Hospitalists outside the hospital

Concerns about readmission rates and care transitions are leading some hospitalists to treat patients in the outpatient setting.

Persistent concerns about readmission rates and care transitions have led a small but increasing number of hospitalists to step beyond their inpatient roles and treat patients in the outpatient setting.

Prior to the launch of the discharge clinic at Delaware's Christiana Care Health System in late 2009, some patients with congestive heart failure, newly prescribed warfarin and other pressing medical needs couldn't see their regular clinicians soon enough after discharge, and risked unnecessary complications or another hospital admission, said James Ruether, MD, FACP, a hospitalist at the clinic and an assistant medical director for transitions of care at Christiana Care.

The clinic, initially staffed by hospitalists, helped ensure that acutely ill patients received follow-up care within a week of hospital discharge. Physician staffing changed in the spring of 2010, with a primary care physician assuming coverage a half day each week because there weren't enough hospitalists to staff the clinic. When the doctor later decided to devote all his time to his own practice, Dr. Ruether was hired to reinvigorate the hospitalist group's clinic oversight, beginning in the fall of 2011.

Hospitalists bring some inherent advantages, he said, given their grounding in acute care.

“We are maybe a little bit better suited than the primary care doctor in some ways to grapple with the immediate post-discharge patient, particularly if the primary care doctor has not seen the patient really recently,” he said. “I think it makes us better hospitalists—it gets us out of the ivory tower a little bit, so to speak.”

There are still relatively few discharge clinics, but interest appears to be on the upswing, said Joseph Li, MD, FACP, president of the Society of Hospital Medicine. “The number of phone calls I get about this is picking up,” said Dr. Li, who directs the hospital medicine program at Boston's Beth Israel Deaconess Medical Center, which operates its own hospitalist-run discharge clinic.

To be sure, migrating into the outpatient setting represents somewhat of a shift for a physician specialty created for inpatient treatment only. And transition challenges remain, as patients still eventually need to be returned to their outpatient clinicians, Dr. Li said.

Still, short-term hospitalist intervention at discharge can help bridge a worrisome treatment gap, when patients are most vulnerable to medication confusion or complications related to their original admission, yet must wait for an opening in their outpatient physician's schedule, he added.

“There is no current model that's perfect,” Dr. Li said. “At the end of the day, it [the post-discharge clinic] is a fix for a problem that we are not yet able to resolve.”

Clinic backup

Beth Israel Deaconess opened its post-discharge clinic in late 2009 after coping with repeated delays, sometimes as long as three to four weeks, before some patients could see their regular physicians, said Lauren Doctoroff, MD, ACP Member, a hospitalist and medical director for the clinic, which is a joint venture between Beth Israel's hospitalist group and its faculty, hospital-based, primary care practice Healthcare Associates.

The clinic only treats a subset of patients who already have a Healthcare Associates primary care doctor and who can't be seen within a week or two, Dr. Doctoroff said. The patients, who are booked for a 40-minute discharge clinic appointment, tend to have medical conditions that could particularly benefit from early physician contact, such as heart failure, cellulitis or poorly controlled hypertension, she said.

Five, four-hour sessions are set aside each week for scheduling the clinic appointments, and four dedicated hospitalists work in the clinic, one month at a time. The visits aim to address clinical issues related to a patient's hospital admission, rather than any broader primary care issues, Dr. Doctoroff said. For hospitalists, the care parallels their inpatient practice to some extent, in that they treat a series of patients with complex medical issues, some of whom they might not have seen previously.

Beth Israel Deaconess and Christiana Care don't have outcomes data related to their clinics, but one analysis found a link between hospitalist outpatient intervention and a reduced length of stay. It involved the California-based Medicare Advantage CareMore program, in which hospitalists treat patients in the hospital, then check up on those considered at high risk for readmission via an outpatient clinic and periodic rounds at skilled nursing facilities.

The analysis found that the readmission rate as of April 2010 averaged 13.4% compared with nearly 20% for Medicare fee-for-service plans, according to data from an Agency for Healthcare Research and Quality report published online October 13, 2010. (The 13.4% excluded patients with end-stage kidney disease, who often require frequent hospitalizations.)

Meanwhile, an older analysis of randomized patients found that a discharge clinic at the Denver Veterans Affairs Medical Center helped reduce emergency department (ED) visits within the first 30 days after discharge. Among 312 patients seen at the clinic, 20.8% went to the ED compared with 28% of the 439 patients who received typical discharge care. Length of stay, readmission rates and mortality didn't significantly differ between the two groups. The findings were published in 1996 in the Journal of General Internal Medicine.

At the time of the study, the clinic was staffed by residents with support from attending physicians. These days the attending physicians are usually hospitalists, said Allan Prochazka, MD, FACP, assistant chief of research in ambulatory care at the Denver VA Medical Center.

The clinic is not high-volume, running twice a week and treating a handful of patients each time. “It's for selected individuals for which follow-up is a high priority,” Dr. Prochazka said.

That the clinic has continued for so long is evidence of its benefit, he noted. “I think the administration at our medical center saw value in this, both from a training point of view and from a patient care point of view,” he said.

Readmission challenges

Recent evidence might encourage more hospital leaders to consider broadening the hospitalist's role beyond discharge, Dr. Prochazka said. He pointed to an August study in Annals of Internal Medicine indicating that some of the cost savings achieved on the inpatient side by hospitalists might be lost upon discharge.

The analysis compared costs and outcomes between patients cared for by a hospitalist versus their primary care doctor and found that the hospital length of stay was shorter and in-hospital costs were lower with a hospitalist's involvement. But the patients studied, hospitalized from 2001 to 2006, were more likely to require emergency department care or a hospital readmission following discharge. “Data like that I think would be an impetus to say, ‘What more can we do?’ Dr. Prochazka said.

At Christiana Care, it's up to the hospitalists' discretion to determine which patients can benefit from a discharge clinic referral, Dr. Ruether said. In a recent five-week period, between 10% and 15% of patients discharged by hospitalists from Christiana Hospital were referred to the nearby clinic.

The discharge clinic doesn't limit how often a patient can be seen, Dr. Ruether said. If a patient urgently needs a second visit and her primary care doctor is still booked up, she might be seen again, he said. But, he stressed, “Our goal is not to become anybody's primary care provider in this clinic.”

Potential downsides

Neil Winawer, MD, ACP Member, has watched the emergence of hospitalist-covered discharge clinics with interest. The acting director of the hospitalist group at Grady Memorial Hospital in Atlanta, Dr. Winawer said a discharge clinic does not avoid transition challenges, only delays them a bit. (Grady doesn't have a hospitalist-staffed discharge clinic per se, but as an academic medical center, its hospitalists for years have alternated monthly stints during which they oversee outpatient clinics.)

Dr. Winawer agrees that vulnerable patients benefit from potentially quicker care. But he worries that the transfer of some vital information might be lost in time and translation before patients reach their regular physicians.

As a hypothetical example, he described a patient admitted and treated for heart failure. During the course of routine lab work, a radiologist might see a spot on the lung that appears innocuous, but recommends a CT scan in six months. What if that information, Dr. Winawer asked, doesn't reach the primary care doctor after the mid-treatment step of the discharge clinic?

Another issue is that, even with a discharge clinic, treatment gaps can develop, Dr. Doctoroff said. One challenge at Beth Israel has been the no-show rate, which runs about 35% in the discharge clinic, including same-day cancellations.

Some patients would rather wait to see their regular physician than a hospitalist, she said. Efforts are being made to identify those patients in advance and somehow squeeze them in with that clinician, she added.

Still, the discharge clinic has paid off for the hospitalists as well as the patients, Dr. Doctoroff said. It has led her to pay closer attention to whether a patient's post-hospital treatment is logistically feasible, given the individual's mobility, family support and other personal constraints. She also strives to get home health care lined up, if needed, and avoids scheduling an unfeasible string of appointments and logistics so that patients “are not trying to see four different specialists on three different days on two different campuses,” she said.

“You see so many disasters that it makes you try to package people up in a better way,” she said.