Patient Care

New technology that infuses a copper oxide into hard surfaces or fabrics in order to boost infection control could soon become a major weapon in hospitals, according to the CEOs of two Virginia companies now developing such technologies.

Cupron (http://www.cupron.com/), based in Richmond, Va., provides the infusion of a proprietary copper oxide compound into such hard surfaces as flooring, countertops, building components, and furniture, and into fabrics such as gowns, uniforms, and linens, says company chairman Paul Rocheleau. Cupron is partnering with EOS Surfaces (http://eos-surfaces.com/cupron/), based in Portsmouth, Va., a developer of solid countertop surfaces, which company president Ken Trinder says are thicker than comparable building products.

Together, the companies are seeking approval from the U.S. Environmental Protection Agency to market these products with registrations for their public health claims of preventing hospital-acquired infections (HAIs) caused by bacteria, fungi, and viruses. The products recently were tested against Staphylococcus and Enterobacter bacteria, with 99.9% effectiveness in killing organisms, Rocheleau says.

“It is well known that copper has the ability to kill pathogens,” he adds. “What’s new are the methods to deliver that technology.”

He calls the copper-ion technology an additional layer of infection control, meant not to supplant other hospital protocols but to become part of overall risk-management programs to control HAIs. Other Cupron products, such as anti-odor footwear, are already on the market, but EOS aims to market the hard-surface products to health facilities starting in the second half of this year. “We’re also well advanced on the first of several clinical studies of the impact of Cupron-infused textiles and hard surfaces on infection rates,” Rocheleau says.

Meanwhile, a new “intelligent handwash monitoring system” to promote hand hygiene compliance in order to prevent HAIs that is now being tested in the United Kingdom by the global thermal technology company Irisys (www.irisys.co.uk/) was presented at the Association for Professionals in Infection Control and Epidemiology 2012 conference in June in San Antonio.

It uses non-intrusive therapy sensors deployed throughout healthcare facilities to detect people’s movements and determine accurate counts of handwashing opportunities, which are then compared to actual handwashing (or sanitizing gel) occurrences. The intention is to promote greater compliance with infection-preventing hand hygiene without violating personal privacy, such as through the use of video surveillance.

New technology that infuses a copper oxide into hard surfaces or fabrics in order to boost infection control could soon become a major weapon in hospitals, according to the CEOs of two Virginia companies now developing such technologies.

Cupron (http://www.cupron.com/), based in Richmond, Va., provides the infusion of a proprietary copper oxide compound into such hard surfaces as flooring, countertops, building components, and furniture, and into fabrics such as gowns, uniforms, and linens, says company chairman Paul Rocheleau. Cupron is partnering with EOS Surfaces (http://eos-surfaces.com/cupron/), based in Portsmouth, Va., a developer of solid countertop surfaces, which company president Ken Trinder says are thicker than comparable building products.

Together, the companies are seeking approval from the U.S. Environmental Protection Agency to market these products with registrations for their public health claims of preventing hospital-acquired infections (HAIs) caused by bacteria, fungi, and viruses. The products recently were tested against Staphylococcus and Enterobacter bacteria, with 99.9% effectiveness in killing organisms, Rocheleau says.

“It is well known that copper has the ability to kill pathogens,” he adds. “What’s new are the methods to deliver that technology.”

He calls the copper-ion technology an additional layer of infection control, meant not to supplant other hospital protocols but to become part of overall risk-management programs to control HAIs. Other Cupron products, such as anti-odor footwear, are already on the market, but EOS aims to market the hard-surface products to health facilities starting in the second half of this year. “We’re also well advanced on the first of several clinical studies of the impact of Cupron-infused textiles and hard surfaces on infection rates,” Rocheleau says.

Meanwhile, a new “intelligent handwash monitoring system” to promote hand hygiene compliance in order to prevent HAIs that is now being tested in the United Kingdom by the global thermal technology company Irisys (www.irisys.co.uk/) was presented at the Association for Professionals in Infection Control and Epidemiology 2012 conference in June in San Antonio.

It uses non-intrusive therapy sensors deployed throughout healthcare facilities to detect people’s movements and determine accurate counts of handwashing opportunities, which are then compared to actual handwashing (or sanitizing gel) occurrences. The intention is to promote greater compliance with infection-preventing hand hygiene without violating personal privacy, such as through the use of video surveillance.

New technology that infuses a copper oxide into hard surfaces or fabrics in order to boost infection control could soon become a major weapon in hospitals, according to the CEOs of two Virginia companies now developing such technologies.

Cupron (http://www.cupron.com/), based in Richmond, Va., provides the infusion of a proprietary copper oxide compound into such hard surfaces as flooring, countertops, building components, and furniture, and into fabrics such as gowns, uniforms, and linens, says company chairman Paul Rocheleau. Cupron is partnering with EOS Surfaces (http://eos-surfaces.com/cupron/), based in Portsmouth, Va., a developer of solid countertop surfaces, which company president Ken Trinder says are thicker than comparable building products.

Together, the companies are seeking approval from the U.S. Environmental Protection Agency to market these products with registrations for their public health claims of preventing hospital-acquired infections (HAIs) caused by bacteria, fungi, and viruses. The products recently were tested against Staphylococcus and Enterobacter bacteria, with 99.9% effectiveness in killing organisms, Rocheleau says.

“It is well known that copper has the ability to kill pathogens,” he adds. “What’s new are the methods to deliver that technology.”

He calls the copper-ion technology an additional layer of infection control, meant not to supplant other hospital protocols but to become part of overall risk-management programs to control HAIs. Other Cupron products, such as anti-odor footwear, are already on the market, but EOS aims to market the hard-surface products to health facilities starting in the second half of this year. “We’re also well advanced on the first of several clinical studies of the impact of Cupron-infused textiles and hard surfaces on infection rates,” Rocheleau says.

Meanwhile, a new “intelligent handwash monitoring system” to promote hand hygiene compliance in order to prevent HAIs that is now being tested in the United Kingdom by the global thermal technology company Irisys (www.irisys.co.uk/) was presented at the Association for Professionals in Infection Control and Epidemiology 2012 conference in June in San Antonio.

It uses non-intrusive therapy sensors deployed throughout healthcare facilities to detect people’s movements and determine accurate counts of handwashing opportunities, which are then compared to actual handwashing (or sanitizing gel) occurrences. The intention is to promote greater compliance with infection-preventing hand hygiene without violating personal privacy, such as through the use of video surveillance.

EDITOR’S NOTE: An incorrect version of Win Whitcomb’s “On the Horizon” column was published in the July issue of The Hospitalist. We deeply regret the error. The correct version of Dr. Whitcomb’s column appears this month, with proper attribution given to hospitalist Brad Flansbaum, DO, SFHM, who contributed to the column.

Assigning the appropriate status to patients (“inpatient” or “observation”) has emerged as a front-and-center issue for hospitalists. Also known as “medical necessity,” many HM groups have been called upon to help solve the “status” problem for their institutions. With nearly 1 in 5 hospitalized patients on observation status in U.S. hospitals, appropriately assigning status is now a dominant, system-level challenge for hospitalists.

This month, we asked two experts to shed light on the nature of this beast, with a focus on the impact on the patient. Brad Flansbaum, DO, SFHM, hospitalist at Lenox Hill Hospital in New York City, and Patrick Conway, MD, FAAP, MSC, SFHM, chief medical officer at the Centers for Medicare & Medicaid Services (CMS), were kind enough to participate in the interview. We start with Dr. Flansbaum.

Dr. Whitcomb: It appears that patients are caught in the middle of the observation status challenge, at least as it relates to footing the bill. Explain the patient perspective of being unwittingly placed on observation status.

Dr. Flansbaum: Recall your last credit card statement. On it is the hotel charge from your last out-of-town CME excursion. Below the total charge, which you were expecting, is a separate line item for a $75 “recreational fee.” You call the hotel, and they inform you that, because you used the hotel gym and pool—accessed with your room key, they levied the fee. No signs, alerts, or postings denoted the policy, so you expected inclusive use of the facilities as a price of your visit. Capture the emotion of the moment, when you see that bill, feel your heart race, and think to yourself, “Get me the manager!”

WW: Why has assigning appropriate status captured the attention of hospitals?

BF: Out of vigilance for penalties and fraud from recovery audit contractor (RAC) investigations, as well attentiveness to unnecessary readmissions, hospitals increasingly are categorizing patients under observation, rather than inpatient, status to avoid conflict with regulators. Beneficiaries are in the crosshairs because of this designation change, and much in the same way of our hotel charge, our patients experience sticker shock when they receive their bill. It is leading to confusion among providers and consternation within the Medicare recipient community.

WW: Why is there so much confusion around appropriate patient status?

BF: The dilemma stems from Medicare payment, and the key distinction between inpatient coverage (Part A) and outpatient coverage, including pharmaceuticals (Parts B and D). When a patient receives their discharge notification—without an “official” inpatient designation, sometimes staying greater than 24 to 48 hours in the ED or in a specially defined observation unit, beneficiary charges are different. This could result in discrete—and sometimes jolting—enrollee copayments and deductibles for drugs and services.

WW: I’ve heard observation status is having a big, adverse impact on patients who go to skilled nursing facilities. Why?

BF: If a patient requires a skilled nursing facility stay (the “three-day stay” inpatient requirement), Medicare will not pay because the patient never registered “official” hospital time. Patients and caregivers are not prepared for the unexpected bills, and consequently, tempers are rising. The rules for Medicare Advantage enrollees (Part C—commercial payers receive a fixed sum from CMS, and oversee parts A, B, and D for an individual beneficiary), which comprise 25% of the program, differ from conventional Medicare. However, commercial plans often shadow traditional, fee-for-service in their policies and, consequently, no exemplar of success in this realm exits.

WW: Why is the number of patients on observation status growing?

BF: Hospitals have significantly increased both the number of their observation stays, as well as their hourly lengths (>48 hours). Because the definition of “observation status” is vague, and even the one- to two-day window is inflating, hospitals and hospitalists often are navigating without a compass. Again, fear of fraud and penalty places hospitals and, indirectly, hospitalists—who often make judgments on admission grade—in a precarious position.

The responsibility of hospitals to notify beneficiaries of their status hinges on this murky determination milieu, which may change in real time during the stay, and makes for an unsatisfactory standard. Understandably, CMS is attempting to rectify this quandary, taking into account a hospital’s need to clarify its billing and designation practices, as well as the beneficiaries’ desire to obtain clear guidance on their responsibilities both during and after the stay. Hospitalists, of course, want direction on coding, along with an understanding of the impact their decisions will have on patients and subspecialty colleagues.

Let’s now bring in Dr. Conway, a pediatric hospitalist. I thank Dr. Flansbaum, who formulated the following questions.

BF/WW: Is it tenable to keep the current system in place? Would it help to require payors and providers to inform beneficiaries of inpatient versus observation status at time zero in a more rigorous, yet to-be-determined manner?

Dr. Conway: Current regulations only require CMS to inform beneficiaries when they are admitted as an inpatient and not when they are an outpatient receiving observation services. There are important implications for beneficiary coverage post-hospital stay, coverage of self-administered drugs, and beneficiary coinsurance from this distinction. As a hospitalist, I think it is best to inform the patient of their status, especially if it has the potential to impact beneficiary liability, including coverage of post-acute care. CMS prepared a pamphlet in 2009, “Are You a Hospital Inpatient or Outpatient? If You Have Medicare, Ask,” to educate beneficiaries on this issue. (Download a PDF of the pamphlet at www.medicare.gov/Publications/Pubs/pdf/11435.pdf.)

BF/WW: Due to the nature of how hospital care is changing, are admission decisions potentially becoming too conflicted an endeavor for inpatient caregivers?  

PC: We want admission decisions to be based on clinical considerations. The decision to admit a patient should be based on the clinical judgment of the primary-care, emergency medicine, and/or HM clinician.

BF/WW: Before the U.S. healthcare system matures to a more full-out, integrated model with internalized risk, can you envision any near-term code changes that might simplify the difficulties all parties are facing, in a budget-neutral fashion?

PC: CMS is currently investigating options to clarify when it is appropriate to admit the patient as an inpatient versus keeping the patient as an outpatient receiving observation services. We understand that this issue is of concern to hospitals, hospitalists, and patients, and we are considering carefully how to simplify the rules in a way that best meets the needs of patients and providers without increasing costs to the system.

With growing attention to observation status coming from patients and provider groups (the AMA is requesting that CMS revise its coverage rules), we will no doubt be hearing more about this going forward.

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.

EDITOR’S NOTE: An incorrect version of Win Whitcomb’s “On the Horizon” column was published in the July issue of The Hospitalist. We deeply regret the error. The correct version of Dr. Whitcomb’s column appears this month, with proper attribution given to hospitalist Brad Flansbaum, DO, SFHM, who contributed to the column.

Assigning the appropriate status to patients (“inpatient” or “observation”) has emerged as a front-and-center issue for hospitalists. Also known as “medical necessity,” many HM groups have been called upon to help solve the “status” problem for their institutions. With nearly 1 in 5 hospitalized patients on observation status in U.S. hospitals, appropriately assigning status is now a dominant, system-level challenge for hospitalists.

This month, we asked two experts to shed light on the nature of this beast, with a focus on the impact on the patient. Brad Flansbaum, DO, SFHM, hospitalist at Lenox Hill Hospital in New York City, and Patrick Conway, MD, FAAP, MSC, SFHM, chief medical officer at the Centers for Medicare & Medicaid Services (CMS), were kind enough to participate in the interview. We start with Dr. Flansbaum.

Dr. Whitcomb: It appears that patients are caught in the middle of the observation status challenge, at least as it relates to footing the bill. Explain the patient perspective of being unwittingly placed on observation status.

Dr. Flansbaum: Recall your last credit card statement. On it is the hotel charge from your last out-of-town CME excursion. Below the total charge, which you were expecting, is a separate line item for a $75 “recreational fee.” You call the hotel, and they inform you that, because you used the hotel gym and pool—accessed with your room key, they levied the fee. No signs, alerts, or postings denoted the policy, so you expected inclusive use of the facilities as a price of your visit. Capture the emotion of the moment, when you see that bill, feel your heart race, and think to yourself, “Get me the manager!”

WW: Why has assigning appropriate status captured the attention of hospitals?

BF: Out of vigilance for penalties and fraud from recovery audit contractor (RAC) investigations, as well attentiveness to unnecessary readmissions, hospitals increasingly are categorizing patients under observation, rather than inpatient, status to avoid conflict with regulators. Beneficiaries are in the crosshairs because of this designation change, and much in the same way of our hotel charge, our patients experience sticker shock when they receive their bill. It is leading to confusion among providers and consternation within the Medicare recipient community.

WW: Why is there so much confusion around appropriate patient status?

BF: The dilemma stems from Medicare payment, and the key distinction between inpatient coverage (Part A) and outpatient coverage, including pharmaceuticals (Parts B and D). When a patient receives their discharge notification—without an “official” inpatient designation, sometimes staying greater than 24 to 48 hours in the ED or in a specially defined observation unit, beneficiary charges are different. This could result in discrete—and sometimes jolting—enrollee copayments and deductibles for drugs and services.

WW: I’ve heard observation status is having a big, adverse impact on patients who go to skilled nursing facilities. Why?

BF: If a patient requires a skilled nursing facility stay (the “three-day stay” inpatient requirement), Medicare will not pay because the patient never registered “official” hospital time. Patients and caregivers are not prepared for the unexpected bills, and consequently, tempers are rising. The rules for Medicare Advantage enrollees (Part C—commercial payers receive a fixed sum from CMS, and oversee parts A, B, and D for an individual beneficiary), which comprise 25% of the program, differ from conventional Medicare. However, commercial plans often shadow traditional, fee-for-service in their policies and, consequently, no exemplar of success in this realm exits.

WW: Why is the number of patients on observation status growing?

BF: Hospitals have significantly increased both the number of their observation stays, as well as their hourly lengths (>48 hours). Because the definition of “observation status” is vague, and even the one- to two-day window is inflating, hospitals and hospitalists often are navigating without a compass. Again, fear of fraud and penalty places hospitals and, indirectly, hospitalists—who often make judgments on admission grade—in a precarious position.

The responsibility of hospitals to notify beneficiaries of their status hinges on this murky determination milieu, which may change in real time during the stay, and makes for an unsatisfactory standard. Understandably, CMS is attempting to rectify this quandary, taking into account a hospital’s need to clarify its billing and designation practices, as well as the beneficiaries’ desire to obtain clear guidance on their responsibilities both during and after the stay. Hospitalists, of course, want direction on coding, along with an understanding of the impact their decisions will have on patients and subspecialty colleagues.

Let’s now bring in Dr. Conway, a pediatric hospitalist. I thank Dr. Flansbaum, who formulated the following questions.

BF/WW: Is it tenable to keep the current system in place? Would it help to require payors and providers to inform beneficiaries of inpatient versus observation status at time zero in a more rigorous, yet to-be-determined manner?

Dr. Conway: Current regulations only require CMS to inform beneficiaries when they are admitted as an inpatient and not when they are an outpatient receiving observation services. There are important implications for beneficiary coverage post-hospital stay, coverage of self-administered drugs, and beneficiary coinsurance from this distinction. As a hospitalist, I think it is best to inform the patient of their status, especially if it has the potential to impact beneficiary liability, including coverage of post-acute care. CMS prepared a pamphlet in 2009, “Are You a Hospital Inpatient or Outpatient? If You Have Medicare, Ask,” to educate beneficiaries on this issue. (Download a PDF of the pamphlet at www.medicare.gov/Publications/Pubs/pdf/11435.pdf.)

BF/WW: Due to the nature of how hospital care is changing, are admission decisions potentially becoming too conflicted an endeavor for inpatient caregivers?  

PC: We want admission decisions to be based on clinical considerations. The decision to admit a patient should be based on the clinical judgment of the primary-care, emergency medicine, and/or HM clinician.

BF/WW: Before the U.S. healthcare system matures to a more full-out, integrated model with internalized risk, can you envision any near-term code changes that might simplify the difficulties all parties are facing, in a budget-neutral fashion?

PC: CMS is currently investigating options to clarify when it is appropriate to admit the patient as an inpatient versus keeping the patient as an outpatient receiving observation services. We understand that this issue is of concern to hospitals, hospitalists, and patients, and we are considering carefully how to simplify the rules in a way that best meets the needs of patients and providers without increasing costs to the system.

With growing attention to observation status coming from patients and provider groups (the AMA is requesting that CMS revise its coverage rules), we will no doubt be hearing more about this going forward.

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.

EDITOR’S NOTE: An incorrect version of Win Whitcomb’s “On the Horizon” column was published in the July issue of The Hospitalist. We deeply regret the error. The correct version of Dr. Whitcomb’s column appears this month, with proper attribution given to hospitalist Brad Flansbaum, DO, SFHM, who contributed to the column.

Assigning the appropriate status to patients (“inpatient” or “observation”) has emerged as a front-and-center issue for hospitalists. Also known as “medical necessity,” many HM groups have been called upon to help solve the “status” problem for their institutions. With nearly 1 in 5 hospitalized patients on observation status in U.S. hospitals, appropriately assigning status is now a dominant, system-level challenge for hospitalists.

This month, we asked two experts to shed light on the nature of this beast, with a focus on the impact on the patient. Brad Flansbaum, DO, SFHM, hospitalist at Lenox Hill Hospital in New York City, and Patrick Conway, MD, FAAP, MSC, SFHM, chief medical officer at the Centers for Medicare & Medicaid Services (CMS), were kind enough to participate in the interview. We start with Dr. Flansbaum.

Dr. Whitcomb: It appears that patients are caught in the middle of the observation status challenge, at least as it relates to footing the bill. Explain the patient perspective of being unwittingly placed on observation status.

Dr. Flansbaum: Recall your last credit card statement. On it is the hotel charge from your last out-of-town CME excursion. Below the total charge, which you were expecting, is a separate line item for a $75 “recreational fee.” You call the hotel, and they inform you that, because you used the hotel gym and pool—accessed with your room key, they levied the fee. No signs, alerts, or postings denoted the policy, so you expected inclusive use of the facilities as a price of your visit. Capture the emotion of the moment, when you see that bill, feel your heart race, and think to yourself, “Get me the manager!”

WW: Why has assigning appropriate status captured the attention of hospitals?

BF: Out of vigilance for penalties and fraud from recovery audit contractor (RAC) investigations, as well attentiveness to unnecessary readmissions, hospitals increasingly are categorizing patients under observation, rather than inpatient, status to avoid conflict with regulators. Beneficiaries are in the crosshairs because of this designation change, and much in the same way of our hotel charge, our patients experience sticker shock when they receive their bill. It is leading to confusion among providers and consternation within the Medicare recipient community.

WW: Why is there so much confusion around appropriate patient status?

BF: The dilemma stems from Medicare payment, and the key distinction between inpatient coverage (Part A) and outpatient coverage, including pharmaceuticals (Parts B and D). When a patient receives their discharge notification—without an “official” inpatient designation, sometimes staying greater than 24 to 48 hours in the ED or in a specially defined observation unit, beneficiary charges are different. This could result in discrete—and sometimes jolting—enrollee copayments and deductibles for drugs and services.

WW: I’ve heard observation status is having a big, adverse impact on patients who go to skilled nursing facilities. Why?

BF: If a patient requires a skilled nursing facility stay (the “three-day stay” inpatient requirement), Medicare will not pay because the patient never registered “official” hospital time. Patients and caregivers are not prepared for the unexpected bills, and consequently, tempers are rising. The rules for Medicare Advantage enrollees (Part C—commercial payers receive a fixed sum from CMS, and oversee parts A, B, and D for an individual beneficiary), which comprise 25% of the program, differ from conventional Medicare. However, commercial plans often shadow traditional, fee-for-service in their policies and, consequently, no exemplar of success in this realm exits.

WW: Why is the number of patients on observation status growing?

BF: Hospitals have significantly increased both the number of their observation stays, as well as their hourly lengths (>48 hours). Because the definition of “observation status” is vague, and even the one- to two-day window is inflating, hospitals and hospitalists often are navigating without a compass. Again, fear of fraud and penalty places hospitals and, indirectly, hospitalists—who often make judgments on admission grade—in a precarious position.

The responsibility of hospitals to notify beneficiaries of their status hinges on this murky determination milieu, which may change in real time during the stay, and makes for an unsatisfactory standard. Understandably, CMS is attempting to rectify this quandary, taking into account a hospital’s need to clarify its billing and designation practices, as well as the beneficiaries’ desire to obtain clear guidance on their responsibilities both during and after the stay. Hospitalists, of course, want direction on coding, along with an understanding of the impact their decisions will have on patients and subspecialty colleagues.

Let’s now bring in Dr. Conway, a pediatric hospitalist. I thank Dr. Flansbaum, who formulated the following questions.

BF/WW: Is it tenable to keep the current system in place? Would it help to require payors and providers to inform beneficiaries of inpatient versus observation status at time zero in a more rigorous, yet to-be-determined manner?

Dr. Conway: Current regulations only require CMS to inform beneficiaries when they are admitted as an inpatient and not when they are an outpatient receiving observation services. There are important implications for beneficiary coverage post-hospital stay, coverage of self-administered drugs, and beneficiary coinsurance from this distinction. As a hospitalist, I think it is best to inform the patient of their status, especially if it has the potential to impact beneficiary liability, including coverage of post-acute care. CMS prepared a pamphlet in 2009, “Are You a Hospital Inpatient or Outpatient? If You Have Medicare, Ask,” to educate beneficiaries on this issue. (Download a PDF of the pamphlet at www.medicare.gov/Publications/Pubs/pdf/11435.pdf.)

BF/WW: Due to the nature of how hospital care is changing, are admission decisions potentially becoming too conflicted an endeavor for inpatient caregivers?  

PC: We want admission decisions to be based on clinical considerations. The decision to admit a patient should be based on the clinical judgment of the primary-care, emergency medicine, and/or HM clinician.

BF/WW: Before the U.S. healthcare system matures to a more full-out, integrated model with internalized risk, can you envision any near-term code changes that might simplify the difficulties all parties are facing, in a budget-neutral fashion?

PC: CMS is currently investigating options to clarify when it is appropriate to admit the patient as an inpatient versus keeping the patient as an outpatient receiving observation services. We understand that this issue is of concern to hospitals, hospitalists, and patients, and we are considering carefully how to simplify the rules in a way that best meets the needs of patients and providers without increasing costs to the system.

With growing attention to observation status coming from patients and provider groups (the AMA is requesting that CMS revise its coverage rules), we will no doubt be hearing more about this going forward.

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.

When Harbor UCLA Medical Center, a teaching hospital in Torrance, Calif., and a major safety-net facility for Los Angeles County, looked at its 30-day readmissions data, it found that readmissions for heart failure patients had increased by about 25% in just one year.

“We parsed the data and said we’re going have to sort this out,” explains Charles McKay, MD, a cardiologist at the hospital. “Then the opportunity to join Project BOOST came along. It’s been helpful to have their tools, mentors, and the whole collaborative experience.”

Harbor UCLA is one of seven Southern California hospitals participating in the yearlong Readmissions Reduction Collaborative, co-sponsored by SHM and the Hospital Association of Southern California (HASC). The hospitals convened in early June in Montebello, Calif., to report results from their quality initiatives. Four of the hospitals reported reductions in readmissions ranging from 24% to 55%. The other three were slower in implementing their quality processes and are just now starting to see results, executives said.

Project BOOST is a national quality initiative created by SHM to improve hospital discharges and care transitions while reducing readmissions—a growing focus for hospitals and health policy makers. About 100 participating sites across the country have benefited from BOOST’s expert mentoring and collaboration, as well as access to such tools as the “teachback” communication techniques and the “8Ps” comprehensive patient risk assessment.

Harbor UCLA’s multidisciplinary readmissions team, with Dr. McKay as its physician champion, zeroed in on heart failure and developed a Cardiovascular Open Access Rapid Evaluation (CORE) service, which he describes as a sort of observation or clinical decisions unit aimed at relieving pressure on the ED. Open 7 a.m. to 7 p.m., the CORE service coordinates medical interventions—stress tests and trips to the cardiac catheter lab, for example—for patients who have not been admitted to the hospital.

The team also focuses on discharged patients who return to the hospital within 72 hours, before the hospital could place post-discharge follow-up phone calls. Many of these patients could not be reached after they left the hospital.

“These are the patients where the system has failed,” Dr. McKay says. “But you could flip it over and say they are our biggest opportunity. That’s where BOOST comes in, to talk about interventions during hospitalization, implementing teachback, streamlining the coordination of care.”

BOOST aims to accelerate the quality-improvement (QI) process, identifying readmission risks and making them a higher priority for nurses and doctors to mobilize resources in the discharge process. “That’s where BOOST shone at our institution,” Dr. McKay says, “and where we still have a lot to learn.”

Harbor UCLA also brought a home healthcare representative onto the team, engaged a discharge advocate, and referred appropriate patients to a heart failure disease management registry. Over the year of the collaborative, it posted a 5.5% decrease in readmissions of heart failure patients.

Hospitalists do not have prominent roles at most HASC readmissions sites; traditional hospitalist services are less common in Southern California hospitals, in part due to the prevalence of independent practice associations (IPAs), which act as intermediaries between physicians and health plans in the region, explains Z. Joseph Wanski, MD, FACE, medical director of the public L.A. Care Health Plan, which co-sponsored the readmissions collaborative. “The IPA is in charge of its members’ hospital and post-hospital care,” he says.

Dr. Wanski, a practicing endocrinologist and a hospitalist at California Hospital Medical Center in Los Angeles, says L.A. Care is now testing the use of hospitalists at some of its contracted acute-care facilities.

In many cases, readmissions involve avoidable costs, as well as reduce patient satisfaction. “If they do not get rehospitalized, patients are happier, their caretakers are happier, and I feel the quality of their care is better,” Dr. Wanski says. “If you can keep the person well at home, make sure they take their medications, hopefully not go back to the ER, and get on with their lives—all those things together are why we’re supporting this collaborative.”

But hospitalists, especially in larger groups, potentially have the leverage to negotiate access to services and the care coordination needed to reduce hospital costs and preventable readmissions, Dr. McKay notes. “In 2012, hospitalists are key, and we need to find a way to make readmission reduction part of their job description, so that they can direct that,” he says.

At Valley Presbyterian Hospital in Van Nuys, which employs three part-time hospitalists who also maintain busy office practices, “the hospitalists have been very cooperative with our project,” reports Adriana Quintero, MSW, the hospital’s full-time Project BOOST facilitator. “They see a lot of our patients in their offices.” The physicians have agreed to carve out time to see, within seven days, discharge patients going home without scheduled appointments with their primary-care physicians (PCPs).

“We find that many of our discharged patients do not call their primary-care physicians for post-discharge appointments” and decline the hospital team’s offers for help—which makes it important for the discharge coordinator to follow up as soon as possible after the patient goes home, Quintero says.

At the collaborative congress in early June, team member Alice Gunderson reported results for Saint Francis Hospital in Lynwood. Gunderson, who sits on the hospital’s quality and safety board, has been a volunteer patient family advocate (PFA) for the past year and a half; she was inspired by her own experience as a family caregiver for her husband and mother, both of whom were Saint Francis patients. Gunderson challenged those in the audience to bring a PFA from their own hospital to the next BOOST meeting.

“From my point of view, wherever healthcare goes, the patient is becoming more educated, with all of the communication technology that is out there, and claiming that empowerment,” Gunderson says. “We must all work together, not in separate silos, for the best outcomes, and we can all learn from one another.”

Larry Beresford is a freelance writer in Oakland, Calif.

When Harbor UCLA Medical Center, a teaching hospital in Torrance, Calif., and a major safety-net facility for Los Angeles County, looked at its 30-day readmissions data, it found that readmissions for heart failure patients had increased by about 25% in just one year.

“We parsed the data and said we’re going have to sort this out,” explains Charles McKay, MD, a cardiologist at the hospital. “Then the opportunity to join Project BOOST came along. It’s been helpful to have their tools, mentors, and the whole collaborative experience.”

Harbor UCLA is one of seven Southern California hospitals participating in the yearlong Readmissions Reduction Collaborative, co-sponsored by SHM and the Hospital Association of Southern California (HASC). The hospitals convened in early June in Montebello, Calif., to report results from their quality initiatives. Four of the hospitals reported reductions in readmissions ranging from 24% to 55%. The other three were slower in implementing their quality processes and are just now starting to see results, executives said.

Project BOOST is a national quality initiative created by SHM to improve hospital discharges and care transitions while reducing readmissions—a growing focus for hospitals and health policy makers. About 100 participating sites across the country have benefited from BOOST’s expert mentoring and collaboration, as well as access to such tools as the “teachback” communication techniques and the “8Ps” comprehensive patient risk assessment.

Harbor UCLA’s multidisciplinary readmissions team, with Dr. McKay as its physician champion, zeroed in on heart failure and developed a Cardiovascular Open Access Rapid Evaluation (CORE) service, which he describes as a sort of observation or clinical decisions unit aimed at relieving pressure on the ED. Open 7 a.m. to 7 p.m., the CORE service coordinates medical interventions—stress tests and trips to the cardiac catheter lab, for example—for patients who have not been admitted to the hospital.

The team also focuses on discharged patients who return to the hospital within 72 hours, before the hospital could place post-discharge follow-up phone calls. Many of these patients could not be reached after they left the hospital.

“These are the patients where the system has failed,” Dr. McKay says. “But you could flip it over and say they are our biggest opportunity. That’s where BOOST comes in, to talk about interventions during hospitalization, implementing teachback, streamlining the coordination of care.”

BOOST aims to accelerate the quality-improvement (QI) process, identifying readmission risks and making them a higher priority for nurses and doctors to mobilize resources in the discharge process. “That’s where BOOST shone at our institution,” Dr. McKay says, “and where we still have a lot to learn.”

Harbor UCLA also brought a home healthcare representative onto the team, engaged a discharge advocate, and referred appropriate patients to a heart failure disease management registry. Over the year of the collaborative, it posted a 5.5% decrease in readmissions of heart failure patients.

Hospitalists do not have prominent roles at most HASC readmissions sites; traditional hospitalist services are less common in Southern California hospitals, in part due to the prevalence of independent practice associations (IPAs), which act as intermediaries between physicians and health plans in the region, explains Z. Joseph Wanski, MD, FACE, medical director of the public L.A. Care Health Plan, which co-sponsored the readmissions collaborative. “The IPA is in charge of its members’ hospital and post-hospital care,” he says.

Dr. Wanski, a practicing endocrinologist and a hospitalist at California Hospital Medical Center in Los Angeles, says L.A. Care is now testing the use of hospitalists at some of its contracted acute-care facilities.

In many cases, readmissions involve avoidable costs, as well as reduce patient satisfaction. “If they do not get rehospitalized, patients are happier, their caretakers are happier, and I feel the quality of their care is better,” Dr. Wanski says. “If you can keep the person well at home, make sure they take their medications, hopefully not go back to the ER, and get on with their lives—all those things together are why we’re supporting this collaborative.”

But hospitalists, especially in larger groups, potentially have the leverage to negotiate access to services and the care coordination needed to reduce hospital costs and preventable readmissions, Dr. McKay notes. “In 2012, hospitalists are key, and we need to find a way to make readmission reduction part of their job description, so that they can direct that,” he says.

At Valley Presbyterian Hospital in Van Nuys, which employs three part-time hospitalists who also maintain busy office practices, “the hospitalists have been very cooperative with our project,” reports Adriana Quintero, MSW, the hospital’s full-time Project BOOST facilitator. “They see a lot of our patients in their offices.” The physicians have agreed to carve out time to see, within seven days, discharge patients going home without scheduled appointments with their primary-care physicians (PCPs).

“We find that many of our discharged patients do not call their primary-care physicians for post-discharge appointments” and decline the hospital team’s offers for help—which makes it important for the discharge coordinator to follow up as soon as possible after the patient goes home, Quintero says.

At the collaborative congress in early June, team member Alice Gunderson reported results for Saint Francis Hospital in Lynwood. Gunderson, who sits on the hospital’s quality and safety board, has been a volunteer patient family advocate (PFA) for the past year and a half; she was inspired by her own experience as a family caregiver for her husband and mother, both of whom were Saint Francis patients. Gunderson challenged those in the audience to bring a PFA from their own hospital to the next BOOST meeting.

“From my point of view, wherever healthcare goes, the patient is becoming more educated, with all of the communication technology that is out there, and claiming that empowerment,” Gunderson says. “We must all work together, not in separate silos, for the best outcomes, and we can all learn from one another.”

Larry Beresford is a freelance writer in Oakland, Calif.

When Harbor UCLA Medical Center, a teaching hospital in Torrance, Calif., and a major safety-net facility for Los Angeles County, looked at its 30-day readmissions data, it found that readmissions for heart failure patients had increased by about 25% in just one year.

“We parsed the data and said we’re going have to sort this out,” explains Charles McKay, MD, a cardiologist at the hospital. “Then the opportunity to join Project BOOST came along. It’s been helpful to have their tools, mentors, and the whole collaborative experience.”

Harbor UCLA is one of seven Southern California hospitals participating in the yearlong Readmissions Reduction Collaborative, co-sponsored by SHM and the Hospital Association of Southern California (HASC). The hospitals convened in early June in Montebello, Calif., to report results from their quality initiatives. Four of the hospitals reported reductions in readmissions ranging from 24% to 55%. The other three were slower in implementing their quality processes and are just now starting to see results, executives said.

Project BOOST is a national quality initiative created by SHM to improve hospital discharges and care transitions while reducing readmissions—a growing focus for hospitals and health policy makers. About 100 participating sites across the country have benefited from BOOST’s expert mentoring and collaboration, as well as access to such tools as the “teachback” communication techniques and the “8Ps” comprehensive patient risk assessment.

Harbor UCLA’s multidisciplinary readmissions team, with Dr. McKay as its physician champion, zeroed in on heart failure and developed a Cardiovascular Open Access Rapid Evaluation (CORE) service, which he describes as a sort of observation or clinical decisions unit aimed at relieving pressure on the ED. Open 7 a.m. to 7 p.m., the CORE service coordinates medical interventions—stress tests and trips to the cardiac catheter lab, for example—for patients who have not been admitted to the hospital.

The team also focuses on discharged patients who return to the hospital within 72 hours, before the hospital could place post-discharge follow-up phone calls. Many of these patients could not be reached after they left the hospital.

“These are the patients where the system has failed,” Dr. McKay says. “But you could flip it over and say they are our biggest opportunity. That’s where BOOST comes in, to talk about interventions during hospitalization, implementing teachback, streamlining the coordination of care.”

BOOST aims to accelerate the quality-improvement (QI) process, identifying readmission risks and making them a higher priority for nurses and doctors to mobilize resources in the discharge process. “That’s where BOOST shone at our institution,” Dr. McKay says, “and where we still have a lot to learn.”

Harbor UCLA also brought a home healthcare representative onto the team, engaged a discharge advocate, and referred appropriate patients to a heart failure disease management registry. Over the year of the collaborative, it posted a 5.5% decrease in readmissions of heart failure patients.

Hospitalists do not have prominent roles at most HASC readmissions sites; traditional hospitalist services are less common in Southern California hospitals, in part due to the prevalence of independent practice associations (IPAs), which act as intermediaries between physicians and health plans in the region, explains Z. Joseph Wanski, MD, FACE, medical director of the public L.A. Care Health Plan, which co-sponsored the readmissions collaborative. “The IPA is in charge of its members’ hospital and post-hospital care,” he says.

Dr. Wanski, a practicing endocrinologist and a hospitalist at California Hospital Medical Center in Los Angeles, says L.A. Care is now testing the use of hospitalists at some of its contracted acute-care facilities.

In many cases, readmissions involve avoidable costs, as well as reduce patient satisfaction. “If they do not get rehospitalized, patients are happier, their caretakers are happier, and I feel the quality of their care is better,” Dr. Wanski says. “If you can keep the person well at home, make sure they take their medications, hopefully not go back to the ER, and get on with their lives—all those things together are why we’re supporting this collaborative.”

But hospitalists, especially in larger groups, potentially have the leverage to negotiate access to services and the care coordination needed to reduce hospital costs and preventable readmissions, Dr. McKay notes. “In 2012, hospitalists are key, and we need to find a way to make readmission reduction part of their job description, so that they can direct that,” he says.

At Valley Presbyterian Hospital in Van Nuys, which employs three part-time hospitalists who also maintain busy office practices, “the hospitalists have been very cooperative with our project,” reports Adriana Quintero, MSW, the hospital’s full-time Project BOOST facilitator. “They see a lot of our patients in their offices.” The physicians have agreed to carve out time to see, within seven days, discharge patients going home without scheduled appointments with their primary-care physicians (PCPs).

“We find that many of our discharged patients do not call their primary-care physicians for post-discharge appointments” and decline the hospital team’s offers for help—which makes it important for the discharge coordinator to follow up as soon as possible after the patient goes home, Quintero says.

At the collaborative congress in early June, team member Alice Gunderson reported results for Saint Francis Hospital in Lynwood. Gunderson, who sits on the hospital’s quality and safety board, has been a volunteer patient family advocate (PFA) for the past year and a half; she was inspired by her own experience as a family caregiver for her husband and mother, both of whom were Saint Francis patients. Gunderson challenged those in the audience to bring a PFA from their own hospital to the next BOOST meeting.

“From my point of view, wherever healthcare goes, the patient is becoming more educated, with all of the communication technology that is out there, and claiming that empowerment,” Gunderson says. “We must all work together, not in separate silos, for the best outcomes, and we can all learn from one another.”

Larry Beresford is a freelance writer in Oakland, Calif.

John Nelson, MD, MHM

Editor’s note: Second in a two-part series.

I used last month’s column to frame the issue of disagreement between doctors over who should admit a particular patient, as well as discuss the value of good social connections to reduce the chance that divergent opinions lead to outright conflict. This month, I’ll review another worthwhile strategy—one that could be a definitive solution to these disagreements but often falls short of that goal in practice.

Service Agreements, or “Compacts,” between Physician Groups

If, at your hospital, there are reasonably frequent cases of divergent opinions regarding whether an ED admission or transfer from elsewhere should be admitted by a hospitalist or doctor in another specialty, why not meet in advance to decide this? Many hospitalist groups have held meetings with doctors in other specialties and now have a collection of agreements outlining scenarios, such as:

• ESRD patients: Hospitalist admits for non-dialysis issues (pneumonia, diabetic issues, etc.); nephrologist admits for urgent dialysis issues (K+>6.3, pH<7.3, etc.).
• Cardiology: Hospitalist admits CHF and non-ST elevation chest pain; cardiologist admits STEMI.
• General surgery: Hospitalist admits ileus, pseudo obstruction, and SBO due to adhesions; general surgery admits bowel obstruction in “virgin abdomen,” volvulus, and any obstruction thought to require urgent surgery.

To be clear, I’m not suggesting the above guidelines are evidence-based or are the right ones for your institution. I just made these up, so yours might differ significantly. I just want to provide a sense of the kinds of issues these agreements typically cover. The comanagement section of the SHM website has several documents regarding hospitalist-orthopedic service agreements.

The Negotiation Process

It’s tempting for the lead hospitalist to just have a hallway chat with a spokesperson from the other specialty, then email a draft agreement, exchange a few messages until both parties are satisfied, then email a copy of the final document to all the doctors in both groups. This might work for some simple service agreements, but for any area with significant ambiguity or disagreements (or potential for disagreements), one or more in-person meetings are usually necessary. Ideally, several doctors in both groups will attend these meetings.

Much work could be done in advance of the first meeting, including surveying other practices to see how they decide which group admits the same kinds of patents, gathering any relevant published research, and possibly drafting a “straw man” proposed agreement. When meeting in person, the doctors will have a chance to explain their points of view, needs, and concerns, and gain a greater appreciation of the way “the other guy” sees things. An important purpose of the in-person meeting is to “look the other guy in the eye” to know if he or she really is committed to following through.

Remember that written agreements like these might become an issue in malpractice suits, so you might want to have them reviewed first by risk managers. You might also write them as guidelines rather than rigid protocols that don’t allow variations.

Maximize Effectiveness

Ideally, every doctor involved in the agreement should document their approval with a signature and date. My experience is that this doesn’t happen at most places, but if there is concern about whether everyone will comply, signing the document will probably help at least a little.

The completed agreements should be provided to all doctors in both groups, the ED, affected hospital nursing units, and others. Any new doctor should get a copy of all such agreements that might be relevant. And, most important, it should be made available electronically so that it is easy to find at any time. Some agreements cover uncommon events, and the doctors on duty might not remember what the agreement said and will need ready access to it.

Most service agreements should be reviewed and updated every two or three years or as needed. If there is confusion or controversy around a particular agreement, or if disagreements about which doctor does the admission are common despite the agreement, then an in-person meeting between the physician groups should be scheduled to revise or update it.

Keep Your Fingers Crossed

If it sounds like a lot of work to develop and maintain these agreements, it is. But they’re worth every bit of that work if they reduce confusion or discord. Sadly, for several reasons, they rarely prove so effective.

One doctor might think the agreement applies, but the other doctor says this patient is an exception and the agreement doesn’t apply. It is impossible to write an agreement that addresses all possible scenarios, so a doctor can argue that any particular patient falls outside the agreement because of things like comorbidities, which service admitted the patient last time (many agreements will have defined “bounce back” intervals), which primary-care physician (PCP) the patient sees, etc.

Even if there is no dispute about whether the agreement covers a particular patient, many doctors simply don’t feel obligated to uphold the agreement. Such a doctor might tell the ED doctor: “Yep, I signed the agreement, but only as a way to get the meeting over with. I was never in favor of it and just can’t admit the patient. Call the other guy to admit.” So in spite of all the work done to create a reasonable agreement, some doctors might feel entitled to ignore it when it suits them.

Compliance Is Critical

Sadly, my take is that despite the tremendous hoped-for benefits that service agreements might provide, poor compliance means they rarely achieve their potential. Even so, they are usually worth the time and effort to create them if it leads doctors in the two specialties to schedule time away from patient care to listen to the other group’s point of view and discuss how best to handle particular types of patients. In some cases, it will be the first time the two groups of doctors have set aside time to talk about the work they do together; that alone can have significant value.

Tom Lorence, MD, a Kaiser hospitalist in Portland, Ore., who is chief of hospital medicine for Northwest Permanente, developed more than 20 service agreements with many different specialties at his institution. He has found that they are worth the effort, and that they helped allay hospitalists’ feeling of being “dumped on.”

He also told me a rule that probably applies to all such agreements in any setting: The tie goes to the hospitalist—that is, when there is reasonable uncertainty or disagreement about which group should admit a patient, it is nearly always the hospitalist who will do so.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course.

John Nelson, MD, MHM

Editor’s note: Second in a two-part series.

I used last month’s column to frame the issue of disagreement between doctors over who should admit a particular patient, as well as discuss the value of good social connections to reduce the chance that divergent opinions lead to outright conflict. This month, I’ll review another worthwhile strategy—one that could be a definitive solution to these disagreements but often falls short of that goal in practice.

Service Agreements, or “Compacts,” between Physician Groups

If, at your hospital, there are reasonably frequent cases of divergent opinions regarding whether an ED admission or transfer from elsewhere should be admitted by a hospitalist or doctor in another specialty, why not meet in advance to decide this? Many hospitalist groups have held meetings with doctors in other specialties and now have a collection of agreements outlining scenarios, such as:

• ESRD patients: Hospitalist admits for non-dialysis issues (pneumonia, diabetic issues, etc.); nephrologist admits for urgent dialysis issues (K+>6.3, pH<7.3, etc.).
• Cardiology: Hospitalist admits CHF and non-ST elevation chest pain; cardiologist admits STEMI.
• General surgery: Hospitalist admits ileus, pseudo obstruction, and SBO due to adhesions; general surgery admits bowel obstruction in “virgin abdomen,” volvulus, and any obstruction thought to require urgent surgery.

To be clear, I’m not suggesting the above guidelines are evidence-based or are the right ones for your institution. I just made these up, so yours might differ significantly. I just want to provide a sense of the kinds of issues these agreements typically cover. The comanagement section of the SHM website has several documents regarding hospitalist-orthopedic service agreements.

The Negotiation Process

It’s tempting for the lead hospitalist to just have a hallway chat with a spokesperson from the other specialty, then email a draft agreement, exchange a few messages until both parties are satisfied, then email a copy of the final document to all the doctors in both groups. This might work for some simple service agreements, but for any area with significant ambiguity or disagreements (or potential for disagreements), one or more in-person meetings are usually necessary. Ideally, several doctors in both groups will attend these meetings.

Much work could be done in advance of the first meeting, including surveying other practices to see how they decide which group admits the same kinds of patents, gathering any relevant published research, and possibly drafting a “straw man” proposed agreement. When meeting in person, the doctors will have a chance to explain their points of view, needs, and concerns, and gain a greater appreciation of the way “the other guy” sees things. An important purpose of the in-person meeting is to “look the other guy in the eye” to know if he or she really is committed to following through.

Remember that written agreements like these might become an issue in malpractice suits, so you might want to have them reviewed first by risk managers. You might also write them as guidelines rather than rigid protocols that don’t allow variations.

Maximize Effectiveness

Ideally, every doctor involved in the agreement should document their approval with a signature and date. My experience is that this doesn’t happen at most places, but if there is concern about whether everyone will comply, signing the document will probably help at least a little.

The completed agreements should be provided to all doctors in both groups, the ED, affected hospital nursing units, and others. Any new doctor should get a copy of all such agreements that might be relevant. And, most important, it should be made available electronically so that it is easy to find at any time. Some agreements cover uncommon events, and the doctors on duty might not remember what the agreement said and will need ready access to it.

Most service agreements should be reviewed and updated every two or three years or as needed. If there is confusion or controversy around a particular agreement, or if disagreements about which doctor does the admission are common despite the agreement, then an in-person meeting between the physician groups should be scheduled to revise or update it.

Keep Your Fingers Crossed

If it sounds like a lot of work to develop and maintain these agreements, it is. But they’re worth every bit of that work if they reduce confusion or discord. Sadly, for several reasons, they rarely prove so effective.

One doctor might think the agreement applies, but the other doctor says this patient is an exception and the agreement doesn’t apply. It is impossible to write an agreement that addresses all possible scenarios, so a doctor can argue that any particular patient falls outside the agreement because of things like comorbidities, which service admitted the patient last time (many agreements will have defined “bounce back” intervals), which primary-care physician (PCP) the patient sees, etc.

Even if there is no dispute about whether the agreement covers a particular patient, many doctors simply don’t feel obligated to uphold the agreement. Such a doctor might tell the ED doctor: “Yep, I signed the agreement, but only as a way to get the meeting over with. I was never in favor of it and just can’t admit the patient. Call the other guy to admit.” So in spite of all the work done to create a reasonable agreement, some doctors might feel entitled to ignore it when it suits them.

Compliance Is Critical

Sadly, my take is that despite the tremendous hoped-for benefits that service agreements might provide, poor compliance means they rarely achieve their potential. Even so, they are usually worth the time and effort to create them if it leads doctors in the two specialties to schedule time away from patient care to listen to the other group’s point of view and discuss how best to handle particular types of patients. In some cases, it will be the first time the two groups of doctors have set aside time to talk about the work they do together; that alone can have significant value.

Tom Lorence, MD, a Kaiser hospitalist in Portland, Ore., who is chief of hospital medicine for Northwest Permanente, developed more than 20 service agreements with many different specialties at his institution. He has found that they are worth the effort, and that they helped allay hospitalists’ feeling of being “dumped on.”

He also told me a rule that probably applies to all such agreements in any setting: The tie goes to the hospitalist—that is, when there is reasonable uncertainty or disagreement about which group should admit a patient, it is nearly always the hospitalist who will do so.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course.

John Nelson, MD, MHM

Editor’s note: Second in a two-part series.

I used last month’s column to frame the issue of disagreement between doctors over who should admit a particular patient, as well as discuss the value of good social connections to reduce the chance that divergent opinions lead to outright conflict. This month, I’ll review another worthwhile strategy—one that could be a definitive solution to these disagreements but often falls short of that goal in practice.

Service Agreements, or “Compacts,” between Physician Groups

If, at your hospital, there are reasonably frequent cases of divergent opinions regarding whether an ED admission or transfer from elsewhere should be admitted by a hospitalist or doctor in another specialty, why not meet in advance to decide this? Many hospitalist groups have held meetings with doctors in other specialties and now have a collection of agreements outlining scenarios, such as:

• ESRD patients: Hospitalist admits for non-dialysis issues (pneumonia, diabetic issues, etc.); nephrologist admits for urgent dialysis issues (K+>6.3, pH<7.3, etc.).
• Cardiology: Hospitalist admits CHF and non-ST elevation chest pain; cardiologist admits STEMI.
• General surgery: Hospitalist admits ileus, pseudo obstruction, and SBO due to adhesions; general surgery admits bowel obstruction in “virgin abdomen,” volvulus, and any obstruction thought to require urgent surgery.

To be clear, I’m not suggesting the above guidelines are evidence-based or are the right ones for your institution. I just made these up, so yours might differ significantly. I just want to provide a sense of the kinds of issues these agreements typically cover. The comanagement section of the SHM website has several documents regarding hospitalist-orthopedic service agreements.

The Negotiation Process

It’s tempting for the lead hospitalist to just have a hallway chat with a spokesperson from the other specialty, then email a draft agreement, exchange a few messages until both parties are satisfied, then email a copy of the final document to all the doctors in both groups. This might work for some simple service agreements, but for any area with significant ambiguity or disagreements (or potential for disagreements), one or more in-person meetings are usually necessary. Ideally, several doctors in both groups will attend these meetings.

Much work could be done in advance of the first meeting, including surveying other practices to see how they decide which group admits the same kinds of patents, gathering any relevant published research, and possibly drafting a “straw man” proposed agreement. When meeting in person, the doctors will have a chance to explain their points of view, needs, and concerns, and gain a greater appreciation of the way “the other guy” sees things. An important purpose of the in-person meeting is to “look the other guy in the eye” to know if he or she really is committed to following through.

Remember that written agreements like these might become an issue in malpractice suits, so you might want to have them reviewed first by risk managers. You might also write them as guidelines rather than rigid protocols that don’t allow variations.

Maximize Effectiveness

Ideally, every doctor involved in the agreement should document their approval with a signature and date. My experience is that this doesn’t happen at most places, but if there is concern about whether everyone will comply, signing the document will probably help at least a little.

The completed agreements should be provided to all doctors in both groups, the ED, affected hospital nursing units, and others. Any new doctor should get a copy of all such agreements that might be relevant. And, most important, it should be made available electronically so that it is easy to find at any time. Some agreements cover uncommon events, and the doctors on duty might not remember what the agreement said and will need ready access to it.

Most service agreements should be reviewed and updated every two or three years or as needed. If there is confusion or controversy around a particular agreement, or if disagreements about which doctor does the admission are common despite the agreement, then an in-person meeting between the physician groups should be scheduled to revise or update it.

Keep Your Fingers Crossed

If it sounds like a lot of work to develop and maintain these agreements, it is. But they’re worth every bit of that work if they reduce confusion or discord. Sadly, for several reasons, they rarely prove so effective.

One doctor might think the agreement applies, but the other doctor says this patient is an exception and the agreement doesn’t apply. It is impossible to write an agreement that addresses all possible scenarios, so a doctor can argue that any particular patient falls outside the agreement because of things like comorbidities, which service admitted the patient last time (many agreements will have defined “bounce back” intervals), which primary-care physician (PCP) the patient sees, etc.

Even if there is no dispute about whether the agreement covers a particular patient, many doctors simply don’t feel obligated to uphold the agreement. Such a doctor might tell the ED doctor: “Yep, I signed the agreement, but only as a way to get the meeting over with. I was never in favor of it and just can’t admit the patient. Call the other guy to admit.” So in spite of all the work done to create a reasonable agreement, some doctors might feel entitled to ignore it when it suits them.

Compliance Is Critical

Sadly, my take is that despite the tremendous hoped-for benefits that service agreements might provide, poor compliance means they rarely achieve their potential. Even so, they are usually worth the time and effort to create them if it leads doctors in the two specialties to schedule time away from patient care to listen to the other group’s point of view and discuss how best to handle particular types of patients. In some cases, it will be the first time the two groups of doctors have set aside time to talk about the work they do together; that alone can have significant value.

Tom Lorence, MD, a Kaiser hospitalist in Portland, Ore., who is chief of hospital medicine for Northwest Permanente, developed more than 20 service agreements with many different specialties at his institution. He has found that they are worth the effort, and that they helped allay hospitalists’ feeling of being “dumped on.”

He also told me a rule that probably applies to all such agreements in any setting: The tie goes to the hospitalist—that is, when there is reasonable uncertainty or disagreement about which group should admit a patient, it is nearly always the hospitalist who will do so.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course.

In response to Dr. Leland Allen and his contention that family medicine hospitalists are less prepared to handle inpatient infectious disease (ID) issues in Birmingham, Ala., I would like to point out the following:

• Family medicine hospitalists do have much more outpatient training than internal medicine (IM) residents, and in the early part of their careers, they will be at a slight disadvantage. After a year or so, the difference will be nil.
• The additional exposure to outpatient care allows family medicine graduates to be in a better position to integrate care of hospitalized patients from Day One.

We have internal medicine and family medicine working together well on our hospitalist teams. Other programs should consider the advantages of benefiting from adding family medicine hospitalists to their teams.

Bob Hollis,

SEP Hospitalists,

Florence, Ky.

In response to Dr. Leland Allen and his contention that family medicine hospitalists are less prepared to handle inpatient infectious disease (ID) issues in Birmingham, Ala., I would like to point out the following:

• Family medicine hospitalists do have much more outpatient training than internal medicine (IM) residents, and in the early part of their careers, they will be at a slight disadvantage. After a year or so, the difference will be nil.
• The additional exposure to outpatient care allows family medicine graduates to be in a better position to integrate care of hospitalized patients from Day One.

We have internal medicine and family medicine working together well on our hospitalist teams. Other programs should consider the advantages of benefiting from adding family medicine hospitalists to their teams.

Bob Hollis,

SEP Hospitalists,

Florence, Ky.

In response to Dr. Leland Allen and his contention that family medicine hospitalists are less prepared to handle inpatient infectious disease (ID) issues in Birmingham, Ala., I would like to point out the following:

• Family medicine hospitalists do have much more outpatient training than internal medicine (IM) residents, and in the early part of their careers, they will be at a slight disadvantage. After a year or so, the difference will be nil.
• The additional exposure to outpatient care allows family medicine graduates to be in a better position to integrate care of hospitalized patients from Day One.

We have internal medicine and family medicine working together well on our hospitalist teams. Other programs should consider the advantages of benefiting from adding family medicine hospitalists to their teams.

Bob Hollis,

SEP Hospitalists,

Florence, Ky.

A recent survey of nearly 1,000 students from three medical schools found that just 15% planned to become primary-care physicians, including 11.2% of first-year students.¹

That startlingly low number might not be reflective of the whole country, and other national surveys have suggested significantly higher rates. But the responses underscore some important contributors beyond financial concerns that include a more negative overall view of PCPs’ work life compared to that of specialists. “Our data suggest that although medical school does not create these negative views of primary-care work life, it may reinforce them,” the authors write.

Conversely, the results suggest that time spent observing physicians could help break negative stereotypes about the ability to develop good relationships with patients, and that career plans might not be based on perceptions, but rather on values and goals. “The study reinforces the importance of admitting students with primary-care-oriented values and primary-care interest and reinforcing those values over the course of medical school,” the authors conclude.

“Maybe we’re not selecting medical students in the optimal way for what society needs,” says Elbert Huang, MD, associate professor of medicine at the University of Chicago. By emphasizing GPA and test scores, “maybe when you do that, you end with people who don’t want to actually take care of patients in primary care.”

Other studies suggest he’s on to something. Research conducted by the Washington, D.C.-based Robert Graham Center found that students in rural medical schools are significantly more likely to go into rural healthcare and primary care than students in urban medical schools.

“The problem there is that we’ve cut the number of people from rural areas going to medical school by half over the last 20 years,” center director Robert Phillips, MD, MSPH, says. “A lot of students just don’t have the background to make them competitive.” Many students in minority communities face similar challenges.

Ed Salsberg, director of the National Center for Health Workforce Analysis in the Health Resources and Services Administration, says many newer osteopathic schools are positioning themselves in rural communities, helping them attract students who might not have gone to medical school otherwise.

Reaching back even earlier into the pipeline to help mentor elementary and high school students might be another way to help build capacity. Medical organizations also seem to be getting the message. New MCAT recommendations by the Association of American Medical Colleges, for example, place less emphasis on scientific knowledge in favor of a more holistic assessment of critical analysis and reasoning skills. The association also is encouraging medical schools to pay more attention to such personal characteristics as integrity and service orientation.

“That’s more of a long-term strategy, but I think it has an impact on who gets recruited to medical school,” Salsberg says.

Reference

1. Phillips J, Weismantel D, Gold K, Schwenk T. How do medical students view the work life of primary care and specialty physicians? Fam Med. 2012;44(1):7-13.

A recent survey of nearly 1,000 students from three medical schools found that just 15% planned to become primary-care physicians, including 11.2% of first-year students.¹

That startlingly low number might not be reflective of the whole country, and other national surveys have suggested significantly higher rates. But the responses underscore some important contributors beyond financial concerns that include a more negative overall view of PCPs’ work life compared to that of specialists. “Our data suggest that although medical school does not create these negative views of primary-care work life, it may reinforce them,” the authors write.

Conversely, the results suggest that time spent observing physicians could help break negative stereotypes about the ability to develop good relationships with patients, and that career plans might not be based on perceptions, but rather on values and goals. “The study reinforces the importance of admitting students with primary-care-oriented values and primary-care interest and reinforcing those values over the course of medical school,” the authors conclude.

“Maybe we’re not selecting medical students in the optimal way for what society needs,” says Elbert Huang, MD, associate professor of medicine at the University of Chicago. By emphasizing GPA and test scores, “maybe when you do that, you end with people who don’t want to actually take care of patients in primary care.”

Other studies suggest he’s on to something. Research conducted by the Washington, D.C.-based Robert Graham Center found that students in rural medical schools are significantly more likely to go into rural healthcare and primary care than students in urban medical schools.

“The problem there is that we’ve cut the number of people from rural areas going to medical school by half over the last 20 years,” center director Robert Phillips, MD, MSPH, says. “A lot of students just don’t have the background to make them competitive.” Many students in minority communities face similar challenges.

Ed Salsberg, director of the National Center for Health Workforce Analysis in the Health Resources and Services Administration, says many newer osteopathic schools are positioning themselves in rural communities, helping them attract students who might not have gone to medical school otherwise.

Reaching back even earlier into the pipeline to help mentor elementary and high school students might be another way to help build capacity. Medical organizations also seem to be getting the message. New MCAT recommendations by the Association of American Medical Colleges, for example, place less emphasis on scientific knowledge in favor of a more holistic assessment of critical analysis and reasoning skills. The association also is encouraging medical schools to pay more attention to such personal characteristics as integrity and service orientation.

“That’s more of a long-term strategy, but I think it has an impact on who gets recruited to medical school,” Salsberg says.

Reference

1. Phillips J, Weismantel D, Gold K, Schwenk T. How do medical students view the work life of primary care and specialty physicians? Fam Med. 2012;44(1):7-13.

A recent survey of nearly 1,000 students from three medical schools found that just 15% planned to become primary-care physicians, including 11.2% of first-year students.¹

That startlingly low number might not be reflective of the whole country, and other national surveys have suggested significantly higher rates. But the responses underscore some important contributors beyond financial concerns that include a more negative overall view of PCPs’ work life compared to that of specialists. “Our data suggest that although medical school does not create these negative views of primary-care work life, it may reinforce them,” the authors write.

Conversely, the results suggest that time spent observing physicians could help break negative stereotypes about the ability to develop good relationships with patients, and that career plans might not be based on perceptions, but rather on values and goals. “The study reinforces the importance of admitting students with primary-care-oriented values and primary-care interest and reinforcing those values over the course of medical school,” the authors conclude.

“Maybe we’re not selecting medical students in the optimal way for what society needs,” says Elbert Huang, MD, associate professor of medicine at the University of Chicago. By emphasizing GPA and test scores, “maybe when you do that, you end with people who don’t want to actually take care of patients in primary care.”

Other studies suggest he’s on to something. Research conducted by the Washington, D.C.-based Robert Graham Center found that students in rural medical schools are significantly more likely to go into rural healthcare and primary care than students in urban medical schools.

“The problem there is that we’ve cut the number of people from rural areas going to medical school by half over the last 20 years,” center director Robert Phillips, MD, MSPH, says. “A lot of students just don’t have the background to make them competitive.” Many students in minority communities face similar challenges.

Ed Salsberg, director of the National Center for Health Workforce Analysis in the Health Resources and Services Administration, says many newer osteopathic schools are positioning themselves in rural communities, helping them attract students who might not have gone to medical school otherwise.

Reaching back even earlier into the pipeline to help mentor elementary and high school students might be another way to help build capacity. Medical organizations also seem to be getting the message. New MCAT recommendations by the Association of American Medical Colleges, for example, place less emphasis on scientific knowledge in favor of a more holistic assessment of critical analysis and reasoning skills. The association also is encouraging medical schools to pay more attention to such personal characteristics as integrity and service orientation.

“That’s more of a long-term strategy, but I think it has an impact on who gets recruited to medical school,” Salsberg says.

Reference

1. Phillips J, Weismantel D, Gold K, Schwenk T. How do medical students view the work life of primary care and specialty physicians? Fam Med. 2012;44(1):7-13.

Click here to listen to Dr. Arora

Click here to listen to Dr. Arora

Click here to listen to Dr. Arora

Click here to listen to Dr. Wanski

Click here to listen to Dr. Wanski

Click here to listen to Dr. Wanski

Hospitalist Jason Adelman, MD, MS, believes computerized physician order-entry (CPOE) systems improve workflow and help prevent many mistakes, but the automation also causes mistakes as physicians toggle back and forth between screens in the system interface.

Dr. Adelman, patient safety officer at Montefiore Medical Center in the Bronx, N.Y., and colleagues developed an automated method for measuring wrong-patient electronic orders. They found that systems that compel physicians to re-enter certain information reduced errors.

CPOE systems have "certainly prevented errors," he says, "but they've unintentionally caused errors, and the name of the game is to keep working on ways to prevent more and more errors and minimize those errors unintentionally caused by these systems."

The researchers hypothesized that some wrong-patient orders are recognized by the orderer shortly after entry, promptly retracted, then re-entered on the correct patient. Their study results, published in the Journal of the American Medical Informatics Association, used a "retract and reorder" measurement tool that flagged any orders placed on a patient that were quickly retracted and replaced with a new order set.

Using the tool, Dr. Adleman and his research team estimated that 5,246 orders were placed on the wrong patients in 2009 at Montefiore.

The study also showed that interventions helped lower the odds of wrong-patient errors. One method made physicians click on a link to verify a patient’s identity, while another required the physician to manually input information to confirm the patient’s identity. Potential other interventions included using photo identification to ensure that physicians entered orders correctly.

"I think the goal is to try to get perfection," Dr. Adelman says. "I don't know if you could ever get totally there ... but you try."

Hospitalist Jason Adelman, MD, MS, believes computerized physician order-entry (CPOE) systems improve workflow and help prevent many mistakes, but the automation also causes mistakes as physicians toggle back and forth between screens in the system interface.

Dr. Adelman, patient safety officer at Montefiore Medical Center in the Bronx, N.Y., and colleagues developed an automated method for measuring wrong-patient electronic orders. They found that systems that compel physicians to re-enter certain information reduced errors.

CPOE systems have "certainly prevented errors," he says, "but they've unintentionally caused errors, and the name of the game is to keep working on ways to prevent more and more errors and minimize those errors unintentionally caused by these systems."

The researchers hypothesized that some wrong-patient orders are recognized by the orderer shortly after entry, promptly retracted, then re-entered on the correct patient. Their study results, published in the Journal of the American Medical Informatics Association, used a "retract and reorder" measurement tool that flagged any orders placed on a patient that were quickly retracted and replaced with a new order set.

Using the tool, Dr. Adleman and his research team estimated that 5,246 orders were placed on the wrong patients in 2009 at Montefiore.

The study also showed that interventions helped lower the odds of wrong-patient errors. One method made physicians click on a link to verify a patient’s identity, while another required the physician to manually input information to confirm the patient’s identity. Potential other interventions included using photo identification to ensure that physicians entered orders correctly.

"I think the goal is to try to get perfection," Dr. Adelman says. "I don't know if you could ever get totally there ... but you try."

Hospitalist Jason Adelman, MD, MS, believes computerized physician order-entry (CPOE) systems improve workflow and help prevent many mistakes, but the automation also causes mistakes as physicians toggle back and forth between screens in the system interface.

Dr. Adelman, patient safety officer at Montefiore Medical Center in the Bronx, N.Y., and colleagues developed an automated method for measuring wrong-patient electronic orders. They found that systems that compel physicians to re-enter certain information reduced errors.

CPOE systems have "certainly prevented errors," he says, "but they've unintentionally caused errors, and the name of the game is to keep working on ways to prevent more and more errors and minimize those errors unintentionally caused by these systems."

The researchers hypothesized that some wrong-patient orders are recognized by the orderer shortly after entry, promptly retracted, then re-entered on the correct patient. Their study results, published in the Journal of the American Medical Informatics Association, used a "retract and reorder" measurement tool that flagged any orders placed on a patient that were quickly retracted and replaced with a new order set.

Using the tool, Dr. Adleman and his research team estimated that 5,246 orders were placed on the wrong patients in 2009 at Montefiore.

The study also showed that interventions helped lower the odds of wrong-patient errors. One method made physicians click on a link to verify a patient’s identity, while another required the physician to manually input information to confirm the patient’s identity. Potential other interventions included using photo identification to ensure that physicians entered orders correctly.

"I think the goal is to try to get perfection," Dr. Adelman says. "I don't know if you could ever get totally there ... but you try."

Unpublished data from a British study of dedicated psychiatric hospitalists shows clear improvements in 17 of 23 measured outcomes, according to the study's lead researcher.

Julian Beezhold, MD, a consultant in emergency psychiatry at Norfolk and Suffolk NHS Foundation Trust (formerly Norfolk and Waveney Mental Health Foundation Trust) presented the data at the annual meeting of the American Psychiatric Association in May in Philadelphia.

The researchers investigated 5,000 patients over nearly eight years. By switching coverage from 13 consultant psychiatrists to dedicated-unit psychiatric hospitalists, the study showed lengths of stay on two inpatient psychiatry units cut in half (just over 11 days from nearly 22 days). Researchers also found reductions in violent episodes and self-harm. Demand for beds on the units declined steadily during the study, resulting in consolidation down to one unit.

"We found overwhelming, robust evidence showing clear benefit from a hospitalist model of care," Dr. Beezhold says. "We found that dedicated doctors are able to achieve better quality of care simply because they are there, able to respond to crises and to change treatment plans more quickly when that is needed."

Psychiatry practice differs from most specialty practice in the United Kingdom, he adds, but the recent trend has been toward a larger division between office-based and hospital-based practices.

In the U.S., models of coverage for acute psychiatric patients include specialized psychiatric hospitals, dedicated psychiatric units within general hospitals, and patients admitted to general hospital units whose psychiatric care is managed by consultation-liaison psychiatrists, says Abigail Donovan, MD, a psychiatrist at Massachusetts General Hospital in Boston.

"At Mass General, we have access to all of these approaches," she says, adding that the new data "reinforces the way we've been doing things with dedicated psychiatric hospitalists—showing the tangible results of this model."

Unpublished data from a British study of dedicated psychiatric hospitalists shows clear improvements in 17 of 23 measured outcomes, according to the study's lead researcher.

Julian Beezhold, MD, a consultant in emergency psychiatry at Norfolk and Suffolk NHS Foundation Trust (formerly Norfolk and Waveney Mental Health Foundation Trust) presented the data at the annual meeting of the American Psychiatric Association in May in Philadelphia.

The researchers investigated 5,000 patients over nearly eight years. By switching coverage from 13 consultant psychiatrists to dedicated-unit psychiatric hospitalists, the study showed lengths of stay on two inpatient psychiatry units cut in half (just over 11 days from nearly 22 days). Researchers also found reductions in violent episodes and self-harm. Demand for beds on the units declined steadily during the study, resulting in consolidation down to one unit.

"We found overwhelming, robust evidence showing clear benefit from a hospitalist model of care," Dr. Beezhold says. "We found that dedicated doctors are able to achieve better quality of care simply because they are there, able to respond to crises and to change treatment plans more quickly when that is needed."

Psychiatry practice differs from most specialty practice in the United Kingdom, he adds, but the recent trend has been toward a larger division between office-based and hospital-based practices.

In the U.S., models of coverage for acute psychiatric patients include specialized psychiatric hospitals, dedicated psychiatric units within general hospitals, and patients admitted to general hospital units whose psychiatric care is managed by consultation-liaison psychiatrists, says Abigail Donovan, MD, a psychiatrist at Massachusetts General Hospital in Boston.

"At Mass General, we have access to all of these approaches," she says, adding that the new data "reinforces the way we've been doing things with dedicated psychiatric hospitalists—showing the tangible results of this model."

Unpublished data from a British study of dedicated psychiatric hospitalists shows clear improvements in 17 of 23 measured outcomes, according to the study's lead researcher.

Julian Beezhold, MD, a consultant in emergency psychiatry at Norfolk and Suffolk NHS Foundation Trust (formerly Norfolk and Waveney Mental Health Foundation Trust) presented the data at the annual meeting of the American Psychiatric Association in May in Philadelphia.

The researchers investigated 5,000 patients over nearly eight years. By switching coverage from 13 consultant psychiatrists to dedicated-unit psychiatric hospitalists, the study showed lengths of stay on two inpatient psychiatry units cut in half (just over 11 days from nearly 22 days). Researchers also found reductions in violent episodes and self-harm. Demand for beds on the units declined steadily during the study, resulting in consolidation down to one unit.

"We found overwhelming, robust evidence showing clear benefit from a hospitalist model of care," Dr. Beezhold says. "We found that dedicated doctors are able to achieve better quality of care simply because they are there, able to respond to crises and to change treatment plans more quickly when that is needed."

Psychiatry practice differs from most specialty practice in the United Kingdom, he adds, but the recent trend has been toward a larger division between office-based and hospital-based practices.

In the U.S., models of coverage for acute psychiatric patients include specialized psychiatric hospitals, dedicated psychiatric units within general hospitals, and patients admitted to general hospital units whose psychiatric care is managed by consultation-liaison psychiatrists, says Abigail Donovan, MD, a psychiatrist at Massachusetts General Hospital in Boston.

"At Mass General, we have access to all of these approaches," she says, adding that the new data "reinforces the way we've been doing things with dedicated psychiatric hospitalists—showing the tangible results of this model."