Association of decision support for hospital discharge disposition with outcomes.

OBJECTIVES: To assess the association of a clinical decision support (CDS) algorithm for hospital discharge disposition with spending, readmissions, and postdischarge emergency department (ED) use. STUDY DESIGN: A retrospective study in a cohort of fee-for-service Medicare patients 65 years or older linked to a database of patients receiving CDS. METHODS: We evaluated (1) patients whose discharge disposition was concordant with the CDS recommendation versus those whose disposition was not and (2) patients receiving CDS for discharge disposition versus those not receiving CDS, regardless of concordance. Outcomes were spending over a 90-day episode, 90-day readmissions, and postdischarge ED utilization not associated with a readmission. RESULTS: Analysis of concordant versus discordant cases showed decreased spending for concordant cases ($860 savings; 95% CI, $162-$1558; P = .016), a decrease in readmissions (adjusted odds ratio [OR], 0.920; 95% CI, 0.850-0.995; P = .038), and no change in rate of postdischarge ED use (adjusted OR, 0.990; 95% CI, 0.882-1.110; P = .858). Analysis of patients receiving CDS versus not receiving CDS showed no significant difference in spending ($221 savings; 95% CI, -$115 to $557; P = .198), ED use (adjusted OR, 0.959; 95% CI, 0.908-1.012; P = .128), or readmission rate (adjusted OR, 1.004; 95% CI, 0.966-1.043; P = .840). CONCLUSIONS: Following the recommendation of a CDS algorithm for hospital discharge disposition was associated with lower spending, fewer readmissions, and no change in ED use over a 90-day episode of care.

A History of the Hospitalist Movement.

Hospitalists work in 90% of US hospitals with over 200 beds. With over 48,000 practicing hospitalists nationwide, the field of hospital medicine has grown rapidly in its 20 years of existence. Obstetrics and gynecology (OBGYN) hospitalists are uncovering similar drivers for their growth. Obstetricians cannot be in both the hospital and the office at the same time, they face an increased acuity of hospitalized patients demanding a full time presence, and hospitals are searching for physicians aligned with their goals. OBGYN hospitalists are at a similar point today at which hospital medicine was in the late 1990s.

Experience with Designing and Implementing a Bundled Payment Program for Total Hip Replacement.

BACKGROUND: Bundled payments, also known as episode-based payments, are intended to contain health care costs and promote quality. In 2011 a bundled payment pilot program for total hip replacement was implemented by an integrated health care delivery system in conjunction with a commercial health plan subsidiary. In July 2015 the Centers for Medicare & Medicaid Services (CMS) proposed the Comprehensive Care for Joint Replacement Model to test bundled payment for hip and knee replacement. METHODS: Stakeholders were identified and a structure for program development and implementation was created. An Oversight Committee provided governance over a Clinical Model Subgroup and a Financial Model Subgroup. RESULTS: The pilot program included (1) a clinical model of care encompassing the period from the preoperative evaluation through the third postoperative visit, (2) a pricing model, (3) a program to share savings, and (4) a patient engagement and expectation strategy. Compared to 32 historical controls-patients treated before bundle implementation-45 post-bundle-implementation patients with total hip replacement had a similar length of hospital stay (3.0 versus 3.4 days, p=.24), higher rates of discharge to home or home with services than to a rehabilitation facility (87% versus 63%), similar adjusted median total payments ($22,272 versus $22,567, p=.43), and lower median posthospital payments ($704 versus $1,121, p=.002), and were more likely to receive guideline-consistent care (99% versus 95%, p=.05). DISCUSSION: The bundled payment pilot program was associated with similar total costs, decreased posthospital costs, fewer discharges to rehabilitation facilities, and improved quality. Successful implementation of the program hinged on buy-in from stakeholders and close collaboration between stakeholders and the clinical and financial teams.

Promoting high value inpatient care via a coaching model of structured, interdisciplinary team rounds.

The professional development of early career hospital physicians may be improved by embedding an experienced physician in a coaching role during structured, interdisciplinary team rounds. This article gives a descriptive report of such a model and discusses how it may promote delivery of high-value care to adult inpatients.

The key principles and characteristics of an effective hospital medicine group: an assessment guide for hospitals and hospitalists.

BACKGROUND: Despite the growth of hospital medicine, few guidelines exist to guide effective management of hospital medicine groups (HMGs). METHODS: The Society of Hospital Medicine Board of Directors appointed a workgroup consisting of individuals who have experience with a wide array of HMG models. The workgroup developed an initial draft of characteristics, which then went through a multistep process of review and redrafting. In addition, the workgroup went through a 2-step Delphi process to consolidate characteristics and/or eliminate characteristics that were redundant or unnecessary. Over an 18-month period, a broad group of stakeholders in hospital medicine and the broader healthcare industry provided comments and feedback. RESULTS: The final framework consists of 47 key characteristics of an effective HMG organized under 10 principles. CONCLUSIONS: These principles and characteristics provide a framework for HMGs seeking to conduct self-assessments, outlining a pathway for improvement and better defining the central role of hospitalists in coordinating team-based, patient-centered care in the acute-care setting. They are designed to be aspirational, helping to raise the bar for the specialty of hospital medicine.

2011 John M. Eisenberg Patient Safety and Quality Awards. Mentored implementation: building leaders and achieving results through a collaborative improvement model. Innovation in patient safety and quality at the national level.

BACKGROUND: The Society of Hospital Medicine (SHM) created "Mentored Implementation" (MI) programs with the dual aims of educating and mentoring hospitalists and their quality improvement (QI) teams and accelerating improvement in the inpatient setting in three signature programs: Venous Thromboembolism (VTE) Prevention, Glycemic Control, and Project BOOST (Better Outcomes for Older adults through Safe Transitions). METHODS: More than 300 hospital improvement teams were enrolled in SHM MI programs in a series of cohorts. Hospitalist mentors worked with individual hospitals/health systems to guide local teams through the life cycle of a QI project. Implementation Guides and comprehensive Web-based "Resource Rooms," as well as the mentor's own experience, provided best-practice definitions, practical implementation tips, measurement strategies, and other tools. E-mail interactions and mentoring were augmented by regularly scheduled teleconferences; group webinars; and, in some instances, a site visit. Performance was tracked in a centralized data tracking center. RESULTS: Preliminary data on all three MI programs show significant improvement in patient outcomes, as well as enhancements of communication and leadership skills of the hospitalists and their QI teams. CONCLUSIONS: Although objective data on outcomes and process measures for the MI program's efficacy remain preliminary at this time, the maturing data tracking system, multiple awards, and early results indicate that the MI programs are successful in providing QI training and accelerating improvement efforts.

Organizing a hospitalist program: an overview of fundamental concepts.

This article has discussed several fundamental concepts in the development and implementation of a hospitalist program. Perhaps the two most important barriers to the success of hospitalist practices are lack of buy-in from PCPs and other physicians (which is becoming much less common) and the inability to gain durable financial support from the hospital or other sponsoring entity. These issues always should be addressed before starting a program. Systems for adequate communication between hospitalists and community physicians will ensure buy-in is maintained. Unique challenges for those administering a hospitalist group include physician scheduling that balances continuity with a sustainable career track. Finally, providing leadership with a medical director increases the likelihood that operational problems are quickly managed, and that strategic planning takes place to ensure the future success of the program.

Passing the clinical baton: 6 principles to guide the hospitalist.

Hospitalist systems make it increasingly common for responsibility for a patient to be passed from one physician to another. During such transfers, patients' outcomes and satisfaction can benefit from better communication between hospitalists and the primary care physicians whose patients they care for. We propose 6 principles to guide such communication, to ensure that critical information about patients is not lost and to optimize the quality of care. We also discuss special considerations for patients discharged to a skilled nursing facility or to home with home care.

Thriving and surviving in a new medical career: the case of hospitalist physicians.

Managed care is cultivating a variety of new work careers within the medical profession, and it is worth asking whether they will function as long- or shorter-term career options for the individuals who participate in them. This paper uses the specific case of hospitalist physicians to explore how the surrounding social and economic work contexts contribute to two individual-level outcomes that inform the issue of career longevity: the concepts of burnout and intent to stay in the career. The findings of a national survey of hospitalists reveal that job burnout and intent to remain in the career are more meaningfully associated with favorable social relations involving colleagues, co-workers, and patients than with negative experiences related to the economically induced pressures of the job, such as reduced autonomy and the use of financial incentives. In addition, career longevity is enhanced by the extent to which individual physicians pursue intrinsic and extrinsic rewards through their choices to become hospitalists. These findings demonstrate that sociologists should pay greater attention to the career trajectories of contemporary doctors in order to understand larger scale professional stratification within medicine. They also offer empirical support for redirecting our focus towards the relational dynamics that shape these trajectories.