At Beth Israel Deaconess Medical Center in Boston, Dr. Joseph M. Li and his team of 33 hospitalists are expanding the traditional role of the specialty, taking on more teaching opportunities and providing limited outpatient care.
Dr. Li, who founded the program in 1998 and serves as the director of hospital medicine, has been pushing the hospitalist team to do more than just the usual inpatient care duties. About 5 years ago, the hospital medicine program launched a procedure service. Now bedside procedures performed by house staff are supervised by a hospitalist, Dr. Li said.
“It's been a wonderful opportunity for us to teach the procedure and to supervise and make sure our patients get quality care,” Dr. Li said. “We've found that it's also a wonderful opportunity for us to interact with house staff.”
With the implementation of the procedure service a success, the hospital medicine program attempted to tackle the thorny issues of avoidable readmissions and continuity of care at discharge.
Last September, Dr. Li and his team launched a postdischarge clinic at the hospital. Due to the shortage of primary care physicians in the Boston area, Dr. Li and his colleagues found that after being discharged from the hospital, patients were waiting 4-6 weeks on average to get follow-up care with their regular physician. That's far from the 2 weeks Dr. Li said is the ideal window for follow-up care. And he has seen some patients return to the hospital with problems that might have been avoided if they had been seen earlier by their primary care physician.
The goal in setting up the postdischarge clinic was not to create outpatient work for hospitalists, he said. In fact, the hospital's call center books the first available appointment with the patient's primary care physician as part of the discharge process. But when that appointment isn't timely, the call center staff sets up an interim visit in the hospitalist-run postdischarge clinic.
The experience has been a bit like looking in a mirror for the hospitalists, Dr. Li said. Now that they hand off their patients to one of their colleagues, they've learned that they don't always do as good a job in the transition of care as they previously thought, he said.
The launch of the clinic has created some confusion for patients, requiring some extra explanation from both the nurse and the inpatient hospitalist. It's also caused some confusion for primary care providers, some of whom initially wondered if the hospitalists were trying to poach their patients, Dr. Li said. “We had to make it very clear that we're going to make every attempt to have that patient follow up with you before we send the patient to the postdischarge clinic,” he said. “That continues to be a work in process.”
But some primary care physicians have been very receptive to the notion that someone can help provide the transition after hospitalization and potentially improve the care for patients. Primary care physicians “are awfully busy today trying to provide timely access for all their patients,” Dr. Li said.
It's too early to tell if the effort is accomplishing the ultimate goal—to reduce unnecessary readmissions and improve quality of care. Dr. Li said they are reviewing data on the readmission rates of each of the hospitalists. However, it's complicated to tease out the impact of having a sicker patient population, as well as to determine the appropriate balance between the patients' length of stay and their chances for readmission. “I think that you can't look just simply at the readmission rate,” he said.
When evaluating improvements in quality of care, 'you can't look just simply at the readmission rate.'