to the American Board of Internal Medicine Foundation’s Choosing Wisely campaign. This campaign encourages physicians and patients to have crucial conversations about appropriate utilization of tests and treatments. Seventeen specialty societies released lists in the second phase of the campaign. Many of the lists, including SHM’s, include recommendations that can help reduce hospital-acquired infections.

For example, one of SHM’s recommendations suggests not placing, or leaving in place, urinary catheters for any reason other than those indicated by the guidelines (e.g. bladder outlet obstruction, acute urinary retention, patient requires prolonged immobilization, to improve comfort for end of life, selected perioperative conditions). As Dr. Whitcomb indicates above, CAUTIs are low-hanging fruit when it comes to improving this condition—the guidelines are clear-cut, and relatively simple protocols can be put into place to prevent CAUTI.

Among the American Academy of Family Physicians and other society recommendations is avoidance of routine prescriptions of antibiotics for acute sinusitis or upper respiratory infections. Good antimicrobial stewardship policies are another approach to reduce or eliminate harmful antibiotic-resistant infections.

SHM will be offering multiple opportunities in the coming months to support your institution in Choosing Wisely. A daylong pre-course and two breakout sessions will be offered at HM13 (www.hospitalmedicine2013.org) addressing how you can implement the various recommendations. Additionally, publications are in the works describing the evidence base for SHM’s “avoid lists.” For resources, more information about SHM’s recommendations, and the latest Choosing Wisely developments, visit www.hospitalmedicine.org/choosingwisely.

2013 marks a turning point in the way hospitals are held accountable for the prevention of healthcare-associated infections (HAIs). It has been known for some time that HAIs are a serious cause of morbidity, with 1 in 20 hospital patients in the U.S. acquiring one. That represents 1.7 million Americans and accounts for about 100,000 lives lost each year. On a personal note, my father died of an HAI after surgery in 2000.

Now, with the Affordable Care Act coming into full swing, hospitals must get serious about preventing HAIs. This presents a major opportunity for hospitalists. There are three ways that hospitals will be affected:

• Since 2008, hospitals have not been reimbursed at a higher rate for vascular catheter-associated infections, catheter-associated urinary tract infections (UTIs), or surgical-site infections when acquired in the hospital.
• Over the next few years, Medicare’s Hospital Value-Based Purchasing (HVBP) program will begin to pay hospitals more or less, depending on how they perform, on six HAIs.
• Beginning in October 2014, in a roll-up measure for hospital-acquired conditions (which include infections), the worst-performing quartile of U.S. hospitals will be penalized 1% of their Medicare inpatient payments (see Table 1, below).

There are six HAIs that will be increasingly tied to hospital reimbursement. Each can be partially or completely prevented based on sets of practices, or care bundles, that require teamwork both in the planning stages and at the bedside. And, of course, the single most important way to reduce the spread of HAIs is to clean your hands before and after each patient encounter.

Clostridium-Difficile-Associated Disease (CDAD)

It is likely that your hospital has some type of CDAD prevention program. Here are a few things to keep in mind for CDAD prevention:

• Avoid alcohol-based hand rubs, because they do not kill C. diff spores. Vigorous hand washing with soap and water is the best approach.
• Use clindamycin, fluoroquinolones, and third-generation cephalosporins judiciously, as their restriction has been associated with reduced rates of CDAD.
• Place patients with suspected or proven C. diff infection on contact precautions, including gloves and gowns.

click for large version

Methicillin-Resistant Staphylococcus Aureus (MRSA)

This includes hospital-acquired MRSA bacteremia. This topic will be discussed in future columns. Approaches to prevention include hand hygiene, cohorting patients, effective environmental cleaning, and antibiotic stewardship.

Central-Line-Associated Bloodstream Infection (CLABSI)

Adherence to the central-line insertion bundle has been conclusively shown to prevent CLABSI. It will become a process measure for HVBP in the near future. Prevention measures include hand hygiene, maximal barrier precautions during insertion, skin antisepsis with chlorhexidine, avoidance of the femoral vein, and daily assessment for readiness to discontinue the central line (which should involve every hospitalist).

Catheter-Associated Urinary Tract Infection (CAUTI)

CAUTI has been mentioned frequently in this column, and for good reason: It is the most common HAI. Although the evidence supporting practices that prevent CAUTI is not as strong as for CLABSI, every institution should have a bundle of practices embedded in nurses’ and doctors’ workflow to prevent CAUTI (see “Quality Meets Finance,” January 2013, p. 31).

Surgical-Site Infection (SSI)

For the most part, SSI can be left to the surgeons and other operating room professionals. However, with increasing involvement of hospitalists in surgical cases, we must have an understanding of how SSIs are prevented. The World Health Organization surgical checklist (www.who.int/patientsafety/safesurgery) is a great starting point for any organization.

Ventilator-Associated Pneumonia (VAP)

For hospitalists who provide critical care, adherence to a VAP prevention bundle includes:

• Elevation of the head of the bed;
• Daily “sedation vacation” and readiness to extubate;
• Oral care with chlorhexidine; and
• Peptic ulcer disease and venous thromboembolism prophylaxis.

In 2009, the U.S. Department of Health and Human Services (HHS) launched an action plan to prevent HAIs. As part of this effort, the Agency for Health Research and Quality (AHRQ) created a comprehensive unit-based safety program (CUSP) aimed at preventing CLABSI and CAUTI. The effort also focuses on safety culture and teamwork. For those interested in participating, visit www.onthecuspstophai.org.

Another way to get involved is to work Partnership for Patients, a public-private partnership led by HHS (http://partnershipforpatients.cms.gov), if a team at your hospital is participating. The Partnership for Patients seeks to reduce harm, including HAIs, by 40% by the end of 2013 compared with a 2010 baseline.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at wfwhit@comcast.net.

The View from The Center

As many of you know, SHM recently submitted five recommendations to the American Board of Internal Medicine Foundation’s Choosing Wisely campaign. This campaign encourages physicians and patients to have crucial conversations about appropriate utilization of tests and treatments. Seventeen specialty societies released lists in the second phase of the campaign. Many of the lists, including SHM’s, include recommendations that can help reduce hospital-acquired infections.

For example, one of SHM’s recommendations suggests not placing, or leaving in place, urinary catheters for any reason other than those indicated by the guidelines (e.g. bladder outlet obstruction, acute urinary retention, patient requires prolonged immobilization, to improve comfort for end of life, selected perioperative conditions). As Dr. Whitcomb indicates above, CAUTIs are low-hanging fruit when it comes to improving this condition—the guidelines are clear-cut, and relatively simple protocols can be put into place to prevent CAUTI.

Among the American Academy of Family Physicians and other society recommendations is avoidance of routine prescriptions of antibiotics for acute sinusitis or upper respiratory infections. Good antimicrobial stewardship policies are another approach to reduce or eliminate harmful antibiotic-resistant infections.

SHM will be offering multiple opportunities in the coming months to support your institution in Choosing Wisely. A daylong pre-course and two breakout sessions will be offered at HM13 (www.hospitalmedicine2013.org) addressing how you can implement the various recommendations. Additionally, publications are in the works describing the evidence base for SHM’s “avoid lists.” For resources, more information about SHM’s recommendations, and the latest Choosing Wisely developments, visit www.hospitalmedicine.org/choosingwisely.

2013 marks a turning point in the way hospitals are held accountable for the prevention of healthcare-associated infections (HAIs). It has been known for some time that HAIs are a serious cause of morbidity, with 1 in 20 hospital patients in the U.S. acquiring one. That represents 1.7 million Americans and accounts for about 100,000 lives lost each year. On a personal note, my father died of an HAI after surgery in 2000.

Now, with the Affordable Care Act coming into full swing, hospitals must get serious about preventing HAIs. This presents a major opportunity for hospitalists. There are three ways that hospitals will be affected:

• Since 2008, hospitals have not been reimbursed at a higher rate for vascular catheter-associated infections, catheter-associated urinary tract infections (UTIs), or surgical-site infections when acquired in the hospital.
• Over the next few years, Medicare’s Hospital Value-Based Purchasing (HVBP) program will begin to pay hospitals more or less, depending on how they perform, on six HAIs.
• Beginning in October 2014, in a roll-up measure for hospital-acquired conditions (which include infections), the worst-performing quartile of U.S. hospitals will be penalized 1% of their Medicare inpatient payments (see Table 1, below).

There are six HAIs that will be increasingly tied to hospital reimbursement. Each can be partially or completely prevented based on sets of practices, or care bundles, that require teamwork both in the planning stages and at the bedside. And, of course, the single most important way to reduce the spread of HAIs is to clean your hands before and after each patient encounter.

Clostridium-Difficile-Associated Disease (CDAD)

It is likely that your hospital has some type of CDAD prevention program. Here are a few things to keep in mind for CDAD prevention:

• Avoid alcohol-based hand rubs, because they do not kill C. diff spores. Vigorous hand washing with soap and water is the best approach.
• Use clindamycin, fluoroquinolones, and third-generation cephalosporins judiciously, as their restriction has been associated with reduced rates of CDAD.
• Place patients with suspected or proven C. diff infection on contact precautions, including gloves and gowns.

click for large version

Methicillin-Resistant Staphylococcus Aureus (MRSA)

This includes hospital-acquired MRSA bacteremia. This topic will be discussed in future columns. Approaches to prevention include hand hygiene, cohorting patients, effective environmental cleaning, and antibiotic stewardship.

Central-Line-Associated Bloodstream Infection (CLABSI)

Adherence to the central-line insertion bundle has been conclusively shown to prevent CLABSI. It will become a process measure for HVBP in the near future. Prevention measures include hand hygiene, maximal barrier precautions during insertion, skin antisepsis with chlorhexidine, avoidance of the femoral vein, and daily assessment for readiness to discontinue the central line (which should involve every hospitalist).

Catheter-Associated Urinary Tract Infection (CAUTI)

CAUTI has been mentioned frequently in this column, and for good reason: It is the most common HAI. Although the evidence supporting practices that prevent CAUTI is not as strong as for CLABSI, every institution should have a bundle of practices embedded in nurses’ and doctors’ workflow to prevent CAUTI (see “Quality Meets Finance,” January 2013, p. 31).

Surgical-Site Infection (SSI)

For the most part, SSI can be left to the surgeons and other operating room professionals. However, with increasing involvement of hospitalists in surgical cases, we must have an understanding of how SSIs are prevented. The World Health Organization surgical checklist (www.who.int/patientsafety/safesurgery) is a great starting point for any organization.

Ventilator-Associated Pneumonia (VAP)

For hospitalists who provide critical care, adherence to a VAP prevention bundle includes:

• Elevation of the head of the bed;
• Daily “sedation vacation” and readiness to extubate;
• Oral care with chlorhexidine; and
• Peptic ulcer disease and venous thromboembolism prophylaxis.

In 2009, the U.S. Department of Health and Human Services (HHS) launched an action plan to prevent HAIs. As part of this effort, the Agency for Health Research and Quality (AHRQ) created a comprehensive unit-based safety program (CUSP) aimed at preventing CLABSI and CAUTI. The effort also focuses on safety culture and teamwork. For those interested in participating, visit www.onthecuspstophai.org.

Another way to get involved is to work Partnership for Patients, a public-private partnership led by HHS (http://partnershipforpatients.cms.gov), if a team at your hospital is participating. The Partnership for Patients seeks to reduce harm, including HAIs, by 40% by the end of 2013 compared with a 2010 baseline.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at wfwhit@comcast.net.

The View from The Center

As many of you know, SHM recently submitted five recommendations to the American Board of Internal Medicine Foundation’s Choosing Wisely campaign. This campaign encourages physicians and patients to have crucial conversations about appropriate utilization of tests and treatments. Seventeen specialty societies released lists in the second phase of the campaign. Many of the lists, including SHM’s, include recommendations that can help reduce hospital-acquired infections.

For example, one of SHM’s recommendations suggests not placing, or leaving in place, urinary catheters for any reason other than those indicated by the guidelines (e.g. bladder outlet obstruction, acute urinary retention, patient requires prolonged immobilization, to improve comfort for end of life, selected perioperative conditions). As Dr. Whitcomb indicates above, CAUTIs are low-hanging fruit when it comes to improving this condition—the guidelines are clear-cut, and relatively simple protocols can be put into place to prevent CAUTI.

Among the American Academy of Family Physicians and other society recommendations is avoidance of routine prescriptions of antibiotics for acute sinusitis or upper respiratory infections. Good antimicrobial stewardship policies are another approach to reduce or eliminate harmful antibiotic-resistant infections.

SHM will be offering multiple opportunities in the coming months to support your institution in Choosing Wisely. A daylong pre-course and two breakout sessions will be offered at HM13 (www.hospitalmedicine2013.org) addressing how you can implement the various recommendations. Additionally, publications are in the works describing the evidence base for SHM’s “avoid lists.” For resources, more information about SHM’s recommendations, and the latest Choosing Wisely developments, visit www.hospitalmedicine.org/choosingwisely.

“Patient centeredness to me is the true north, and I think everything else that we’ve done that isn’t patient-centered has been a distraction. It’s why we signed up to get into healthcare. It’s what we should be doing today and tonight, and it should guide our future tomorrow.”

–David Feinberg, MD, MBA, president of UCLA Health System in Los Angeles

Patient satisfaction is a buzzword in HM circles, as compensation is increasingly tied to performance in keeping inpatients happy. David Feinberg, MD, MBA, president of UCLA Health System in Los Angeles, could be called a guru of patient satisfaction.

Just don’t tell him that.

“I hope I’m not seen as ‘patient satisfaction,’” he says. “I hope I’m seen as ‘patient centeredness.’ And patient satisfaction is a key piece of patient centeredness.”

Dr. Feinberg, who assumed his current role UCLA Health System in 2011, is a national voice for pushing a patient-centric model of care delivery. To wit, he will be one of the keynote speakers at HM13 next month at the Gaylord National Resort & Convention Center in National Harbor, Md. His address is fittingly titled “Healing Humankind One Patient at a Time.”

The Hospitalist spoke to Dr. Feinberg about his message to hospitalists.

Question: What do you think is the evolution of patient centeredness, as that becomes more of a focus for others?

Answer: Patient centeredness to me is the true north, and I think everything else that we’ve done that isn’t patient-centered has been a distraction. … It’s why we signed up to get into healthcare. It’s what we should be doing today and tonight, and it should guide our future tomorrow. It would be like me saying to the restaurateur, “How important is the food?”

click for large version

click for large version

click for large version

Q: Is it something that hasn’t always been done?

A: It’s pathetic. You’re totally right. We’ve lost our way.

Q: If it’s so common-sense, how did we lose our way?

A: It really became, to me, the coin of the realm in medicine was how much the doctor made, how great their reputation was. It even got to the point of: You were a good doctor if your waiting room was packed. … I keep saying the waiting room should be for the doctors. The patient shouldn’t have to wait. You should be back in the exam room and the doctor should be waiting to see you. So we’ve got to completely change the paradigm. … It’s really the patient who’s at the top of the pyramid. And I just think we’ve lost that completely.

Q: How does a hospitalist engage quickly to ensure that they’re trying to accomplish patient centeredness and manage outcomes properly?

A: Hospitalists have a unique opportunity there, because everybody remembers when they got put in the hospital. It is a big deal when you’re hospitalized. Your family is in a vulnerable state, everybody is in a heightened sense of alertness and focus. Think about how important those four days are around education, around myths and demystifying, around beliefs and disbelief.

Check out our 6-minute feature video: "Five Reasons You Should Attend HM13"

Q: So what is the one thing you want hospitalists to take away from your address?

A: That they should join with all of us who want to heal humankind; that they are healers, above all.

Q: How do you translate “I want to be a healer” to the grind of daily work?

A: Well, I don’t think this is a grind. I think that when you’re in this healing profession, that you come here with a purpose. I think if we asked them to look at their personal statements of why they went into med school, every single one of them has something to do with, “I was sick as a kid, my grandmother got sick, I had had this doctor who was a role model, I like to help people, I was a volunteer and I met this patient.” Everyone says that. So this is different than trying to inspire the workers at Costco. These are people that, by definition, have gone and chosen this. We know they’re all smart. They could have all become investment bankers, they could have all become schoolteachers, but what they chose was to go into this field that’s about healing others, and that’s what I think we need to and what I would want them to do, is to get back in touch with themselves because I know it’s there. By definition, it’s there.

Q: Then why don’t more people just make that connection? What is the hurdle?

A: There are a lot of distractions. There are a lot of things coming your way. Worrying about your own life; doctors have lives at home. Worrying about the pressures of making a living. Some of this stuff is really, really hard. There are a million things going on. I believe, and I hope at UCLA, that we believe the strategy to make all of that stuff work is to get it right with the patient. And if you get it right with the patient, then all of that other stuff seems to fall into place and starts to make sense. The finances work out. The market share works out. The healthcare reform works out. I think it is the answer.

Richard Quinn is a freelance writer in New Jersey.

“Patient centeredness to me is the true north, and I think everything else that we’ve done that isn’t patient-centered has been a distraction. It’s why we signed up to get into healthcare. It’s what we should be doing today and tonight, and it should guide our future tomorrow.”

–David Feinberg, MD, MBA, president of UCLA Health System in Los Angeles

Patient satisfaction is a buzzword in HM circles, as compensation is increasingly tied to performance in keeping inpatients happy. David Feinberg, MD, MBA, president of UCLA Health System in Los Angeles, could be called a guru of patient satisfaction.

Just don’t tell him that.

“I hope I’m not seen as ‘patient satisfaction,’” he says. “I hope I’m seen as ‘patient centeredness.’ And patient satisfaction is a key piece of patient centeredness.”

Dr. Feinberg, who assumed his current role UCLA Health System in 2011, is a national voice for pushing a patient-centric model of care delivery. To wit, he will be one of the keynote speakers at HM13 next month at the Gaylord National Resort & Convention Center in National Harbor, Md. His address is fittingly titled “Healing Humankind One Patient at a Time.”

The Hospitalist spoke to Dr. Feinberg about his message to hospitalists.

Question: What do you think is the evolution of patient centeredness, as that becomes more of a focus for others?

Answer: Patient centeredness to me is the true north, and I think everything else that we’ve done that isn’t patient-centered has been a distraction. … It’s why we signed up to get into healthcare. It’s what we should be doing today and tonight, and it should guide our future tomorrow. It would be like me saying to the restaurateur, “How important is the food?”

click for large version

click for large version

click for large version

Q: Is it something that hasn’t always been done?

A: It’s pathetic. You’re totally right. We’ve lost our way.

Q: If it’s so common-sense, how did we lose our way?

A: It really became, to me, the coin of the realm in medicine was how much the doctor made, how great their reputation was. It even got to the point of: You were a good doctor if your waiting room was packed. … I keep saying the waiting room should be for the doctors. The patient shouldn’t have to wait. You should be back in the exam room and the doctor should be waiting to see you. So we’ve got to completely change the paradigm. … It’s really the patient who’s at the top of the pyramid. And I just think we’ve lost that completely.

Q: How does a hospitalist engage quickly to ensure that they’re trying to accomplish patient centeredness and manage outcomes properly?

A: Hospitalists have a unique opportunity there, because everybody remembers when they got put in the hospital. It is a big deal when you’re hospitalized. Your family is in a vulnerable state, everybody is in a heightened sense of alertness and focus. Think about how important those four days are around education, around myths and demystifying, around beliefs and disbelief.

Check out our 6-minute feature video: "Five Reasons You Should Attend HM13"

Q: So what is the one thing you want hospitalists to take away from your address?

A: That they should join with all of us who want to heal humankind; that they are healers, above all.

Q: How do you translate “I want to be a healer” to the grind of daily work?

A: Well, I don’t think this is a grind. I think that when you’re in this healing profession, that you come here with a purpose. I think if we asked them to look at their personal statements of why they went into med school, every single one of them has something to do with, “I was sick as a kid, my grandmother got sick, I had had this doctor who was a role model, I like to help people, I was a volunteer and I met this patient.” Everyone says that. So this is different than trying to inspire the workers at Costco. These are people that, by definition, have gone and chosen this. We know they’re all smart. They could have all become investment bankers, they could have all become schoolteachers, but what they chose was to go into this field that’s about healing others, and that’s what I think we need to and what I would want them to do, is to get back in touch with themselves because I know it’s there. By definition, it’s there.

Q: Then why don’t more people just make that connection? What is the hurdle?

A: There are a lot of distractions. There are a lot of things coming your way. Worrying about your own life; doctors have lives at home. Worrying about the pressures of making a living. Some of this stuff is really, really hard. There are a million things going on. I believe, and I hope at UCLA, that we believe the strategy to make all of that stuff work is to get it right with the patient. And if you get it right with the patient, then all of that other stuff seems to fall into place and starts to make sense. The finances work out. The market share works out. The healthcare reform works out. I think it is the answer.

Richard Quinn is a freelance writer in New Jersey.

“Patient centeredness to me is the true north, and I think everything else that we’ve done that isn’t patient-centered has been a distraction. It’s why we signed up to get into healthcare. It’s what we should be doing today and tonight, and it should guide our future tomorrow.”

–David Feinberg, MD, MBA, president of UCLA Health System in Los Angeles

Patient satisfaction is a buzzword in HM circles, as compensation is increasingly tied to performance in keeping inpatients happy. David Feinberg, MD, MBA, president of UCLA Health System in Los Angeles, could be called a guru of patient satisfaction.

Just don’t tell him that.

“I hope I’m not seen as ‘patient satisfaction,’” he says. “I hope I’m seen as ‘patient centeredness.’ And patient satisfaction is a key piece of patient centeredness.”

Dr. Feinberg, who assumed his current role UCLA Health System in 2011, is a national voice for pushing a patient-centric model of care delivery. To wit, he will be one of the keynote speakers at HM13 next month at the Gaylord National Resort & Convention Center in National Harbor, Md. His address is fittingly titled “Healing Humankind One Patient at a Time.”

The Hospitalist spoke to Dr. Feinberg about his message to hospitalists.

Question: What do you think is the evolution of patient centeredness, as that becomes more of a focus for others?

Answer: Patient centeredness to me is the true north, and I think everything else that we’ve done that isn’t patient-centered has been a distraction. … It’s why we signed up to get into healthcare. It’s what we should be doing today and tonight, and it should guide our future tomorrow. It would be like me saying to the restaurateur, “How important is the food?”

click for large version

click for large version

click for large version

Q: Is it something that hasn’t always been done?

A: It’s pathetic. You’re totally right. We’ve lost our way.

Q: If it’s so common-sense, how did we lose our way?

A: It really became, to me, the coin of the realm in medicine was how much the doctor made, how great their reputation was. It even got to the point of: You were a good doctor if your waiting room was packed. … I keep saying the waiting room should be for the doctors. The patient shouldn’t have to wait. You should be back in the exam room and the doctor should be waiting to see you. So we’ve got to completely change the paradigm. … It’s really the patient who’s at the top of the pyramid. And I just think we’ve lost that completely.

Q: How does a hospitalist engage quickly to ensure that they’re trying to accomplish patient centeredness and manage outcomes properly?

A: Hospitalists have a unique opportunity there, because everybody remembers when they got put in the hospital. It is a big deal when you’re hospitalized. Your family is in a vulnerable state, everybody is in a heightened sense of alertness and focus. Think about how important those four days are around education, around myths and demystifying, around beliefs and disbelief.

Check out our 6-minute feature video: "Five Reasons You Should Attend HM13"

Q: So what is the one thing you want hospitalists to take away from your address?

A: That they should join with all of us who want to heal humankind; that they are healers, above all.

Q: How do you translate “I want to be a healer” to the grind of daily work?

A: Well, I don’t think this is a grind. I think that when you’re in this healing profession, that you come here with a purpose. I think if we asked them to look at their personal statements of why they went into med school, every single one of them has something to do with, “I was sick as a kid, my grandmother got sick, I had had this doctor who was a role model, I like to help people, I was a volunteer and I met this patient.” Everyone says that. So this is different than trying to inspire the workers at Costco. These are people that, by definition, have gone and chosen this. We know they’re all smart. They could have all become investment bankers, they could have all become schoolteachers, but what they chose was to go into this field that’s about healing others, and that’s what I think we need to and what I would want them to do, is to get back in touch with themselves because I know it’s there. By definition, it’s there.

Q: Then why don’t more people just make that connection? What is the hurdle?

A: There are a lot of distractions. There are a lot of things coming your way. Worrying about your own life; doctors have lives at home. Worrying about the pressures of making a living. Some of this stuff is really, really hard. There are a million things going on. I believe, and I hope at UCLA, that we believe the strategy to make all of that stuff work is to get it right with the patient. And if you get it right with the patient, then all of that other stuff seems to fall into place and starts to make sense. The finances work out. The market share works out. The healthcare reform works out. I think it is the answer.

Richard Quinn is a freelance writer in New Jersey.

“The days of you just graduating residency, seeing as many patients as you can, and you go home at the end of the day—that’s gone for hospital medicine.”

–Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer, Centers for Medicaid & Medicare Service

Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer of the Centers for Medicaid & Medicare Services (CMS), often says that physicians need to come to the proverbial table to tell CMS what they think is best. So it’s fitting that at HM13 at the Gaylord National Resort & Convention Center in National Harbor, Md., Dr. Conway will be a keynote speaker who can deliver his message of quality through teamwork to more than 2,500 hospitalists.

A pediatric hospitalist who also serves as director of the Office of Clinical Standards and Quality at the U.S. Department of Health and Human Services in Washington, D.C., Dr. Conway will paint a picture of what hospitalists can do to become the quality-improvement (QI) leaders healthcare needs in the coming years in a presentation titled “The Ideal Hospitalist in 2014 and Beyond: Active Change Agent.”

“Are hospitalists going to accept that challenge?” he asks. “I hope they are.”

This is the second year in a row that Dr. Conway will be a plenary speaker. Last year in San Diego, he told a packed room that CMS had to move from a “passive payor to an active facilitator and catalyst for quality improvement,” says Danielle Scheurer, MD, MSCR, SFHM, physician editor of The Hospitalist. Or, in his own words: “better health, better care, and lower cost.”

But many of the issues in his 2012 commentary were in flux. The Affordable Care Act (ACA), now moving through the slow process of implementation, was then still a law very much in doubt. It wasn’t until last summer that the law was upheld by a bitterly divided U.S. Supreme Court and it became clear much of the proposed reforms would move forward.

This year, he will urge hospitalists to step up their focus on patient-centered outcomes and stop questioning whether that should be the way the HM and other physicians should be judged.

“Given the changing context of payment, hospitalists are going to have to become true experts in managing the quality of care,” Dr. Conway says. “The days of you just graduating residency, seeing as many patients as you can, and you go home at the end of the day—that’s gone for hospital medicine.”

Check out our 6-minute feature video: "Five Reasons You Should Attend HM13"

Hospitalists can take charge of quality initiatives via involvement with accountable-care organizations (ACOs), health exchanges, and CMS’ value-based purchasing modifier (VBPM). In part, HM is perfectly positioned to assume leadership roles over the next few years because hospitalists already work across multiple departments.

“Hospital medicine is already ahead of a lot of specialties,” Dr. Conway says. “Hospital medicine physicians are already taking on much larger roles in their systems. I think you’re going to see an increasing trend.”

Richard Quinn is a freelance writer in New Jersey.

“The days of you just graduating residency, seeing as many patients as you can, and you go home at the end of the day—that’s gone for hospital medicine.”

–Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer, Centers for Medicaid & Medicare Service

Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer of the Centers for Medicaid & Medicare Services (CMS), often says that physicians need to come to the proverbial table to tell CMS what they think is best. So it’s fitting that at HM13 at the Gaylord National Resort & Convention Center in National Harbor, Md., Dr. Conway will be a keynote speaker who can deliver his message of quality through teamwork to more than 2,500 hospitalists.

A pediatric hospitalist who also serves as director of the Office of Clinical Standards and Quality at the U.S. Department of Health and Human Services in Washington, D.C., Dr. Conway will paint a picture of what hospitalists can do to become the quality-improvement (QI) leaders healthcare needs in the coming years in a presentation titled “The Ideal Hospitalist in 2014 and Beyond: Active Change Agent.”

“Are hospitalists going to accept that challenge?” he asks. “I hope they are.”

This is the second year in a row that Dr. Conway will be a plenary speaker. Last year in San Diego, he told a packed room that CMS had to move from a “passive payor to an active facilitator and catalyst for quality improvement,” says Danielle Scheurer, MD, MSCR, SFHM, physician editor of The Hospitalist. Or, in his own words: “better health, better care, and lower cost.”

But many of the issues in his 2012 commentary were in flux. The Affordable Care Act (ACA), now moving through the slow process of implementation, was then still a law very much in doubt. It wasn’t until last summer that the law was upheld by a bitterly divided U.S. Supreme Court and it became clear much of the proposed reforms would move forward.

This year, he will urge hospitalists to step up their focus on patient-centered outcomes and stop questioning whether that should be the way the HM and other physicians should be judged.

“Given the changing context of payment, hospitalists are going to have to become true experts in managing the quality of care,” Dr. Conway says. “The days of you just graduating residency, seeing as many patients as you can, and you go home at the end of the day—that’s gone for hospital medicine.”

Check out our 6-minute feature video: "Five Reasons You Should Attend HM13"

Hospitalists can take charge of quality initiatives via involvement with accountable-care organizations (ACOs), health exchanges, and CMS’ value-based purchasing modifier (VBPM). In part, HM is perfectly positioned to assume leadership roles over the next few years because hospitalists already work across multiple departments.

“Hospital medicine is already ahead of a lot of specialties,” Dr. Conway says. “Hospital medicine physicians are already taking on much larger roles in their systems. I think you’re going to see an increasing trend.”

Richard Quinn is a freelance writer in New Jersey.

“The days of you just graduating residency, seeing as many patients as you can, and you go home at the end of the day—that’s gone for hospital medicine.”

–Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer, Centers for Medicaid & Medicare Service

Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer of the Centers for Medicaid & Medicare Services (CMS), often says that physicians need to come to the proverbial table to tell CMS what they think is best. So it’s fitting that at HM13 at the Gaylord National Resort & Convention Center in National Harbor, Md., Dr. Conway will be a keynote speaker who can deliver his message of quality through teamwork to more than 2,500 hospitalists.

A pediatric hospitalist who also serves as director of the Office of Clinical Standards and Quality at the U.S. Department of Health and Human Services in Washington, D.C., Dr. Conway will paint a picture of what hospitalists can do to become the quality-improvement (QI) leaders healthcare needs in the coming years in a presentation titled “The Ideal Hospitalist in 2014 and Beyond: Active Change Agent.”

“Are hospitalists going to accept that challenge?” he asks. “I hope they are.”

This is the second year in a row that Dr. Conway will be a plenary speaker. Last year in San Diego, he told a packed room that CMS had to move from a “passive payor to an active facilitator and catalyst for quality improvement,” says Danielle Scheurer, MD, MSCR, SFHM, physician editor of The Hospitalist. Or, in his own words: “better health, better care, and lower cost.”

But many of the issues in his 2012 commentary were in flux. The Affordable Care Act (ACA), now moving through the slow process of implementation, was then still a law very much in doubt. It wasn’t until last summer that the law was upheld by a bitterly divided U.S. Supreme Court and it became clear much of the proposed reforms would move forward.

This year, he will urge hospitalists to step up their focus on patient-centered outcomes and stop questioning whether that should be the way the HM and other physicians should be judged.

“Given the changing context of payment, hospitalists are going to have to become true experts in managing the quality of care,” Dr. Conway says. “The days of you just graduating residency, seeing as many patients as you can, and you go home at the end of the day—that’s gone for hospital medicine.”

Check out our 6-minute feature video: "Five Reasons You Should Attend HM13"

Hospitalists can take charge of quality initiatives via involvement with accountable-care organizations (ACOs), health exchanges, and CMS’ value-based purchasing modifier (VBPM). In part, HM is perfectly positioned to assume leadership roles over the next few years because hospitalists already work across multiple departments.

“Hospital medicine is already ahead of a lot of specialties,” Dr. Conway says. “Hospital medicine physicians are already taking on much larger roles in their systems. I think you’re going to see an increasing trend.”

Richard Quinn is a freelance writer in New Jersey.

Eight educational tracks, an equal number of credit bearing pre-courses, a score of small-group forums, three plenaries, and an SHM Town Hall meeting offers a lot of professional development in a four-day span. But that’s just a sampling of what HM13 has slated May 16-19 at the Gaylord National Resort & Convention Center in National Harbor, Md., just outside Washington, D.C.

So how does one get the most value out of the conference?

“The highest-yield content is going to depend on what your background is and how to spend that time in a way that augments your knowledge, your perspective, or your exposure to like-minded colleagues in a very individual way,” says HM13 course director Daniel Brotman, MD, FACP, SFHM, director of the hospitalist program at Johns Hopkins Hospital in Baltimore. “One of the things that’s so cool about hospital medicine is its diversity.”

But don’t take Dr. Brotman’s well-educated word for it. Here’s a list of recommendations from Team Hospitalist, the only reader-involvement group of its kind in HM, on events they would not miss this year.

The New Anticoagulants: When Should We Be Using Them?

2:45 p.m., May 17

Dr. Ma: “I’m very interested about the new anticoagulants talk. What I’m curious to see is what the speaker thinks about the survivability of these medications in our society, with so many lawyers. Pradaxa already has fallen out of favor. Let’s see what happens to Xarelto.”

How do CFOs Value Their Hospitalist Programs?

2:50 p.m., May 18

Dr. Ma: “The problem today is CFOs have to valuate their hospitalists in the setting of other specialists who also receive subsidies. There is less money to be spent on hospitalists, as other specialists vie for this allotment of savings from hospital-based value purchasing.”

Check out our 6-minute feature video: "Five Reasons You Should Attend HM13"

Mentoring/Coaching an Improvement Team: Lessons from SHM’s Mentored Implementation Programs

2:45 p.m., May 17

Dr. Perumalswami: “As a Project BOOST physician mentor in Illinois, I would highly recommend the session because the discussion will involve an inside look into valuable experience-based observations and analysis for the success of any process improvement team. The nature of teams and the culture of improvement at various sites will also be discussed. There will be a mentee side of the presentation, too, which will help other mentors of implementation programs better understand what the issues are ‘from the other side.’”

Strategies to Improve Communication with Patients and Families to Improve Care

2:45 p.m., May 17

Dr. Hale: “It is well known in pediatrics that you are treating two patients: both the child and the parents. If the family has a shared understanding of the child’s illness and there is collaboration for the care plan, there will be improved care.”

Neonatal HSV: When to Consider It, How to Evaluate for It, and How to Treat It

11 a.m., May 18

Dr. Hale: “Neonatal HSV is a devastating disease. It is essential to recognize high-risk patients to decrease morbidity and mortality for this illness. There have been recent updates in the understanding of epidemiology of this disease that can assist the provider in recognizing high-risk patients.”

Supporting Transition for Youth with Special Healthcare Needs: Coordinating Care and Preparing to Pass the Baton

4:15 p.m., May 18

Dr. Hale: “The transition of adolescents and young adults from pediatric-care teams to adult-medicine-care teams should be seamless for the sake of the patient, but often it is a blurry transition over the course of years. This session is high-yield for both pediatric and adult hospitalists.”

Getting Ready for Physician Value-Based Purchasing

9:50 a.m., May 19

Dr. Simone: “Dr. [Pat] Torcson’s presentation last year was one of the best at HM12, and I expect this year to be the same. He chairs SHM’s Performance Measurement and Reporting Committee and is well versed in these matters. He speaks in terms that will capture all audiences, whether they are experienced or new to the business aspects of medicine. Highly recommended.”

BOOSTing the Hospital Discharge Process: What Works and What Doesn’t

10:35 a.m., May 17

Dr. Simone: “Both panelists are excellent presenters as well as leading authorities when it comes to discharge processes. This presentation is very timely with the new CMS payment system, which penalizes unnecessary and unexpected readmissions.”

Success Stories: How to Integrate NPs and PAs into a Hospitalist Practice

4:15 p.m., May 18

Cardin: “This is an important session because, as every hard-working hospitalist knows, there simply aren’t enough physicians to fill the needs of our medically complex hospitalized patients. It is simply a reality that there will be an increased need in the future for mid-level providers, and it is valuable to maximize the success of a program by learning how to assimilate them into hospitalized practice.”

Diagnostic Errors and the Hospitalist: Why They Happen and How to Avoid Them

12:45 p.m., May 17

Cardin: “Half of practicing medicine is pattern recognition, and if there are patterns to making diagnostic errors, it would be so valuable to be aware of them. We have tremendous responsibility when caring for patients, and I think it is always beneficial to learn from mistakes.”

Richard Quinn is a freelance writer in New Jersey.

Eight educational tracks, an equal number of credit bearing pre-courses, a score of small-group forums, three plenaries, and an SHM Town Hall meeting offers a lot of professional development in a four-day span. But that’s just a sampling of what HM13 has slated May 16-19 at the Gaylord National Resort & Convention Center in National Harbor, Md., just outside Washington, D.C.

So how does one get the most value out of the conference?

“The highest-yield content is going to depend on what your background is and how to spend that time in a way that augments your knowledge, your perspective, or your exposure to like-minded colleagues in a very individual way,” says HM13 course director Daniel Brotman, MD, FACP, SFHM, director of the hospitalist program at Johns Hopkins Hospital in Baltimore. “One of the things that’s so cool about hospital medicine is its diversity.”

But don’t take Dr. Brotman’s well-educated word for it. Here’s a list of recommendations from Team Hospitalist, the only reader-involvement group of its kind in HM, on events they would not miss this year.

The New Anticoagulants: When Should We Be Using Them?

2:45 p.m., May 17

Dr. Ma: “I’m very interested about the new anticoagulants talk. What I’m curious to see is what the speaker thinks about the survivability of these medications in our society, with so many lawyers. Pradaxa already has fallen out of favor. Let’s see what happens to Xarelto.”

How do CFOs Value Their Hospitalist Programs?

2:50 p.m., May 18

Dr. Ma: “The problem today is CFOs have to valuate their hospitalists in the setting of other specialists who also receive subsidies. There is less money to be spent on hospitalists, as other specialists vie for this allotment of savings from hospital-based value purchasing.”

Check out our 6-minute feature video: "Five Reasons You Should Attend HM13"

Mentoring/Coaching an Improvement Team: Lessons from SHM’s Mentored Implementation Programs

2:45 p.m., May 17

Dr. Perumalswami: “As a Project BOOST physician mentor in Illinois, I would highly recommend the session because the discussion will involve an inside look into valuable experience-based observations and analysis for the success of any process improvement team. The nature of teams and the culture of improvement at various sites will also be discussed. There will be a mentee side of the presentation, too, which will help other mentors of implementation programs better understand what the issues are ‘from the other side.’”

Strategies to Improve Communication with Patients and Families to Improve Care

2:45 p.m., May 17

Dr. Hale: “It is well known in pediatrics that you are treating two patients: both the child and the parents. If the family has a shared understanding of the child’s illness and there is collaboration for the care plan, there will be improved care.”

Neonatal HSV: When to Consider It, How to Evaluate for It, and How to Treat It

11 a.m., May 18

Dr. Hale: “Neonatal HSV is a devastating disease. It is essential to recognize high-risk patients to decrease morbidity and mortality for this illness. There have been recent updates in the understanding of epidemiology of this disease that can assist the provider in recognizing high-risk patients.”

Supporting Transition for Youth with Special Healthcare Needs: Coordinating Care and Preparing to Pass the Baton

4:15 p.m., May 18

Dr. Hale: “The transition of adolescents and young adults from pediatric-care teams to adult-medicine-care teams should be seamless for the sake of the patient, but often it is a blurry transition over the course of years. This session is high-yield for both pediatric and adult hospitalists.”

Getting Ready for Physician Value-Based Purchasing

9:50 a.m., May 19

Dr. Simone: “Dr. [Pat] Torcson’s presentation last year was one of the best at HM12, and I expect this year to be the same. He chairs SHM’s Performance Measurement and Reporting Committee and is well versed in these matters. He speaks in terms that will capture all audiences, whether they are experienced or new to the business aspects of medicine. Highly recommended.”

BOOSTing the Hospital Discharge Process: What Works and What Doesn’t

10:35 a.m., May 17

Dr. Simone: “Both panelists are excellent presenters as well as leading authorities when it comes to discharge processes. This presentation is very timely with the new CMS payment system, which penalizes unnecessary and unexpected readmissions.”

Success Stories: How to Integrate NPs and PAs into a Hospitalist Practice

4:15 p.m., May 18

Cardin: “This is an important session because, as every hard-working hospitalist knows, there simply aren’t enough physicians to fill the needs of our medically complex hospitalized patients. It is simply a reality that there will be an increased need in the future for mid-level providers, and it is valuable to maximize the success of a program by learning how to assimilate them into hospitalized practice.”

Diagnostic Errors and the Hospitalist: Why They Happen and How to Avoid Them

12:45 p.m., May 17

Cardin: “Half of practicing medicine is pattern recognition, and if there are patterns to making diagnostic errors, it would be so valuable to be aware of them. We have tremendous responsibility when caring for patients, and I think it is always beneficial to learn from mistakes.”

Richard Quinn is a freelance writer in New Jersey.

Eight educational tracks, an equal number of credit bearing pre-courses, a score of small-group forums, three plenaries, and an SHM Town Hall meeting offers a lot of professional development in a four-day span. But that’s just a sampling of what HM13 has slated May 16-19 at the Gaylord National Resort & Convention Center in National Harbor, Md., just outside Washington, D.C.

So how does one get the most value out of the conference?

“The highest-yield content is going to depend on what your background is and how to spend that time in a way that augments your knowledge, your perspective, or your exposure to like-minded colleagues in a very individual way,” says HM13 course director Daniel Brotman, MD, FACP, SFHM, director of the hospitalist program at Johns Hopkins Hospital in Baltimore. “One of the things that’s so cool about hospital medicine is its diversity.”

But don’t take Dr. Brotman’s well-educated word for it. Here’s a list of recommendations from Team Hospitalist, the only reader-involvement group of its kind in HM, on events they would not miss this year.

The New Anticoagulants: When Should We Be Using Them?

2:45 p.m., May 17

Dr. Ma: “I’m very interested about the new anticoagulants talk. What I’m curious to see is what the speaker thinks about the survivability of these medications in our society, with so many lawyers. Pradaxa already has fallen out of favor. Let’s see what happens to Xarelto.”

How do CFOs Value Their Hospitalist Programs?

2:50 p.m., May 18

Dr. Ma: “The problem today is CFOs have to valuate their hospitalists in the setting of other specialists who also receive subsidies. There is less money to be spent on hospitalists, as other specialists vie for this allotment of savings from hospital-based value purchasing.”

Check out our 6-minute feature video: "Five Reasons You Should Attend HM13"

Mentoring/Coaching an Improvement Team: Lessons from SHM’s Mentored Implementation Programs

2:45 p.m., May 17

Dr. Perumalswami: “As a Project BOOST physician mentor in Illinois, I would highly recommend the session because the discussion will involve an inside look into valuable experience-based observations and analysis for the success of any process improvement team. The nature of teams and the culture of improvement at various sites will also be discussed. There will be a mentee side of the presentation, too, which will help other mentors of implementation programs better understand what the issues are ‘from the other side.’”

Strategies to Improve Communication with Patients and Families to Improve Care

2:45 p.m., May 17

Dr. Hale: “It is well known in pediatrics that you are treating two patients: both the child and the parents. If the family has a shared understanding of the child’s illness and there is collaboration for the care plan, there will be improved care.”

Neonatal HSV: When to Consider It, How to Evaluate for It, and How to Treat It

11 a.m., May 18

Dr. Hale: “Neonatal HSV is a devastating disease. It is essential to recognize high-risk patients to decrease morbidity and mortality for this illness. There have been recent updates in the understanding of epidemiology of this disease that can assist the provider in recognizing high-risk patients.”

Supporting Transition for Youth with Special Healthcare Needs: Coordinating Care and Preparing to Pass the Baton

4:15 p.m., May 18

Dr. Hale: “The transition of adolescents and young adults from pediatric-care teams to adult-medicine-care teams should be seamless for the sake of the patient, but often it is a blurry transition over the course of years. This session is high-yield for both pediatric and adult hospitalists.”

Getting Ready for Physician Value-Based Purchasing

9:50 a.m., May 19

Dr. Simone: “Dr. [Pat] Torcson’s presentation last year was one of the best at HM12, and I expect this year to be the same. He chairs SHM’s Performance Measurement and Reporting Committee and is well versed in these matters. He speaks in terms that will capture all audiences, whether they are experienced or new to the business aspects of medicine. Highly recommended.”

BOOSTing the Hospital Discharge Process: What Works and What Doesn’t

10:35 a.m., May 17

Dr. Simone: “Both panelists are excellent presenters as well as leading authorities when it comes to discharge processes. This presentation is very timely with the new CMS payment system, which penalizes unnecessary and unexpected readmissions.”

Success Stories: How to Integrate NPs and PAs into a Hospitalist Practice

4:15 p.m., May 18

Cardin: “This is an important session because, as every hard-working hospitalist knows, there simply aren’t enough physicians to fill the needs of our medically complex hospitalized patients. It is simply a reality that there will be an increased need in the future for mid-level providers, and it is valuable to maximize the success of a program by learning how to assimilate them into hospitalized practice.”

Diagnostic Errors and the Hospitalist: Why They Happen and How to Avoid Them

12:45 p.m., May 17

Cardin: “Half of practicing medicine is pattern recognition, and if there are patterns to making diagnostic errors, it would be so valuable to be aware of them. We have tremendous responsibility when caring for patients, and I think it is always beneficial to learn from mistakes.”

Richard Quinn is a freelance writer in New Jersey.

SHM’s annual meeting—or annui conventus, for you Latin lovers—is right around the corner, so be sure to cement your intentions and prepare to go if you have not already.

Now a “longstanding” tradition, the annual meeting serves many purposes, one of which is to act as a reservoir of time for individual hospitalists and for hospitalist groups to reflect on where they have been, where they are now, and where they are (or would like to be) going. A brief history of the SHM annual meeting makes us quickly realize how far we have come, and how far we have to go.

Where We’ve Been

The annual meeting’s history dates back to 1998, when a rogue gathering of about 100 self-proclaimed hospitalists gathered at the National Association of Inpatient Physicians (NAIP) meeting in San Diego. From the year before the first annual meeting to the year after the first annual meeting, membership in NAIP had grown from about 20 hospitalists to about 800 hospitalists. That rapidity of growth had never been seen by another specialty in the history of modern medicine. By the 2003 annual meeting in San Diego, the name had officially changed to the Society of Hospital Medicine, and membership had grown to more than 3,000; less than 10 years later, when the meeting returned to San Diego, membership had grown to more than 10,000. These continued steady increases in both membership size and attendance at the meeting serves as a testimony to the strength of the field and the leadership of the society.

Check out our 6-minute feature video: "Five Reasons You Should Attend HM13"

click for large version

Where We Are Now

Growth: SHM’s annual meeting now has a track record to be reckoned with. The number of attendees expected for 2013 is a staggering 3,000, which is only a portion of the more than 11,000 SHM members who can actually take time away from their busy practices to attend. The event has now expanded to more than three and a half days, including eight pre-courses and more than 100 workshops/breakout sessions to meet the needs of most any hospitalist. The number of submissions for the Research, Innovations, and Clinical Vignettes competition has steadily risen over the years, topping an all-time record of 800 submissions in 2013. This is a testimony to the curiosity and productivity of so many hospitalists and HM groups.

Advocacy: SHM has been a longstanding and considerable advocate for healthcare reform for more than a decade. With the annual meeting in Washington, D.C., this year, and in lieu of the pre-courses, more than 100 hospitalists and SHM staff will be making a field trip to Capitol Hill to advocate for changes in the structure and payment within the medical industry, to promote good patient care for those we serve, and to promote continued research for better ways of delivering care in the future. Over the course of 2012, SHM submitted more than 20 influential advocacy letters to a variety of stakeholders on topics ranging from sustainable growth rate (SGR) repeal to Agency for Healthcare Research and Quality (AHRQ) funding.

Impact: The annual meeting is not just bigger and longer; it is better. The quality and reputation of the plenary, breakout, and workshop speakers is tremendous, with this year’s plenary speakers including Patrick Conway, chief medical officer of CMS, and David Feinberg, president of UCLA Health System and CEO of UCLA Hospital System. The annual award ceremony will recognize a highly qualified repertoire of dedicated hospitalists and teams and reflect the number and quality of those involved in HM in the areas of clinical excellence, teaching, research, service, and teamwork. The annual Fellows in Hospital Medicine induction will include more than 300 additional fellows and senior fellows, which is a testimony to the level of involvement so many hospitalists have within our specialty.

Where We Are Going

Growth: I suspect the annual meeting will continue to grow in size, and it will expand to better serve the needs of other types of hospital-based physicians (neurologists, obstetricians, etc.), other types of practitioners (NPs, PAs, other specialty nurses), and other types of professionals (administrators and executives). It likely will attract an international community of hospitalists as other nations identify and execute better models of care for hospitalized patients.

Advocacy: SHM and the annual meeting will continue to serve as a nidus for directing the best pathways toward a better healthcare system. It will continue to serve as an avenue by which we partner with and/or influence impactful organizations, such as federal, state, and local governments, the Centers for Medicare & Medicaid Services (CMS), the Joint Commission, and the American Hospital Association, to name a few.

Impact: SHM and the annual meeting will expand its role as the focus for learning and sharing new research and innovations within the field. It will serve as a platform for initiating and spreading standardized evidence-based implementation of best practices through a repertoire of mentored implementation programs. And it will continue to serve as proof of the strength of our hospital medicine community as we spread into every U.S. hospital system and beyond.

Reputation: The future of our annual meeting and reputation will be dependent on how fast and how carefully we craft the pathway for HM. Currently, about half of all the nation’s hospitalists have been in practice for five years or less. We will need to carefully focus on how to be compassionate providers and system advocates—not just shift workers and billing specialists. We will have to be the mentors by which other countries define best practice for inpatient care, including what ideal training for a hospitalist should look like, and what their scope of practice should entail.

If you ask one of the attendees of the first annui conventus what it was like, they will say it was a small mom-and-pop gathering of disparate physicians, with a pie-in-the-sky idea of the future of hospitalist practice. And someday, when our current generation of hospitalists attends an international conference of hospitalists, in Prague, in 2033, we can say, “Remember when we met in that tiny hotel in D.C. in 2013?”

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

SHM’s annual meeting—or annui conventus, for you Latin lovers—is right around the corner, so be sure to cement your intentions and prepare to go if you have not already.

Now a “longstanding” tradition, the annual meeting serves many purposes, one of which is to act as a reservoir of time for individual hospitalists and for hospitalist groups to reflect on where they have been, where they are now, and where they are (or would like to be) going. A brief history of the SHM annual meeting makes us quickly realize how far we have come, and how far we have to go.

Where We’ve Been

The annual meeting’s history dates back to 1998, when a rogue gathering of about 100 self-proclaimed hospitalists gathered at the National Association of Inpatient Physicians (NAIP) meeting in San Diego. From the year before the first annual meeting to the year after the first annual meeting, membership in NAIP had grown from about 20 hospitalists to about 800 hospitalists. That rapidity of growth had never been seen by another specialty in the history of modern medicine. By the 2003 annual meeting in San Diego, the name had officially changed to the Society of Hospital Medicine, and membership had grown to more than 3,000; less than 10 years later, when the meeting returned to San Diego, membership had grown to more than 10,000. These continued steady increases in both membership size and attendance at the meeting serves as a testimony to the strength of the field and the leadership of the society.

Check out our 6-minute feature video: "Five Reasons You Should Attend HM13"

click for large version

Where We Are Now

Growth: SHM’s annual meeting now has a track record to be reckoned with. The number of attendees expected for 2013 is a staggering 3,000, which is only a portion of the more than 11,000 SHM members who can actually take time away from their busy practices to attend. The event has now expanded to more than three and a half days, including eight pre-courses and more than 100 workshops/breakout sessions to meet the needs of most any hospitalist. The number of submissions for the Research, Innovations, and Clinical Vignettes competition has steadily risen over the years, topping an all-time record of 800 submissions in 2013. This is a testimony to the curiosity and productivity of so many hospitalists and HM groups.

Advocacy: SHM has been a longstanding and considerable advocate for healthcare reform for more than a decade. With the annual meeting in Washington, D.C., this year, and in lieu of the pre-courses, more than 100 hospitalists and SHM staff will be making a field trip to Capitol Hill to advocate for changes in the structure and payment within the medical industry, to promote good patient care for those we serve, and to promote continued research for better ways of delivering care in the future. Over the course of 2012, SHM submitted more than 20 influential advocacy letters to a variety of stakeholders on topics ranging from sustainable growth rate (SGR) repeal to Agency for Healthcare Research and Quality (AHRQ) funding.

Impact: The annual meeting is not just bigger and longer; it is better. The quality and reputation of the plenary, breakout, and workshop speakers is tremendous, with this year’s plenary speakers including Patrick Conway, chief medical officer of CMS, and David Feinberg, president of UCLA Health System and CEO of UCLA Hospital System. The annual award ceremony will recognize a highly qualified repertoire of dedicated hospitalists and teams and reflect the number and quality of those involved in HM in the areas of clinical excellence, teaching, research, service, and teamwork. The annual Fellows in Hospital Medicine induction will include more than 300 additional fellows and senior fellows, which is a testimony to the level of involvement so many hospitalists have within our specialty.

Where We Are Going

Growth: I suspect the annual meeting will continue to grow in size, and it will expand to better serve the needs of other types of hospital-based physicians (neurologists, obstetricians, etc.), other types of practitioners (NPs, PAs, other specialty nurses), and other types of professionals (administrators and executives). It likely will attract an international community of hospitalists as other nations identify and execute better models of care for hospitalized patients.

Advocacy: SHM and the annual meeting will continue to serve as a nidus for directing the best pathways toward a better healthcare system. It will continue to serve as an avenue by which we partner with and/or influence impactful organizations, such as federal, state, and local governments, the Centers for Medicare & Medicaid Services (CMS), the Joint Commission, and the American Hospital Association, to name a few.

Impact: SHM and the annual meeting will expand its role as the focus for learning and sharing new research and innovations within the field. It will serve as a platform for initiating and spreading standardized evidence-based implementation of best practices through a repertoire of mentored implementation programs. And it will continue to serve as proof of the strength of our hospital medicine community as we spread into every U.S. hospital system and beyond.

Reputation: The future of our annual meeting and reputation will be dependent on how fast and how carefully we craft the pathway for HM. Currently, about half of all the nation’s hospitalists have been in practice for five years or less. We will need to carefully focus on how to be compassionate providers and system advocates—not just shift workers and billing specialists. We will have to be the mentors by which other countries define best practice for inpatient care, including what ideal training for a hospitalist should look like, and what their scope of practice should entail.

If you ask one of the attendees of the first annui conventus what it was like, they will say it was a small mom-and-pop gathering of disparate physicians, with a pie-in-the-sky idea of the future of hospitalist practice. And someday, when our current generation of hospitalists attends an international conference of hospitalists, in Prague, in 2033, we can say, “Remember when we met in that tiny hotel in D.C. in 2013?”

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

SHM’s annual meeting—or annui conventus, for you Latin lovers—is right around the corner, so be sure to cement your intentions and prepare to go if you have not already.

Now a “longstanding” tradition, the annual meeting serves many purposes, one of which is to act as a reservoir of time for individual hospitalists and for hospitalist groups to reflect on where they have been, where they are now, and where they are (or would like to be) going. A brief history of the SHM annual meeting makes us quickly realize how far we have come, and how far we have to go.

Where We’ve Been

The annual meeting’s history dates back to 1998, when a rogue gathering of about 100 self-proclaimed hospitalists gathered at the National Association of Inpatient Physicians (NAIP) meeting in San Diego. From the year before the first annual meeting to the year after the first annual meeting, membership in NAIP had grown from about 20 hospitalists to about 800 hospitalists. That rapidity of growth had never been seen by another specialty in the history of modern medicine. By the 2003 annual meeting in San Diego, the name had officially changed to the Society of Hospital Medicine, and membership had grown to more than 3,000; less than 10 years later, when the meeting returned to San Diego, membership had grown to more than 10,000. These continued steady increases in both membership size and attendance at the meeting serves as a testimony to the strength of the field and the leadership of the society.

Check out our 6-minute feature video: "Five Reasons You Should Attend HM13"

click for large version

Where We Are Now

Growth: SHM’s annual meeting now has a track record to be reckoned with. The number of attendees expected for 2013 is a staggering 3,000, which is only a portion of the more than 11,000 SHM members who can actually take time away from their busy practices to attend. The event has now expanded to more than three and a half days, including eight pre-courses and more than 100 workshops/breakout sessions to meet the needs of most any hospitalist. The number of submissions for the Research, Innovations, and Clinical Vignettes competition has steadily risen over the years, topping an all-time record of 800 submissions in 2013. This is a testimony to the curiosity and productivity of so many hospitalists and HM groups.

Advocacy: SHM has been a longstanding and considerable advocate for healthcare reform for more than a decade. With the annual meeting in Washington, D.C., this year, and in lieu of the pre-courses, more than 100 hospitalists and SHM staff will be making a field trip to Capitol Hill to advocate for changes in the structure and payment within the medical industry, to promote good patient care for those we serve, and to promote continued research for better ways of delivering care in the future. Over the course of 2012, SHM submitted more than 20 influential advocacy letters to a variety of stakeholders on topics ranging from sustainable growth rate (SGR) repeal to Agency for Healthcare Research and Quality (AHRQ) funding.

Impact: The annual meeting is not just bigger and longer; it is better. The quality and reputation of the plenary, breakout, and workshop speakers is tremendous, with this year’s plenary speakers including Patrick Conway, chief medical officer of CMS, and David Feinberg, president of UCLA Health System and CEO of UCLA Hospital System. The annual award ceremony will recognize a highly qualified repertoire of dedicated hospitalists and teams and reflect the number and quality of those involved in HM in the areas of clinical excellence, teaching, research, service, and teamwork. The annual Fellows in Hospital Medicine induction will include more than 300 additional fellows and senior fellows, which is a testimony to the level of involvement so many hospitalists have within our specialty.

Where We Are Going

Growth: I suspect the annual meeting will continue to grow in size, and it will expand to better serve the needs of other types of hospital-based physicians (neurologists, obstetricians, etc.), other types of practitioners (NPs, PAs, other specialty nurses), and other types of professionals (administrators and executives). It likely will attract an international community of hospitalists as other nations identify and execute better models of care for hospitalized patients.

Advocacy: SHM and the annual meeting will continue to serve as a nidus for directing the best pathways toward a better healthcare system. It will continue to serve as an avenue by which we partner with and/or influence impactful organizations, such as federal, state, and local governments, the Centers for Medicare & Medicaid Services (CMS), the Joint Commission, and the American Hospital Association, to name a few.

Impact: SHM and the annual meeting will expand its role as the focus for learning and sharing new research and innovations within the field. It will serve as a platform for initiating and spreading standardized evidence-based implementation of best practices through a repertoire of mentored implementation programs. And it will continue to serve as proof of the strength of our hospital medicine community as we spread into every U.S. hospital system and beyond.

Reputation: The future of our annual meeting and reputation will be dependent on how fast and how carefully we craft the pathway for HM. Currently, about half of all the nation’s hospitalists have been in practice for five years or less. We will need to carefully focus on how to be compassionate providers and system advocates—not just shift workers and billing specialists. We will have to be the mentors by which other countries define best practice for inpatient care, including what ideal training for a hospitalist should look like, and what their scope of practice should entail.

If you ask one of the attendees of the first annui conventus what it was like, they will say it was a small mom-and-pop gathering of disparate physicians, with a pie-in-the-sky idea of the future of hospitalist practice. And someday, when our current generation of hospitalists attends an international conference of hospitalists, in Prague, in 2033, we can say, “Remember when we met in that tiny hotel in D.C. in 2013?”

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

Success as an ACO likely won’t come from any one strategy, but from many. Christopher Kim, MD, MBA, SFHM, a hospitalist and associate professor of internal medicine at the University of Michigan, says the Michigan Pioneer ACO serving roughly 20,000 beneficiaries in the state’s southeastern region has benefited greatly from a variety of pre-existing relationships and initiatives. The university’s medical center, one of 10 participants in a Medicare ACO precursor called the Physician Group Practice demonstration project, was among the few sites to successfully meet the requirements and gain the full cost savings benefits in all five years.

The newer ACO, which officially launched in January 2012, pairs the university’s Faculty Group Practice with Integrated Health Associates Inc. (IHA), a large multispecialty private-practice group. Many IHA providers already had access to the university’s electronic health records so they could track admitted patients. One preliminary collaborative effort between the two entities hinted at a trend toward lower readmission rates among a small group of patients who were seen by a primary-care provider within seven days of a hospital discharge, underscoring the importance of a smooth transition.

Providers also have been able to tap into statewide initiatives aimed at improving quality and care coordination in key areas, such as cardiovascular disease, cancer, and hospital care transitions (sponsored by Blue Cross Blue Shield of Michigan).

These programs have helped physician organizations and hospitals throughout the state become familiar with best practices.

—Christopher Kim, MD, MBA, SFHM, associate professor of internal medicine, University of Michigan Health System, Ann Arbor

“These programs helped physician organizations and hospitals throughout the state become familiar with best practices related to these kinds of conditions,” Dr. Kim says, “and I think partly because of that, we were very prepared to work on a quality-improvement initiative such as this while also improving efficiency.”

Listen to Dr. Kim discuss the added responsibility hospitalists in ACOs like the one formed between the university faculty and a large multi-specialty practice called Integrated Health Associates, Inc.

For stratifying beneficiaries by risk, the ACO has benefited from a separate initiative called the Michigan Primary Care Transformation Project, which uses the concept of a pyramid to classify increasingly complicated patients. A complex-case manager, typically an advanced practice nurse, acts as the point person for guiding patients in the upper half of the pyramid toward the best resources while preventing unnecessary duplication of tasks or consultation referrals. Optimal coordination means that hospitalists need to communicate effectively with these managers as well as with other providers.

From Medicare claims supplied by CMS, Beth Israel Deaconess Physician Organization (BIDPO) in the Boston metropolitan region has used software to identify its highest-risk patients, or those most likely to be admitted to the hospital within the next 12 months. As part of the process, BIDPO officials asked doctors to validate the results based on their own patient records and observations.

The ACO has hired nurse practitioners through a company called INSPIRIS Massachusetts to visit its sickest and frailest Medicare beneficiaries at home to prevent hospital admissions and to avoid post-discharge readmissions among the highest-risk patients. BIDPO also uses nurse care managers to do telephone-based care management for less acute patients, and is asking emergency department staff to recognize patients who could be sent home safely with appropriate care rather than be admitted. Patients with cellulitis, for example, could be treated via IV antibiotic therapy at home, a service made possible through a collaboration with a home infusion company.

Dr. Parker, BIDPO’s medical director, says hospitalists will be key to understanding the need for excellent inpatient care and thoughtful, comprehensive discharge planning that helps avoid adverse events post-discharge.

Success as an ACO likely won’t come from any one strategy, but from many. Christopher Kim, MD, MBA, SFHM, a hospitalist and associate professor of internal medicine at the University of Michigan, says the Michigan Pioneer ACO serving roughly 20,000 beneficiaries in the state’s southeastern region has benefited greatly from a variety of pre-existing relationships and initiatives. The university’s medical center, one of 10 participants in a Medicare ACO precursor called the Physician Group Practice demonstration project, was among the few sites to successfully meet the requirements and gain the full cost savings benefits in all five years.

The newer ACO, which officially launched in January 2012, pairs the university’s Faculty Group Practice with Integrated Health Associates Inc. (IHA), a large multispecialty private-practice group. Many IHA providers already had access to the university’s electronic health records so they could track admitted patients. One preliminary collaborative effort between the two entities hinted at a trend toward lower readmission rates among a small group of patients who were seen by a primary-care provider within seven days of a hospital discharge, underscoring the importance of a smooth transition.

Providers also have been able to tap into statewide initiatives aimed at improving quality and care coordination in key areas, such as cardiovascular disease, cancer, and hospital care transitions (sponsored by Blue Cross Blue Shield of Michigan).

These programs have helped physician organizations and hospitals throughout the state become familiar with best practices.

—Christopher Kim, MD, MBA, SFHM, associate professor of internal medicine, University of Michigan Health System, Ann Arbor

“These programs helped physician organizations and hospitals throughout the state become familiar with best practices related to these kinds of conditions,” Dr. Kim says, “and I think partly because of that, we were very prepared to work on a quality-improvement initiative such as this while also improving efficiency.”

Listen to Dr. Kim discuss the added responsibility hospitalists in ACOs like the one formed between the university faculty and a large multi-specialty practice called Integrated Health Associates, Inc.

For stratifying beneficiaries by risk, the ACO has benefited from a separate initiative called the Michigan Primary Care Transformation Project, which uses the concept of a pyramid to classify increasingly complicated patients. A complex-case manager, typically an advanced practice nurse, acts as the point person for guiding patients in the upper half of the pyramid toward the best resources while preventing unnecessary duplication of tasks or consultation referrals. Optimal coordination means that hospitalists need to communicate effectively with these managers as well as with other providers.

From Medicare claims supplied by CMS, Beth Israel Deaconess Physician Organization (BIDPO) in the Boston metropolitan region has used software to identify its highest-risk patients, or those most likely to be admitted to the hospital within the next 12 months. As part of the process, BIDPO officials asked doctors to validate the results based on their own patient records and observations.

The ACO has hired nurse practitioners through a company called INSPIRIS Massachusetts to visit its sickest and frailest Medicare beneficiaries at home to prevent hospital admissions and to avoid post-discharge readmissions among the highest-risk patients. BIDPO also uses nurse care managers to do telephone-based care management for less acute patients, and is asking emergency department staff to recognize patients who could be sent home safely with appropriate care rather than be admitted. Patients with cellulitis, for example, could be treated via IV antibiotic therapy at home, a service made possible through a collaboration with a home infusion company.

Dr. Parker, BIDPO’s medical director, says hospitalists will be key to understanding the need for excellent inpatient care and thoughtful, comprehensive discharge planning that helps avoid adverse events post-discharge.

Success as an ACO likely won’t come from any one strategy, but from many. Christopher Kim, MD, MBA, SFHM, a hospitalist and associate professor of internal medicine at the University of Michigan, says the Michigan Pioneer ACO serving roughly 20,000 beneficiaries in the state’s southeastern region has benefited greatly from a variety of pre-existing relationships and initiatives. The university’s medical center, one of 10 participants in a Medicare ACO precursor called the Physician Group Practice demonstration project, was among the few sites to successfully meet the requirements and gain the full cost savings benefits in all five years.

The newer ACO, which officially launched in January 2012, pairs the university’s Faculty Group Practice with Integrated Health Associates Inc. (IHA), a large multispecialty private-practice group. Many IHA providers already had access to the university’s electronic health records so they could track admitted patients. One preliminary collaborative effort between the two entities hinted at a trend toward lower readmission rates among a small group of patients who were seen by a primary-care provider within seven days of a hospital discharge, underscoring the importance of a smooth transition.

Providers also have been able to tap into statewide initiatives aimed at improving quality and care coordination in key areas, such as cardiovascular disease, cancer, and hospital care transitions (sponsored by Blue Cross Blue Shield of Michigan).

These programs have helped physician organizations and hospitals throughout the state become familiar with best practices.

—Christopher Kim, MD, MBA, SFHM, associate professor of internal medicine, University of Michigan Health System, Ann Arbor

“These programs helped physician organizations and hospitals throughout the state become familiar with best practices related to these kinds of conditions,” Dr. Kim says, “and I think partly because of that, we were very prepared to work on a quality-improvement initiative such as this while also improving efficiency.”

Listen to Dr. Kim discuss the added responsibility hospitalists in ACOs like the one formed between the university faculty and a large multi-specialty practice called Integrated Health Associates, Inc.

For stratifying beneficiaries by risk, the ACO has benefited from a separate initiative called the Michigan Primary Care Transformation Project, which uses the concept of a pyramid to classify increasingly complicated patients. A complex-case manager, typically an advanced practice nurse, acts as the point person for guiding patients in the upper half of the pyramid toward the best resources while preventing unnecessary duplication of tasks or consultation referrals. Optimal coordination means that hospitalists need to communicate effectively with these managers as well as with other providers.

From Medicare claims supplied by CMS, Beth Israel Deaconess Physician Organization (BIDPO) in the Boston metropolitan region has used software to identify its highest-risk patients, or those most likely to be admitted to the hospital within the next 12 months. As part of the process, BIDPO officials asked doctors to validate the results based on their own patient records and observations.

The ACO has hired nurse practitioners through a company called INSPIRIS Massachusetts to visit its sickest and frailest Medicare beneficiaries at home to prevent hospital admissions and to avoid post-discharge readmissions among the highest-risk patients. BIDPO also uses nurse care managers to do telephone-based care management for less acute patients, and is asking emergency department staff to recognize patients who could be sent home safely with appropriate care rather than be admitted. Patients with cellulitis, for example, could be treated via IV antibiotic therapy at home, a service made possible through a collaboration with a home infusion company.

Dr. Parker, BIDPO’s medical director, says hospitalists will be key to understanding the need for excellent inpatient care and thoughtful, comprehensive discharge planning that helps avoid adverse events post-discharge.

click for large version

Throughout much of 2011, ambivalence plagued efforts by the Centers for Medicare & Medicaid Services (CMS) to expand the federal government’s reach into integrated care delivery to help improve patient outcomes while lowering costs. Critics panned the initial draft of regulations for a large accountable-care demonstration project called the Shared Savings Program, and prominent medical groups announced their intention to sit on the sidelines.

At the start of 2013, the atmosphere couldn’t be more different. CMS won over most of its critics with a well-received final version of the rules that provided more incentives for groups to form accountable-care organizations (ACOs), and the presidential election provided more clarity about the future of healthcare reform. Medical groups around the country are readily jumping on the ACO bandwagon, with its emphasis on shared responsibility among provider groups for a defined pool of patients.

Few medical groups have enough data to suggest whether their varied approaches to managing patient populations will lead to better-quality care that’s also more affordable; the first batch of Medicare ACO data isn’t expected until later this spring. And healthcare experts differ on which models and components are likely to make the biggest long-term impact; even the precise definition of an ACO remains a moving target. But industry observers say they’re surprised and encouraged not only by the speed with which the movement has taken off, but also by the breadth of models being investigated, the strong engagement of the private sector, and a spreading sense of cautious optimism.

“This is actually moving faster than I thought—faster than I think anybody thought,” says SHM Public Policy Committee chair Ron Greeno, MD, FCCP, MHM.

Although CMS still is in the beginning stages of its work and has focused most of its efforts on reviewing applications and providing feedback on organizations’ historical expenditure and utilization patterns, agency officials say the ACO initiative has not encountered any unexpected setbacks. “As with any new program, there are bumps along the way, but I don’t think we’ve experienced anything that is out of the ordinary,” says John Pilotte, director of Performance-Based Payment Policy in the Center for Medicare. “We’re pretty happy with where we are with the program.”

The Shared Savings Program, which Pilotte describes as “an easier on-ramp” to population management for providers and offers low financial risk in exchange for a modest level of shared cost savings, is proving especially popular. Combined, several hundred organizations submitted applications for the program’s second and third rounds, which began July 1, 2012, and Jan. 1, 2013, respectively.

“Two hundred twenty ACOs are currently up and running, and we expect to continue to add ACOs to the program annually,” Pilotte says.

Some people have said they haven’t had to make any major changes to their organization, while some people have had to drastically think how they provide care.

—David Muhlestein, analyst, Leavitt Partners

Last January, another 32 groups joined Medicare’s Pioneer ACO program, designed for more experienced organizations with more resources. The groups assume more risk, and in return are more handsomely rewarded if they meet benchmarks.

All told, the tally of confirmed ACOs in the U.S. reached 428 by the end of January, according to Leavitt Partners, a Salt Lake City-based healthcare consulting firm that is tracking the growth of accountable care (see “A Sampling of Significant ACO Programs,” below). David Muhlestein, an analyst with Leavitt Partners, says private ACOs now account for roughly half of that total, a trend driven by their ability to experiment with different approaches and more easily track costs through clearly defined patient populations.

The central role for hospitalists within most ACOs is rooted in the reality that hospital care is the most expensive part of healthcare. Successfully implementing a plan to coordinate care and prevent hospital readmissions might not correlate directly with improved quality metrics, but it can lead to significant savings.

The diverse ACO models now being tested, however, could result in varying responsibilities for hospitalists, depending on the focal points of the sponsoring entities. After patients have been admitted to a hospital, for example, many hospitalists assume responsibility for managing inpatient care and the inpatient-outpatient handoff. A main goal of a physician-owned medical group, such as an independent practice association (IPA), by contrast, is to keep patients out of the hospital altogether, placing more of the focus on primary and specialty care. An IPA that forms an ACO, Muhlestein says, might hire its own hospitalists to monitor the care of patients in affiliated hospitals while using the association’s approach to limiting costs.

ACO participants also have varied widely in the effort expended to get up to speed. “Some people have said they haven’t had to make any major changes to their organization, while some people have had to drastically think how they provide care,” Muhlestein says. In general, many of the former have had the luxury of working within relatively integrated facilities and building upon existing frameworks, whereas many of the latter previously toiled away in silos and are now scrambling to establish more cohesive working relationships from scratch.

Optimism Abounds

Though many ACOs have only limited data so far, Muhlestein says most are generally optimistic that their early results will be positive. Even so, Dr. Greeno says, he fully expects the Pioneer ACOs to produce the best results among the Medicare demonstration projects. Those organizations already have successful track records in managing patient populations, and the Pioneer model’s incentives are stronger because the groups are assuming more risk. If the Pioneer ACO results are eclipsed by those of the Shared Savings Program, he says, “I’d fall out of my chair.”

The Beth Israel Deaconess Physician Organization (BIDPO) now has four global payment contracts, including its Pioneer ACO arrangement with CMS that serves 33,000 beneficiaries in the Boston metropolitan region. “The decision-making around joining was a recognition that the fee-for-service model is highly dysfunctional,” says Richard Parker, MD, BIDPO’s medical director. “Our organization and our leadership believed that most of the country, both private payor and governmental payor, would be moving toward global payment and that it would be to our advantage to get in early.”

Dr. Parker

Despite the complicated rollout and delays in receiving Medicare data on patients from CMS, Dr. Parker says, the feedback from both providers and patients has been mostly positive. “I would say, anecdotally, that the doctors seem appreciative that we’re trying to fix some of these gaps in care that we all know have existed for some time,” he says. “And, anecdotally from the patients, we get appreciation that we’re trying to take better care of them.”

Chris Coleman, chief financial officer for Phoenix-based Banner Health Network, another Pioneer ACO participant, says the project fits in well with his company’s decision “to transform itself into more of a value-based, performance-based provider.” Banner’s ACO, which serves about 50,000 beneficiaries, is still setting up needed systems, including a consistent platform for electronic medical records throughout the entire provider network. Even during the building phase, however, Coleman says company officials have been pleasantly surprised by the ACO’s positive effect on utilization, patient care, and apparent savings.

Although the company has only a partial year of Medicare claims to go by, Coleman says the data look “pretty good” so far and suggest the ACO is on track for modest savings of perhaps 3% or 4%. Like BIDPO, Banner has other shared-risk agreements in place, including one for a Medicare Advantage population and another with a private payor. So far, Coleman says, those arrangements also seem to be “performing positively.”

Dr. Greeno and other experts see the best ACO results coming from such rapidly growing private arrangements, and early published data have been generally encouraging.¹ The ability to more narrowly define patient groups and assume more control over payments, he says, has allowed private ACOs to keep better track of costs and implement innovative population health interventions.

This is actually moving faster than I thought—faster than I think anybody thought.

—Ron Greeno, MD, FCCP, MHM, SHM Public Policy Committee chair

Built to Last?

Whether public, private, or a hybrid between the two, some ACOs are trying to manage the care of their entire patient pool and look at everything that might help them accrue cost savings. Others are focusing only on the sickest patients to reach their quality improvement (QI) and savings goals, and targeting specific parameters, such as blood pressure or medication adherence, for patients with myocardial infarction.

Dr. Goodroe

Joane Goodroe, an Atlanta-based healthcare consultant, favors the latter approach, at least for new ACOs. Goodroe recommends adopting a streamlined strategy that will get an ACO up and running, then allow the group to gradually add to it, rather than waiting until all of the right pieces fall into place. Her own data analysis of Medicare patients, for example, suggests that a diabetic who’s been an inpatient can average $50,000 in yearly costs, compared with $2,400 for a diabetic who has never been admitted to a hospital.

Setting up a system to manage every diabetic patient from the start, she says, would require too much time and money. “If you try to build the perfect ACO structure, it’s going to be too expensive for the results you initially get back,” she says, making it seem like the ACO is an unsustainable failure. “You’ve got to figure out how to build a cost-effective infrastructure while you’re also improving the care of the patients, and the best place to go is to target your sickest patients first.”

CMS’ Advance Payment ACO Model is designed to help by providing upfront payments to smaller ACO organizations that might lack capital, giving them an advance on potential shared savings so they can install the infrastructure and support structures necessary to redesign care.

To maximize the overall chances of success, Dr. Parker says, ACO leadership should be fully engaged, and each organization should have enough resources to address its own care management and information technology needs. “My goal as medical director is to improve the quality of care of the patients and, hopefully, also improve the working life of the doctors and staff,” he says. “And my belief and expectation is that if we do that, the cost of care will ultimately go down.”

Bryn Nelson is a freelance medical writer in Seattle.

Reference

1. Salmon RB, Sanderson MI, Walters BA, et al. Innovation profile: a collaborative accountable care model in three practices showed promising early results on costs and quality of care. Health Aff. 2012;31:2379-2387.

click for large version

Throughout much of 2011, ambivalence plagued efforts by the Centers for Medicare & Medicaid Services (CMS) to expand the federal government’s reach into integrated care delivery to help improve patient outcomes while lowering costs. Critics panned the initial draft of regulations for a large accountable-care demonstration project called the Shared Savings Program, and prominent medical groups announced their intention to sit on the sidelines.

At the start of 2013, the atmosphere couldn’t be more different. CMS won over most of its critics with a well-received final version of the rules that provided more incentives for groups to form accountable-care organizations (ACOs), and the presidential election provided more clarity about the future of healthcare reform. Medical groups around the country are readily jumping on the ACO bandwagon, with its emphasis on shared responsibility among provider groups for a defined pool of patients.

Few medical groups have enough data to suggest whether their varied approaches to managing patient populations will lead to better-quality care that’s also more affordable; the first batch of Medicare ACO data isn’t expected until later this spring. And healthcare experts differ on which models and components are likely to make the biggest long-term impact; even the precise definition of an ACO remains a moving target. But industry observers say they’re surprised and encouraged not only by the speed with which the movement has taken off, but also by the breadth of models being investigated, the strong engagement of the private sector, and a spreading sense of cautious optimism.

“This is actually moving faster than I thought—faster than I think anybody thought,” says SHM Public Policy Committee chair Ron Greeno, MD, FCCP, MHM.

Although CMS still is in the beginning stages of its work and has focused most of its efforts on reviewing applications and providing feedback on organizations’ historical expenditure and utilization patterns, agency officials say the ACO initiative has not encountered any unexpected setbacks. “As with any new program, there are bumps along the way, but I don’t think we’ve experienced anything that is out of the ordinary,” says John Pilotte, director of Performance-Based Payment Policy in the Center for Medicare. “We’re pretty happy with where we are with the program.”

The Shared Savings Program, which Pilotte describes as “an easier on-ramp” to population management for providers and offers low financial risk in exchange for a modest level of shared cost savings, is proving especially popular. Combined, several hundred organizations submitted applications for the program’s second and third rounds, which began July 1, 2012, and Jan. 1, 2013, respectively.

“Two hundred twenty ACOs are currently up and running, and we expect to continue to add ACOs to the program annually,” Pilotte says.

Some people have said they haven’t had to make any major changes to their organization, while some people have had to drastically think how they provide care.

—David Muhlestein, analyst, Leavitt Partners

Last January, another 32 groups joined Medicare’s Pioneer ACO program, designed for more experienced organizations with more resources. The groups assume more risk, and in return are more handsomely rewarded if they meet benchmarks.

All told, the tally of confirmed ACOs in the U.S. reached 428 by the end of January, according to Leavitt Partners, a Salt Lake City-based healthcare consulting firm that is tracking the growth of accountable care (see “A Sampling of Significant ACO Programs,” below). David Muhlestein, an analyst with Leavitt Partners, says private ACOs now account for roughly half of that total, a trend driven by their ability to experiment with different approaches and more easily track costs through clearly defined patient populations.

The central role for hospitalists within most ACOs is rooted in the reality that hospital care is the most expensive part of healthcare. Successfully implementing a plan to coordinate care and prevent hospital readmissions might not correlate directly with improved quality metrics, but it can lead to significant savings.

The diverse ACO models now being tested, however, could result in varying responsibilities for hospitalists, depending on the focal points of the sponsoring entities. After patients have been admitted to a hospital, for example, many hospitalists assume responsibility for managing inpatient care and the inpatient-outpatient handoff. A main goal of a physician-owned medical group, such as an independent practice association (IPA), by contrast, is to keep patients out of the hospital altogether, placing more of the focus on primary and specialty care. An IPA that forms an ACO, Muhlestein says, might hire its own hospitalists to monitor the care of patients in affiliated hospitals while using the association’s approach to limiting costs.

ACO participants also have varied widely in the effort expended to get up to speed. “Some people have said they haven’t had to make any major changes to their organization, while some people have had to drastically think how they provide care,” Muhlestein says. In general, many of the former have had the luxury of working within relatively integrated facilities and building upon existing frameworks, whereas many of the latter previously toiled away in silos and are now scrambling to establish more cohesive working relationships from scratch.

Optimism Abounds

Though many ACOs have only limited data so far, Muhlestein says most are generally optimistic that their early results will be positive. Even so, Dr. Greeno says, he fully expects the Pioneer ACOs to produce the best results among the Medicare demonstration projects. Those organizations already have successful track records in managing patient populations, and the Pioneer model’s incentives are stronger because the groups are assuming more risk. If the Pioneer ACO results are eclipsed by those of the Shared Savings Program, he says, “I’d fall out of my chair.”

The Beth Israel Deaconess Physician Organization (BIDPO) now has four global payment contracts, including its Pioneer ACO arrangement with CMS that serves 33,000 beneficiaries in the Boston metropolitan region. “The decision-making around joining was a recognition that the fee-for-service model is highly dysfunctional,” says Richard Parker, MD, BIDPO’s medical director. “Our organization and our leadership believed that most of the country, both private payor and governmental payor, would be moving toward global payment and that it would be to our advantage to get in early.”

Dr. Parker

Despite the complicated rollout and delays in receiving Medicare data on patients from CMS, Dr. Parker says, the feedback from both providers and patients has been mostly positive. “I would say, anecdotally, that the doctors seem appreciative that we’re trying to fix some of these gaps in care that we all know have existed for some time,” he says. “And, anecdotally from the patients, we get appreciation that we’re trying to take better care of them.”

Chris Coleman, chief financial officer for Phoenix-based Banner Health Network, another Pioneer ACO participant, says the project fits in well with his company’s decision “to transform itself into more of a value-based, performance-based provider.” Banner’s ACO, which serves about 50,000 beneficiaries, is still setting up needed systems, including a consistent platform for electronic medical records throughout the entire provider network. Even during the building phase, however, Coleman says company officials have been pleasantly surprised by the ACO’s positive effect on utilization, patient care, and apparent savings.

Although the company has only a partial year of Medicare claims to go by, Coleman says the data look “pretty good” so far and suggest the ACO is on track for modest savings of perhaps 3% or 4%. Like BIDPO, Banner has other shared-risk agreements in place, including one for a Medicare Advantage population and another with a private payor. So far, Coleman says, those arrangements also seem to be “performing positively.”

Dr. Greeno and other experts see the best ACO results coming from such rapidly growing private arrangements, and early published data have been generally encouraging.¹ The ability to more narrowly define patient groups and assume more control over payments, he says, has allowed private ACOs to keep better track of costs and implement innovative population health interventions.

This is actually moving faster than I thought—faster than I think anybody thought.

—Ron Greeno, MD, FCCP, MHM, SHM Public Policy Committee chair

Built to Last?

Whether public, private, or a hybrid between the two, some ACOs are trying to manage the care of their entire patient pool and look at everything that might help them accrue cost savings. Others are focusing only on the sickest patients to reach their quality improvement (QI) and savings goals, and targeting specific parameters, such as blood pressure or medication adherence, for patients with myocardial infarction.

Dr. Goodroe

Joane Goodroe, an Atlanta-based healthcare consultant, favors the latter approach, at least for new ACOs. Goodroe recommends adopting a streamlined strategy that will get an ACO up and running, then allow the group to gradually add to it, rather than waiting until all of the right pieces fall into place. Her own data analysis of Medicare patients, for example, suggests that a diabetic who’s been an inpatient can average $50,000 in yearly costs, compared with $2,400 for a diabetic who has never been admitted to a hospital.

Setting up a system to manage every diabetic patient from the start, she says, would require too much time and money. “If you try to build the perfect ACO structure, it’s going to be too expensive for the results you initially get back,” she says, making it seem like the ACO is an unsustainable failure. “You’ve got to figure out how to build a cost-effective infrastructure while you’re also improving the care of the patients, and the best place to go is to target your sickest patients first.”

CMS’ Advance Payment ACO Model is designed to help by providing upfront payments to smaller ACO organizations that might lack capital, giving them an advance on potential shared savings so they can install the infrastructure and support structures necessary to redesign care.

To maximize the overall chances of success, Dr. Parker says, ACO leadership should be fully engaged, and each organization should have enough resources to address its own care management and information technology needs. “My goal as medical director is to improve the quality of care of the patients and, hopefully, also improve the working life of the doctors and staff,” he says. “And my belief and expectation is that if we do that, the cost of care will ultimately go down.”

Bryn Nelson is a freelance medical writer in Seattle.

Reference

1. Salmon RB, Sanderson MI, Walters BA, et al. Innovation profile: a collaborative accountable care model in three practices showed promising early results on costs and quality of care. Health Aff. 2012;31:2379-2387.

click for large version

Throughout much of 2011, ambivalence plagued efforts by the Centers for Medicare & Medicaid Services (CMS) to expand the federal government’s reach into integrated care delivery to help improve patient outcomes while lowering costs. Critics panned the initial draft of regulations for a large accountable-care demonstration project called the Shared Savings Program, and prominent medical groups announced their intention to sit on the sidelines.

At the start of 2013, the atmosphere couldn’t be more different. CMS won over most of its critics with a well-received final version of the rules that provided more incentives for groups to form accountable-care organizations (ACOs), and the presidential election provided more clarity about the future of healthcare reform. Medical groups around the country are readily jumping on the ACO bandwagon, with its emphasis on shared responsibility among provider groups for a defined pool of patients.

Few medical groups have enough data to suggest whether their varied approaches to managing patient populations will lead to better-quality care that’s also more affordable; the first batch of Medicare ACO data isn’t expected until later this spring. And healthcare experts differ on which models and components are likely to make the biggest long-term impact; even the precise definition of an ACO remains a moving target. But industry observers say they’re surprised and encouraged not only by the speed with which the movement has taken off, but also by the breadth of models being investigated, the strong engagement of the private sector, and a spreading sense of cautious optimism.

“This is actually moving faster than I thought—faster than I think anybody thought,” says SHM Public Policy Committee chair Ron Greeno, MD, FCCP, MHM.

Although CMS still is in the beginning stages of its work and has focused most of its efforts on reviewing applications and providing feedback on organizations’ historical expenditure and utilization patterns, agency officials say the ACO initiative has not encountered any unexpected setbacks. “As with any new program, there are bumps along the way, but I don’t think we’ve experienced anything that is out of the ordinary,” says John Pilotte, director of Performance-Based Payment Policy in the Center for Medicare. “We’re pretty happy with where we are with the program.”

The Shared Savings Program, which Pilotte describes as “an easier on-ramp” to population management for providers and offers low financial risk in exchange for a modest level of shared cost savings, is proving especially popular. Combined, several hundred organizations submitted applications for the program’s second and third rounds, which began July 1, 2012, and Jan. 1, 2013, respectively.

“Two hundred twenty ACOs are currently up and running, and we expect to continue to add ACOs to the program annually,” Pilotte says.

Some people have said they haven’t had to make any major changes to their organization, while some people have had to drastically think how they provide care.

—David Muhlestein, analyst, Leavitt Partners

Last January, another 32 groups joined Medicare’s Pioneer ACO program, designed for more experienced organizations with more resources. The groups assume more risk, and in return are more handsomely rewarded if they meet benchmarks.

All told, the tally of confirmed ACOs in the U.S. reached 428 by the end of January, according to Leavitt Partners, a Salt Lake City-based healthcare consulting firm that is tracking the growth of accountable care (see “A Sampling of Significant ACO Programs,” below). David Muhlestein, an analyst with Leavitt Partners, says private ACOs now account for roughly half of that total, a trend driven by their ability to experiment with different approaches and more easily track costs through clearly defined patient populations.

The central role for hospitalists within most ACOs is rooted in the reality that hospital care is the most expensive part of healthcare. Successfully implementing a plan to coordinate care and prevent hospital readmissions might not correlate directly with improved quality metrics, but it can lead to significant savings.

The diverse ACO models now being tested, however, could result in varying responsibilities for hospitalists, depending on the focal points of the sponsoring entities. After patients have been admitted to a hospital, for example, many hospitalists assume responsibility for managing inpatient care and the inpatient-outpatient handoff. A main goal of a physician-owned medical group, such as an independent practice association (IPA), by contrast, is to keep patients out of the hospital altogether, placing more of the focus on primary and specialty care. An IPA that forms an ACO, Muhlestein says, might hire its own hospitalists to monitor the care of patients in affiliated hospitals while using the association’s approach to limiting costs.

ACO participants also have varied widely in the effort expended to get up to speed. “Some people have said they haven’t had to make any major changes to their organization, while some people have had to drastically think how they provide care,” Muhlestein says. In general, many of the former have had the luxury of working within relatively integrated facilities and building upon existing frameworks, whereas many of the latter previously toiled away in silos and are now scrambling to establish more cohesive working relationships from scratch.

Optimism Abounds

Though many ACOs have only limited data so far, Muhlestein says most are generally optimistic that their early results will be positive. Even so, Dr. Greeno says, he fully expects the Pioneer ACOs to produce the best results among the Medicare demonstration projects. Those organizations already have successful track records in managing patient populations, and the Pioneer model’s incentives are stronger because the groups are assuming more risk. If the Pioneer ACO results are eclipsed by those of the Shared Savings Program, he says, “I’d fall out of my chair.”

The Beth Israel Deaconess Physician Organization (BIDPO) now has four global payment contracts, including its Pioneer ACO arrangement with CMS that serves 33,000 beneficiaries in the Boston metropolitan region. “The decision-making around joining was a recognition that the fee-for-service model is highly dysfunctional,” says Richard Parker, MD, BIDPO’s medical director. “Our organization and our leadership believed that most of the country, both private payor and governmental payor, would be moving toward global payment and that it would be to our advantage to get in early.”

Dr. Parker

Despite the complicated rollout and delays in receiving Medicare data on patients from CMS, Dr. Parker says, the feedback from both providers and patients has been mostly positive. “I would say, anecdotally, that the doctors seem appreciative that we’re trying to fix some of these gaps in care that we all know have existed for some time,” he says. “And, anecdotally from the patients, we get appreciation that we’re trying to take better care of them.”

Chris Coleman, chief financial officer for Phoenix-based Banner Health Network, another Pioneer ACO participant, says the project fits in well with his company’s decision “to transform itself into more of a value-based, performance-based provider.” Banner’s ACO, which serves about 50,000 beneficiaries, is still setting up needed systems, including a consistent platform for electronic medical records throughout the entire provider network. Even during the building phase, however, Coleman says company officials have been pleasantly surprised by the ACO’s positive effect on utilization, patient care, and apparent savings.

Although the company has only a partial year of Medicare claims to go by, Coleman says the data look “pretty good” so far and suggest the ACO is on track for modest savings of perhaps 3% or 4%. Like BIDPO, Banner has other shared-risk agreements in place, including one for a Medicare Advantage population and another with a private payor. So far, Coleman says, those arrangements also seem to be “performing positively.”

Dr. Greeno and other experts see the best ACO results coming from such rapidly growing private arrangements, and early published data have been generally encouraging.¹ The ability to more narrowly define patient groups and assume more control over payments, he says, has allowed private ACOs to keep better track of costs and implement innovative population health interventions.

This is actually moving faster than I thought—faster than I think anybody thought.

—Ron Greeno, MD, FCCP, MHM, SHM Public Policy Committee chair

Built to Last?

Whether public, private, or a hybrid between the two, some ACOs are trying to manage the care of their entire patient pool and look at everything that might help them accrue cost savings. Others are focusing only on the sickest patients to reach their quality improvement (QI) and savings goals, and targeting specific parameters, such as blood pressure or medication adherence, for patients with myocardial infarction.

Dr. Goodroe

Joane Goodroe, an Atlanta-based healthcare consultant, favors the latter approach, at least for new ACOs. Goodroe recommends adopting a streamlined strategy that will get an ACO up and running, then allow the group to gradually add to it, rather than waiting until all of the right pieces fall into place. Her own data analysis of Medicare patients, for example, suggests that a diabetic who’s been an inpatient can average $50,000 in yearly costs, compared with $2,400 for a diabetic who has never been admitted to a hospital.

Setting up a system to manage every diabetic patient from the start, she says, would require too much time and money. “If you try to build the perfect ACO structure, it’s going to be too expensive for the results you initially get back,” she says, making it seem like the ACO is an unsustainable failure. “You’ve got to figure out how to build a cost-effective infrastructure while you’re also improving the care of the patients, and the best place to go is to target your sickest patients first.”

CMS’ Advance Payment ACO Model is designed to help by providing upfront payments to smaller ACO organizations that might lack capital, giving them an advance on potential shared savings so they can install the infrastructure and support structures necessary to redesign care.

To maximize the overall chances of success, Dr. Parker says, ACO leadership should be fully engaged, and each organization should have enough resources to address its own care management and information technology needs. “My goal as medical director is to improve the quality of care of the patients and, hopefully, also improve the working life of the doctors and staff,” he says. “And my belief and expectation is that if we do that, the cost of care will ultimately go down.”

Bryn Nelson is a freelance medical writer in Seattle.

Reference

1. Salmon RB, Sanderson MI, Walters BA, et al. Innovation profile: a collaborative accountable care model in three practices showed promising early results on costs and quality of care. Health Aff. 2012;31:2379-2387.

20 Things At A Glance

1. Acknowledge that collaboration between health professionals is important, even when schedules are hectic and reimbursement doesn’t cover these discussions.
2. Secure patient consent before consulting a psychiatrist.
3. Present the psychiatrist’s anticipated insight as a benefit to the patient.
4. Ask the patient if it’s all right to discuss their health status and needs with family members.
5. Recognize that psychiatric illness is real, not imaginary.
6. Realize that not all sadness constitutes depression.
7. Don’t gloss over the possibility of delirium.
8. Take the time to really listen.
9. Always remain conscious of alcohol and substance abuse.
10. Monitor patients’ vital signs for autonomic instability.
11. Avoid arguments and power struggles with difficult or demanding patients.
12. Adapt your vocabulary to the patient’s and family’s level of understanding.
13. Be mindful of your nonverbal cues.
14. Always take suicide risk seriously.
15. Beware of patients who exhibit attention-seeking behavior, which can have a negative impact on the healthcare team and the care provided to the patient.
16. Consider the possibility of a factitious disorder when there is a lack of objective evidence for pathology to explain a patient’s symptoms despite extensive evaluation.
17. Choose an intravenous psychiatric medication when a patient with severe and persistent mental illness should avoid oral medication for a procedure.
18. Listen to your instincts.
19. Arrange for post-discharge follow-up with a primary-care physician or psychiatrist.
20. Extend genuine compassion to your patients.

Patients can be hospitalized with chest pain, a kidney infection, pneumonia, or myriad other medical conditions. Hospital stays on occasion upend a patient’s mental state, with upcoming tests, surgery, or other procedures triggering anxiety or other conditions.

That doesn’t mean these patients have psychiatric or psychological problems, but some of them might. Hospitalists walk a fine line in deciding when to consult a psychiatrist in certain cases.

Dr. Muskin

“A common mistake, when it comes to psychiatry, for hospitalists is to either think they know too much or they know too little,” says Philip R. Muskin, MD, professor of clinical psychiatry at Columbia University College of Physicians & Surgeons in New York City. “Sometimes they’re too quick to call a psychiatrist, and sometimes they’re too slow to call a specialist because they don’t think it’s a psychiatric problem.”

The Hospitalist asked more than half a dozen specialists in psychiatry and hospital medicine to shed light on when to seek additional expertise—and how to inform patients about your request to do so. “If I say, ‘You need to see a psychiatrist,’ it carries some stigma,” says Dr. Muskin, who is the chief of consultation for liaison psychiatry at New York-Presbyterian Medical Center’s Columbia campus. “We have to be sensitive to that.”

So how can you more comfortably approach psychiatric or psychological issues in the hospital setting?

1. Acknowledge that collaboration between health professionals is important, even when schedules are hectic and reimbursement doesn’t cover these discussions.

“Because of the overwhelming comorbidity between psychiatric illness and medical illness, it’s important to have some communication between the emergency room, caregiver, the hospitalist, and the psychiatrist,” says Ken Duckworth, MD, medical director of the National Alliance on Mental Illness (NAMI) and an assistant clinical professor of psychiatry at Harvard Medical School in Boston. “We know that people with mental health vulnerabilities consume a much higher amount of medical services. That’s a well-known phenomenon.”

2. Secure patient consent before consulting a psychiatrist.

Dr. Duckworth

“You need the patient’s permission,” Dr. Duckworth says. “That’s an important piece of the equation.” There are exceptions in emergencies, and the laws pertaining to this vary by state. Verbal consent may suffice if written authorization is already on file. If a patient declines, a hospitalist has to respect those wishes.

3. Present the psychiatrist’s anticipated insight as a benefit to the patient.

Dr. Worley

Physicians sometimes are uncomfortable informing their patients that they’re asking for a psychiatric consultation. They fear a bad reaction, such as “You think I’m crazy?” The consultation will be more useful if the patient is open and accepting of the process. For example, tell your patient at the outset: “I’d really like you to talk to one of my colleagues, whom I trust a great deal. He/she is an expert in the overlapping area between the body and the brain. I need their help so that I can take better care of you,’” says Linda L.M. Worley, MD, FAPM, professor of psychiatry and obstetrics and gynecology at the University of Arkansas for Medical Sciences in Little Rock.

4. Ask the patient if it’s all right to discuss their health status and needs with family members.

Get to know their names. Identify the medical expert in the family and be certain to involve them in overall discussions and the decision-making process, Dr. Worley says.

5. Recognize that psychiatric illness is real, not imaginary.

The illness “should be placed in exactly the same arena as other medical problems,” Dr. Muskin says. Patients with psychiatric conditions are “not weak. They’re not dumb. It’s not all in their head.” Their mental health “deserves the same attention as their heart, stomach, or kidneys.”

6. Realize that not all sadness constitutes depression.

Dr. Boland

“There are many reasons why people cry or feel down, and most are not psychiatric illnesses. Depression is often overdiagnosed, leading to wasted time and inappropriate medications,” says Robert Boland, MD, professor of psychiatry and human behavior at Brown University’s Warren Alpert School of Medicine in Providence, R.I. “Unfortunately, the opposite is also true. Depression is often missed in the hospital.”

So how does a hospitalist reconcile those extremes? First, consider depression in any patient who is predisposed, then rely on a consistent way of working it up. The Diagnostic and Statistical Manual of Mental Disorders (DSM, http://www.dsm5.org) offers a conservative approach, so you usually can’t go wrong by following it.

7. Don’t gloss over the possibility of delirium.

It is probably the most frequently missed diagnosis in the general hospital. “We usually recognize it when patients are agitated, but most patients aren’t,” Dr. Boland says. “If anything, they are hypoactive or change throughout the day. When a patient seems confused, we want to find a cause, but that cause isn’t always obvious.”

These situations are particularly true in fragile patients (e.g. the very old or those with dementia). Sometimes medical problems that seem very minor can “push them over the edge,” he adds. When you do expect dementia, the main treatments revolve around medically stabilizing the patient, and psychiatric medications are a minor part of the management, if at all.

8. Take the time to really listen.

Patients’ biggest complaint is that physicians don’t listen. “The best doctors in any specialty know how to communicate with patients,” Dr. Boland says. “It doesn’t take longer—in fact, good communication usually saves time. But it does take attention and focus to let the patient try and explain what is going on with them. It always pays off in the end.”

9. Always remain conscious of alcohol and substance abuse.

Although it might not be the reason patients are hospitalized, it is one of the more common underlying causes. When this is the case, don’t be nihilistic. Many patients improve with treatment, and some get better simply because a physician explained how damaging substance abuse can be to their health, Dr. Boland says.

For those in complete remission from a past addiction to alcohol, benzodiazepines, opiates, or a combination thereof, beware that prescribing certain medications puts them at substantially increased risk for relapse. Use alternative treatments whenever possible; if clinically indicated, be certain that these patients have a safety net to prevent relapse. Patients with severe pain need effective relief.

“If a patient has been exposed to significant dosages of pain medications in the past, their neurotransmitters will have physically adapted,” says Dr. Worley, president-elect of the Academy of Psychosomatic Medicine. “They will require higher doses than normal for effective pain relief.”

“Hopelessness about the future correlates with completed suicide. Additionally, it is helpful to ask about the 4 H’s: Hate, humiliation, hostility, handguns.”

—Gregory Ruhnke, MD, assistant professor in the section of hospital medicine, University of Chicago Pritzker School of Medicine

10. Monitor patients’ vital signs for autonomic instability.

“Patients in withdrawal from physiologically addictive medications may have forgotten to tell you that they were taking these medications,” Dr. Worley says. “Abrupt discontinuation can cause incapacitating anxiety and life-threatening delirium.”

11. Avoid arguments and power struggles with difficult or demanding patients.

Put on your thick skin. Don’t take insults or slights personally. And resist the urge to flee or counterattack. Instead, Dr. Worley suggests hospitalists stay calm and focused on providing the best medical care that they can. “Chronically noncompliant patients can be excruciatingly frustrating to care for when they don’t follow through on what they are repeatedly advised to do, but lecturing more vigorously at them won’t help,” she says. “It only makes them shut down more and feel more helpless and you more exhausted. Shift to more of a listening mode and inquire about what they hope to accomplish by coming to you for help.”

12. Adapt your vocabulary to the patient’s and family’s level of understanding.

After your explanation, ask them, “Do me a favor and explain back to me in your words what I said. I want to be sure I got across what I wanted to say.” Then ask whether they have any questions. Also know that all too often patients are so anxious and upset that they are “emotionally flooded” and unable to hear much of what you communicated. You can save a lot of time if they understand you in the first place.

13. Be mindful of your nonverbal cues.

A majority of communication is nonverbal, and your facial expressions, gestures, and body posture speak volumes to patients and family members. “The innocent tilt of a chin upwards while peering through bifocals can be misperceived as arrogance,” Dr. Worley says. “The thoughtful furled brow of contemplation may be misconstrued as irritability or disapproval.”

14. Always take suicide risk seriously.

It’s better to call a psychiatrist unnecessarily than to overlook a patient at risk for suicide. Benzodiazepines, alcohol, or a combination of the two might reduce inhibition and increase the likelihood of a suicide attempt. Be sure to assess suicidal ideation, intent, and lethality of suicide attempt.

“Hopelessness about the future correlates with completed suicide,” says Gregory Ruhnke, MD, assistant professor in the section of hospital medicine at the University of Chicago Pritzker School of Medicine. “Additionally, it is helpful to ask about the four H’s: Hate, humiliation, hostility, handguns.”

15. Beware of patients who exhibit attention-seeking behavior, which can have a negative impact on the healthcare team and the care provided to the patient.

“The patient may become angry and engage in splitting, whereby he or she emphatically expresses the view that certain caregivers are all good or all bad. This may reflect such [a] patient’s desire to divide the caregivers into opposing factions. It’s a maladaptive way of coping,” says Marie Tobin, MD, associate professor of psychiatry and consult-liaison psychiatrist at the Pritzker School of Medicine. This can be very time-consuming, and it can breed hostility among colleagues. “Communication between caregivers is really important in creating a unified treatment plan that is coherently presented to the patient in a single voice.”

Fortunately, she says, “even though these situations can arise, they are the exception rather than the rule.”

“Communication between caregivers is really important in creating a unified treatment plan that is coherently presented to the patient in a single voice.”

—Marie Tobin, MD, associate professor of psychiatry and consult-liaison psychiatrist, University of Chicago Pritzker School of Medicine

16. Consider the possibility of a factitious disorder when there is a lack of objective evidence for pathology to explain a patient’s symptoms despite extensive evaluation.

For example, Dr. Ruhnke says, if a patient complains of hemoptysis and hematochezia with negative endoscopies, talk to the nurse about the patient’s diet, and be suspicious if it includes only red foods and liquids. The most common symptoms among patients who come to medical attention because of factitious disorders are diarrhea, fever of unknown origin, gastrointestinal bleeding, hematuria, seizures, and hypoglycemia.

17. Choose an intravenous psychiatric medication when a patient with severe and persistent mental illness should avoid oral medication for a procedure.

A patient with schizophrenia or bipolar disorder could experience a severe psychiatric episode without psychiatric medication. An appropriate alternative, perhaps administered intravenously if necessary, “can make all the difference in the world,” says Christopher Dobbelstein, MD, assistant professor of psychiatry at the University of Pittsburgh School of Medicine.

18. Listen to your instincts.

Medical teams can handle many psychiatric issues. Straightforward delirium is a good example. The bigger question, which takes experience and confidence, is to recognize when a line has been crossed. “The decision to consult psychiatry is not formulaic,” Dr. Dobbelstein says.

Sometimes a patient is acting strangely, and the team can’t explain why a psychiatrist could offer sound advice. “That’s when they should trust their instincts and consult us,” he says, “because the patient likely does have something more complex going on.”

19. Arrange for post-discharge follow-up with a primary-care physician or psychiatrist.

Sometimes psychiatric medications are started without good oversight. Suicide risk is highest during the weeks following an inpatient psychiatric admission, so a patient should see an outpatient mental health provider within seven days after hospital discharge, says NAMI’s Dr. Duckworth.

20. Extend genuine compassion to your patients.

“This is the secret to achieving a lifelong rewarding career in medicine,” Dr. Worley says, “and is the most important ingredient in positive outcomes.”

Susan Kreimer is a freelance writer in New York.

Survival Tips

Dr. Muskin

• Pull up a chair and sit down.
• Ask what name your patient likes to go by. Be respectful and use correct titles when appropriate. One size doesn’t fit all. “Mrs. X” might be a mother-in-law.
• Appreciate how terrifying it can be as a patient—ill, in pain, having no control, with a loss of privacy and at times dignity.
• Remember that any one of us in the role of a patient regresses and copes in different ways. Some become demanding and express a strong need for control, while others want and need information from their physician.
• Privacy is important. Close the door. Don’t ask sensitive questions within earshot of other patients or visitors.

20 Things At A Glance

1. Acknowledge that collaboration between health professionals is important, even when schedules are hectic and reimbursement doesn’t cover these discussions.
2. Secure patient consent before consulting a psychiatrist.
3. Present the psychiatrist’s anticipated insight as a benefit to the patient.
4. Ask the patient if it’s all right to discuss their health status and needs with family members.
5. Recognize that psychiatric illness is real, not imaginary.
6. Realize that not all sadness constitutes depression.
7. Don’t gloss over the possibility of delirium.
8. Take the time to really listen.
9. Always remain conscious of alcohol and substance abuse.
10. Monitor patients’ vital signs for autonomic instability.
11. Avoid arguments and power struggles with difficult or demanding patients.
12. Adapt your vocabulary to the patient’s and family’s level of understanding.
13. Be mindful of your nonverbal cues.
14. Always take suicide risk seriously.
15. Beware of patients who exhibit attention-seeking behavior, which can have a negative impact on the healthcare team and the care provided to the patient.
16. Consider the possibility of a factitious disorder when there is a lack of objective evidence for pathology to explain a patient’s symptoms despite extensive evaluation.
17. Choose an intravenous psychiatric medication when a patient with severe and persistent mental illness should avoid oral medication for a procedure.
18. Listen to your instincts.
19. Arrange for post-discharge follow-up with a primary-care physician or psychiatrist.
20. Extend genuine compassion to your patients.

Patients can be hospitalized with chest pain, a kidney infection, pneumonia, or myriad other medical conditions. Hospital stays on occasion upend a patient’s mental state, with upcoming tests, surgery, or other procedures triggering anxiety or other conditions.

That doesn’t mean these patients have psychiatric or psychological problems, but some of them might. Hospitalists walk a fine line in deciding when to consult a psychiatrist in certain cases.

Dr. Muskin

“A common mistake, when it comes to psychiatry, for hospitalists is to either think they know too much or they know too little,” says Philip R. Muskin, MD, professor of clinical psychiatry at Columbia University College of Physicians & Surgeons in New York City. “Sometimes they’re too quick to call a psychiatrist, and sometimes they’re too slow to call a specialist because they don’t think it’s a psychiatric problem.”

The Hospitalist asked more than half a dozen specialists in psychiatry and hospital medicine to shed light on when to seek additional expertise—and how to inform patients about your request to do so. “If I say, ‘You need to see a psychiatrist,’ it carries some stigma,” says Dr. Muskin, who is the chief of consultation for liaison psychiatry at New York-Presbyterian Medical Center’s Columbia campus. “We have to be sensitive to that.”

So how can you more comfortably approach psychiatric or psychological issues in the hospital setting?

1. Acknowledge that collaboration between health professionals is important, even when schedules are hectic and reimbursement doesn’t cover these discussions.

“Because of the overwhelming comorbidity between psychiatric illness and medical illness, it’s important to have some communication between the emergency room, caregiver, the hospitalist, and the psychiatrist,” says Ken Duckworth, MD, medical director of the National Alliance on Mental Illness (NAMI) and an assistant clinical professor of psychiatry at Harvard Medical School in Boston. “We know that people with mental health vulnerabilities consume a much higher amount of medical services. That’s a well-known phenomenon.”

2. Secure patient consent before consulting a psychiatrist.

Dr. Duckworth

“You need the patient’s permission,” Dr. Duckworth says. “That’s an important piece of the equation.” There are exceptions in emergencies, and the laws pertaining to this vary by state. Verbal consent may suffice if written authorization is already on file. If a patient declines, a hospitalist has to respect those wishes.

3. Present the psychiatrist’s anticipated insight as a benefit to the patient.

Dr. Worley

Physicians sometimes are uncomfortable informing their patients that they’re asking for a psychiatric consultation. They fear a bad reaction, such as “You think I’m crazy?” The consultation will be more useful if the patient is open and accepting of the process. For example, tell your patient at the outset: “I’d really like you to talk to one of my colleagues, whom I trust a great deal. He/she is an expert in the overlapping area between the body and the brain. I need their help so that I can take better care of you,’” says Linda L.M. Worley, MD, FAPM, professor of psychiatry and obstetrics and gynecology at the University of Arkansas for Medical Sciences in Little Rock.

4. Ask the patient if it’s all right to discuss their health status and needs with family members.

Get to know their names. Identify the medical expert in the family and be certain to involve them in overall discussions and the decision-making process, Dr. Worley says.

5. Recognize that psychiatric illness is real, not imaginary.

The illness “should be placed in exactly the same arena as other medical problems,” Dr. Muskin says. Patients with psychiatric conditions are “not weak. They’re not dumb. It’s not all in their head.” Their mental health “deserves the same attention as their heart, stomach, or kidneys.”

6. Realize that not all sadness constitutes depression.

Dr. Boland

“There are many reasons why people cry or feel down, and most are not psychiatric illnesses. Depression is often overdiagnosed, leading to wasted time and inappropriate medications,” says Robert Boland, MD, professor of psychiatry and human behavior at Brown University’s Warren Alpert School of Medicine in Providence, R.I. “Unfortunately, the opposite is also true. Depression is often missed in the hospital.”

So how does a hospitalist reconcile those extremes? First, consider depression in any patient who is predisposed, then rely on a consistent way of working it up. The Diagnostic and Statistical Manual of Mental Disorders (DSM, http://www.dsm5.org) offers a conservative approach, so you usually can’t go wrong by following it.

7. Don’t gloss over the possibility of delirium.

It is probably the most frequently missed diagnosis in the general hospital. “We usually recognize it when patients are agitated, but most patients aren’t,” Dr. Boland says. “If anything, they are hypoactive or change throughout the day. When a patient seems confused, we want to find a cause, but that cause isn’t always obvious.”

These situations are particularly true in fragile patients (e.g. the very old or those with dementia). Sometimes medical problems that seem very minor can “push them over the edge,” he adds. When you do expect dementia, the main treatments revolve around medically stabilizing the patient, and psychiatric medications are a minor part of the management, if at all.

8. Take the time to really listen.

Patients’ biggest complaint is that physicians don’t listen. “The best doctors in any specialty know how to communicate with patients,” Dr. Boland says. “It doesn’t take longer—in fact, good communication usually saves time. But it does take attention and focus to let the patient try and explain what is going on with them. It always pays off in the end.”

9. Always remain conscious of alcohol and substance abuse.

Although it might not be the reason patients are hospitalized, it is one of the more common underlying causes. When this is the case, don’t be nihilistic. Many patients improve with treatment, and some get better simply because a physician explained how damaging substance abuse can be to their health, Dr. Boland says.

For those in complete remission from a past addiction to alcohol, benzodiazepines, opiates, or a combination thereof, beware that prescribing certain medications puts them at substantially increased risk for relapse. Use alternative treatments whenever possible; if clinically indicated, be certain that these patients have a safety net to prevent relapse. Patients with severe pain need effective relief.

“If a patient has been exposed to significant dosages of pain medications in the past, their neurotransmitters will have physically adapted,” says Dr. Worley, president-elect of the Academy of Psychosomatic Medicine. “They will require higher doses than normal for effective pain relief.”

“Hopelessness about the future correlates with completed suicide. Additionally, it is helpful to ask about the 4 H’s: Hate, humiliation, hostility, handguns.”

—Gregory Ruhnke, MD, assistant professor in the section of hospital medicine, University of Chicago Pritzker School of Medicine

10. Monitor patients’ vital signs for autonomic instability.

“Patients in withdrawal from physiologically addictive medications may have forgotten to tell you that they were taking these medications,” Dr. Worley says. “Abrupt discontinuation can cause incapacitating anxiety and life-threatening delirium.”

11. Avoid arguments and power struggles with difficult or demanding patients.

Put on your thick skin. Don’t take insults or slights personally. And resist the urge to flee or counterattack. Instead, Dr. Worley suggests hospitalists stay calm and focused on providing the best medical care that they can. “Chronically noncompliant patients can be excruciatingly frustrating to care for when they don’t follow through on what they are repeatedly advised to do, but lecturing more vigorously at them won’t help,” she says. “It only makes them shut down more and feel more helpless and you more exhausted. Shift to more of a listening mode and inquire about what they hope to accomplish by coming to you for help.”

12. Adapt your vocabulary to the patient’s and family’s level of understanding.

After your explanation, ask them, “Do me a favor and explain back to me in your words what I said. I want to be sure I got across what I wanted to say.” Then ask whether they have any questions. Also know that all too often patients are so anxious and upset that they are “emotionally flooded” and unable to hear much of what you communicated. You can save a lot of time if they understand you in the first place.

13. Be mindful of your nonverbal cues.

A majority of communication is nonverbal, and your facial expressions, gestures, and body posture speak volumes to patients and family members. “The innocent tilt of a chin upwards while peering through bifocals can be misperceived as arrogance,” Dr. Worley says. “The thoughtful furled brow of contemplation may be misconstrued as irritability or disapproval.”

14. Always take suicide risk seriously.

It’s better to call a psychiatrist unnecessarily than to overlook a patient at risk for suicide. Benzodiazepines, alcohol, or a combination of the two might reduce inhibition and increase the likelihood of a suicide attempt. Be sure to assess suicidal ideation, intent, and lethality of suicide attempt.

“Hopelessness about the future correlates with completed suicide,” says Gregory Ruhnke, MD, assistant professor in the section of hospital medicine at the University of Chicago Pritzker School of Medicine. “Additionally, it is helpful to ask about the four H’s: Hate, humiliation, hostility, handguns.”

15. Beware of patients who exhibit attention-seeking behavior, which can have a negative impact on the healthcare team and the care provided to the patient.

“The patient may become angry and engage in splitting, whereby he or she emphatically expresses the view that certain caregivers are all good or all bad. This may reflect such [a] patient’s desire to divide the caregivers into opposing factions. It’s a maladaptive way of coping,” says Marie Tobin, MD, associate professor of psychiatry and consult-liaison psychiatrist at the Pritzker School of Medicine. This can be very time-consuming, and it can breed hostility among colleagues. “Communication between caregivers is really important in creating a unified treatment plan that is coherently presented to the patient in a single voice.”

Fortunately, she says, “even though these situations can arise, they are the exception rather than the rule.”

“Communication between caregivers is really important in creating a unified treatment plan that is coherently presented to the patient in a single voice.”

—Marie Tobin, MD, associate professor of psychiatry and consult-liaison psychiatrist, University of Chicago Pritzker School of Medicine

16. Consider the possibility of a factitious disorder when there is a lack of objective evidence for pathology to explain a patient’s symptoms despite extensive evaluation.

For example, Dr. Ruhnke says, if a patient complains of hemoptysis and hematochezia with negative endoscopies, talk to the nurse about the patient’s diet, and be suspicious if it includes only red foods and liquids. The most common symptoms among patients who come to medical attention because of factitious disorders are diarrhea, fever of unknown origin, gastrointestinal bleeding, hematuria, seizures, and hypoglycemia.

17. Choose an intravenous psychiatric medication when a patient with severe and persistent mental illness should avoid oral medication for a procedure.

A patient with schizophrenia or bipolar disorder could experience a severe psychiatric episode without psychiatric medication. An appropriate alternative, perhaps administered intravenously if necessary, “can make all the difference in the world,” says Christopher Dobbelstein, MD, assistant professor of psychiatry at the University of Pittsburgh School of Medicine.

18. Listen to your instincts.

Medical teams can handle many psychiatric issues. Straightforward delirium is a good example. The bigger question, which takes experience and confidence, is to recognize when a line has been crossed. “The decision to consult psychiatry is not formulaic,” Dr. Dobbelstein says.

Sometimes a patient is acting strangely, and the team can’t explain why a psychiatrist could offer sound advice. “That’s when they should trust their instincts and consult us,” he says, “because the patient likely does have something more complex going on.”

19. Arrange for post-discharge follow-up with a primary-care physician or psychiatrist.

Sometimes psychiatric medications are started without good oversight. Suicide risk is highest during the weeks following an inpatient psychiatric admission, so a patient should see an outpatient mental health provider within seven days after hospital discharge, says NAMI’s Dr. Duckworth.

20. Extend genuine compassion to your patients.

“This is the secret to achieving a lifelong rewarding career in medicine,” Dr. Worley says, “and is the most important ingredient in positive outcomes.”

Susan Kreimer is a freelance writer in New York.

Survival Tips

Dr. Muskin

• Pull up a chair and sit down.
• Ask what name your patient likes to go by. Be respectful and use correct titles when appropriate. One size doesn’t fit all. “Mrs. X” might be a mother-in-law.
• Appreciate how terrifying it can be as a patient—ill, in pain, having no control, with a loss of privacy and at times dignity.
• Remember that any one of us in the role of a patient regresses and copes in different ways. Some become demanding and express a strong need for control, while others want and need information from their physician.
• Privacy is important. Close the door. Don’t ask sensitive questions within earshot of other patients or visitors.

20 Things At A Glance

1. Acknowledge that collaboration between health professionals is important, even when schedules are hectic and reimbursement doesn’t cover these discussions.
2. Secure patient consent before consulting a psychiatrist.
3. Present the psychiatrist’s anticipated insight as a benefit to the patient.
4. Ask the patient if it’s all right to discuss their health status and needs with family members.
5. Recognize that psychiatric illness is real, not imaginary.
6. Realize that not all sadness constitutes depression.
7. Don’t gloss over the possibility of delirium.
8. Take the time to really listen.
9. Always remain conscious of alcohol and substance abuse.
10. Monitor patients’ vital signs for autonomic instability.
11. Avoid arguments and power struggles with difficult or demanding patients.
12. Adapt your vocabulary to the patient’s and family’s level of understanding.
13. Be mindful of your nonverbal cues.
14. Always take suicide risk seriously.
15. Beware of patients who exhibit attention-seeking behavior, which can have a negative impact on the healthcare team and the care provided to the patient.
16. Consider the possibility of a factitious disorder when there is a lack of objective evidence for pathology to explain a patient’s symptoms despite extensive evaluation.
17. Choose an intravenous psychiatric medication when a patient with severe and persistent mental illness should avoid oral medication for a procedure.
18. Listen to your instincts.
19. Arrange for post-discharge follow-up with a primary-care physician or psychiatrist.
20. Extend genuine compassion to your patients.

Patients can be hospitalized with chest pain, a kidney infection, pneumonia, or myriad other medical conditions. Hospital stays on occasion upend a patient’s mental state, with upcoming tests, surgery, or other procedures triggering anxiety or other conditions.

That doesn’t mean these patients have psychiatric or psychological problems, but some of them might. Hospitalists walk a fine line in deciding when to consult a psychiatrist in certain cases.

Dr. Muskin

“A common mistake, when it comes to psychiatry, for hospitalists is to either think they know too much or they know too little,” says Philip R. Muskin, MD, professor of clinical psychiatry at Columbia University College of Physicians & Surgeons in New York City. “Sometimes they’re too quick to call a psychiatrist, and sometimes they’re too slow to call a specialist because they don’t think it’s a psychiatric problem.”

The Hospitalist asked more than half a dozen specialists in psychiatry and hospital medicine to shed light on when to seek additional expertise—and how to inform patients about your request to do so. “If I say, ‘You need to see a psychiatrist,’ it carries some stigma,” says Dr. Muskin, who is the chief of consultation for liaison psychiatry at New York-Presbyterian Medical Center’s Columbia campus. “We have to be sensitive to that.”

So how can you more comfortably approach psychiatric or psychological issues in the hospital setting?

1. Acknowledge that collaboration between health professionals is important, even when schedules are hectic and reimbursement doesn’t cover these discussions.

“Because of the overwhelming comorbidity between psychiatric illness and medical illness, it’s important to have some communication between the emergency room, caregiver, the hospitalist, and the psychiatrist,” says Ken Duckworth, MD, medical director of the National Alliance on Mental Illness (NAMI) and an assistant clinical professor of psychiatry at Harvard Medical School in Boston. “We know that people with mental health vulnerabilities consume a much higher amount of medical services. That’s a well-known phenomenon.”

2. Secure patient consent before consulting a psychiatrist.

Dr. Duckworth

“You need the patient’s permission,” Dr. Duckworth says. “That’s an important piece of the equation.” There are exceptions in emergencies, and the laws pertaining to this vary by state. Verbal consent may suffice if written authorization is already on file. If a patient declines, a hospitalist has to respect those wishes.

3. Present the psychiatrist’s anticipated insight as a benefit to the patient.

Dr. Worley

Physicians sometimes are uncomfortable informing their patients that they’re asking for a psychiatric consultation. They fear a bad reaction, such as “You think I’m crazy?” The consultation will be more useful if the patient is open and accepting of the process. For example, tell your patient at the outset: “I’d really like you to talk to one of my colleagues, whom I trust a great deal. He/she is an expert in the overlapping area between the body and the brain. I need their help so that I can take better care of you,’” says Linda L.M. Worley, MD, FAPM, professor of psychiatry and obstetrics and gynecology at the University of Arkansas for Medical Sciences in Little Rock.

4. Ask the patient if it’s all right to discuss their health status and needs with family members.

Get to know their names. Identify the medical expert in the family and be certain to involve them in overall discussions and the decision-making process, Dr. Worley says.

5. Recognize that psychiatric illness is real, not imaginary.

The illness “should be placed in exactly the same arena as other medical problems,” Dr. Muskin says. Patients with psychiatric conditions are “not weak. They’re not dumb. It’s not all in their head.” Their mental health “deserves the same attention as their heart, stomach, or kidneys.”

6. Realize that not all sadness constitutes depression.

Dr. Boland

“There are many reasons why people cry or feel down, and most are not psychiatric illnesses. Depression is often overdiagnosed, leading to wasted time and inappropriate medications,” says Robert Boland, MD, professor of psychiatry and human behavior at Brown University’s Warren Alpert School of Medicine in Providence, R.I. “Unfortunately, the opposite is also true. Depression is often missed in the hospital.”

So how does a hospitalist reconcile those extremes? First, consider depression in any patient who is predisposed, then rely on a consistent way of working it up. The Diagnostic and Statistical Manual of Mental Disorders (DSM, http://www.dsm5.org) offers a conservative approach, so you usually can’t go wrong by following it.

7. Don’t gloss over the possibility of delirium.

It is probably the most frequently missed diagnosis in the general hospital. “We usually recognize it when patients are agitated, but most patients aren’t,” Dr. Boland says. “If anything, they are hypoactive or change throughout the day. When a patient seems confused, we want to find a cause, but that cause isn’t always obvious.”

These situations are particularly true in fragile patients (e.g. the very old or those with dementia). Sometimes medical problems that seem very minor can “push them over the edge,” he adds. When you do expect dementia, the main treatments revolve around medically stabilizing the patient, and psychiatric medications are a minor part of the management, if at all.

8. Take the time to really listen.

Patients’ biggest complaint is that physicians don’t listen. “The best doctors in any specialty know how to communicate with patients,” Dr. Boland says. “It doesn’t take longer—in fact, good communication usually saves time. But it does take attention and focus to let the patient try and explain what is going on with them. It always pays off in the end.”

9. Always remain conscious of alcohol and substance abuse.

Although it might not be the reason patients are hospitalized, it is one of the more common underlying causes. When this is the case, don’t be nihilistic. Many patients improve with treatment, and some get better simply because a physician explained how damaging substance abuse can be to their health, Dr. Boland says.

For those in complete remission from a past addiction to alcohol, benzodiazepines, opiates, or a combination thereof, beware that prescribing certain medications puts them at substantially increased risk for relapse. Use alternative treatments whenever possible; if clinically indicated, be certain that these patients have a safety net to prevent relapse. Patients with severe pain need effective relief.

“If a patient has been exposed to significant dosages of pain medications in the past, their neurotransmitters will have physically adapted,” says Dr. Worley, president-elect of the Academy of Psychosomatic Medicine. “They will require higher doses than normal for effective pain relief.”

“Hopelessness about the future correlates with completed suicide. Additionally, it is helpful to ask about the 4 H’s: Hate, humiliation, hostility, handguns.”

—Gregory Ruhnke, MD, assistant professor in the section of hospital medicine, University of Chicago Pritzker School of Medicine

10. Monitor patients’ vital signs for autonomic instability.

“Patients in withdrawal from physiologically addictive medications may have forgotten to tell you that they were taking these medications,” Dr. Worley says. “Abrupt discontinuation can cause incapacitating anxiety and life-threatening delirium.”

11. Avoid arguments and power struggles with difficult or demanding patients.

Put on your thick skin. Don’t take insults or slights personally. And resist the urge to flee or counterattack. Instead, Dr. Worley suggests hospitalists stay calm and focused on providing the best medical care that they can. “Chronically noncompliant patients can be excruciatingly frustrating to care for when they don’t follow through on what they are repeatedly advised to do, but lecturing more vigorously at them won’t help,” she says. “It only makes them shut down more and feel more helpless and you more exhausted. Shift to more of a listening mode and inquire about what they hope to accomplish by coming to you for help.”

12. Adapt your vocabulary to the patient’s and family’s level of understanding.

After your explanation, ask them, “Do me a favor and explain back to me in your words what I said. I want to be sure I got across what I wanted to say.” Then ask whether they have any questions. Also know that all too often patients are so anxious and upset that they are “emotionally flooded” and unable to hear much of what you communicated. You can save a lot of time if they understand you in the first place.

13. Be mindful of your nonverbal cues.

A majority of communication is nonverbal, and your facial expressions, gestures, and body posture speak volumes to patients and family members. “The innocent tilt of a chin upwards while peering through bifocals can be misperceived as arrogance,” Dr. Worley says. “The thoughtful furled brow of contemplation may be misconstrued as irritability or disapproval.”

14. Always take suicide risk seriously.

It’s better to call a psychiatrist unnecessarily than to overlook a patient at risk for suicide. Benzodiazepines, alcohol, or a combination of the two might reduce inhibition and increase the likelihood of a suicide attempt. Be sure to assess suicidal ideation, intent, and lethality of suicide attempt.

“Hopelessness about the future correlates with completed suicide,” says Gregory Ruhnke, MD, assistant professor in the section of hospital medicine at the University of Chicago Pritzker School of Medicine. “Additionally, it is helpful to ask about the four H’s: Hate, humiliation, hostility, handguns.”

15. Beware of patients who exhibit attention-seeking behavior, which can have a negative impact on the healthcare team and the care provided to the patient.

“The patient may become angry and engage in splitting, whereby he or she emphatically expresses the view that certain caregivers are all good or all bad. This may reflect such [a] patient’s desire to divide the caregivers into opposing factions. It’s a maladaptive way of coping,” says Marie Tobin, MD, associate professor of psychiatry and consult-liaison psychiatrist at the Pritzker School of Medicine. This can be very time-consuming, and it can breed hostility among colleagues. “Communication between caregivers is really important in creating a unified treatment plan that is coherently presented to the patient in a single voice.”

Fortunately, she says, “even though these situations can arise, they are the exception rather than the rule.”

“Communication between caregivers is really important in creating a unified treatment plan that is coherently presented to the patient in a single voice.”

—Marie Tobin, MD, associate professor of psychiatry and consult-liaison psychiatrist, University of Chicago Pritzker School of Medicine

16. Consider the possibility of a factitious disorder when there is a lack of objective evidence for pathology to explain a patient’s symptoms despite extensive evaluation.

For example, Dr. Ruhnke says, if a patient complains of hemoptysis and hematochezia with negative endoscopies, talk to the nurse about the patient’s diet, and be suspicious if it includes only red foods and liquids. The most common symptoms among patients who come to medical attention because of factitious disorders are diarrhea, fever of unknown origin, gastrointestinal bleeding, hematuria, seizures, and hypoglycemia.

17. Choose an intravenous psychiatric medication when a patient with severe and persistent mental illness should avoid oral medication for a procedure.

A patient with schizophrenia or bipolar disorder could experience a severe psychiatric episode without psychiatric medication. An appropriate alternative, perhaps administered intravenously if necessary, “can make all the difference in the world,” says Christopher Dobbelstein, MD, assistant professor of psychiatry at the University of Pittsburgh School of Medicine.

18. Listen to your instincts.

Medical teams can handle many psychiatric issues. Straightforward delirium is a good example. The bigger question, which takes experience and confidence, is to recognize when a line has been crossed. “The decision to consult psychiatry is not formulaic,” Dr. Dobbelstein says.

Sometimes a patient is acting strangely, and the team can’t explain why a psychiatrist could offer sound advice. “That’s when they should trust their instincts and consult us,” he says, “because the patient likely does have something more complex going on.”

19. Arrange for post-discharge follow-up with a primary-care physician or psychiatrist.

Sometimes psychiatric medications are started without good oversight. Suicide risk is highest during the weeks following an inpatient psychiatric admission, so a patient should see an outpatient mental health provider within seven days after hospital discharge, says NAMI’s Dr. Duckworth.

20. Extend genuine compassion to your patients.

“This is the secret to achieving a lifelong rewarding career in medicine,” Dr. Worley says, “and is the most important ingredient in positive outcomes.”

Susan Kreimer is a freelance writer in New York.

Survival Tips

Dr. Muskin

• Pull up a chair and sit down.
• Ask what name your patient likes to go by. Be respectful and use correct titles when appropriate. One size doesn’t fit all. “Mrs. X” might be a mother-in-law.
• Appreciate how terrifying it can be as a patient—ill, in pain, having no control, with a loss of privacy and at times dignity.
• Remember that any one of us in the role of a patient regresses and copes in different ways. Some become demanding and express a strong need for control, while others want and need information from their physician.
• Privacy is important. Close the door. Don’t ask sensitive questions within earshot of other patients or visitors.