Hospital medicine matures

Post-acute care is emerging as a dedicated field of practice on a path similar to hospital medicine's a decade or so ago.

Being a post-acute hospitalist hadn't been a lifelong dream for Jerry Wilborn, MD, an internist who trained in pulmonology and critical care. Like the original hospitalists, he was already on the job before it developed a name.

“I partnered with an outpatient provider who was seeing a large volume of patients in the office, and he thought there was synergy behind sending his patients to me in the hospital. That worked really well. He said, ‘I'm going to start sending you these nursing home patients from time to time,’” Dr. Wilborn explained. That plan worked really well, too, and today he is the post-acute medical director for IPC The Hospitalist Company.

Photo by Thinkstock
Photo by Thinkstock.

A growing number of physicians are joining him in focusing their careers on post-acute care. Called post-acute hospitalists, or nursing home specialists, or even SNFists (for skilled nursing facility), these physicians have diverse schedules, responsibilities and backgrounds, but they are focused on a single goal—improving care for nursing home patients.

A new specialty

Post-acute care is emerging today as a dedicated field of practice on a path similar to hospital medicine's a decade or so ago.

First, the patients presented a need for more care. “The patients were leaving the hospital so quickly, when they got to the SNFs, the rehab, the long-term acute care (LTAC), they were sicker than they used to be,” said Donald R. Quinn, MD, MBA, a regional director for IPC.

These sicker patients were requiring more frequent visits. Under some traditional nursing home systems, some physicians were seeing their patients just once a week or less. The increasing complexity of clinical care and health care systems was also adding to the challenges.

“There's a special skill set necessary for physicians in nursing homes,” said Paul Katz, MD, ACP Member, chief medical officer of Baycrest Health Centre in Toronto, Canada. “The nursing home environment is different,” requiring knowledge of systems and procedures as well as strong clinical skills.

Meanwhile, the primary care physicians who had traditionally seen these patients were getting busier in their outpatient practices. “They do not want to go to the nursing home. They do not have time. They don't want the extra burden of phone calls, laboratory testing, chest X-ray results,” said Dr. Wilborn.

Money was also a problem. “Solo practitioners in particular have started to shy away from nursing home work or from acute hospital care simply because financially it's not viable for them. We've seen less and less reimbursement and it is difficult for them to leave a busy office practice,” said F. Michael Gloth III, MD, FACP, chief medical officer at Moorings Park Healthy Living in Naples, Fla.

However, recent and proposed changes to the reimbursement system, including bundled payments, accountable care organizations and penalties for readmission, have made the field more financially appealing to those affiliated with hospitals. “We see more and more incentives to manage episodic care and to manage the unnecessary readmissions to hospitals,” said Michael Radzienda, MD, a regional chief medical officer for Sound Physicians.

In the middle

The net result is a field of medicine (not yet a specialty, but more on that later) that sits between hospital medicine and outpatient care. As in hospital medicine, there is a strong focus on measuring outcomes and processes of care.

“We have things that we've set in stone that we'd like to do—decrease our readmission rates, increase our quality of care, increase the communication with families,” said Dr. Quinn. “Clinical pathways and order sets and quality mandates, we are now bringing those into the nursing home.”

Like hospitalists, post-acute hospitalists focus their attention on the health of the facility as well as the patients. “You're not just a doctor who goes to the hospital, to the facility, but you're a person who has clinical responsibilities to the facility, responsibility for the level of care,” Dr. Quinn said.

But unlike his inpatient colleagues, a post-acute hospitalist can take his time. “You're not under this pressure cooker of a three- to five-day length of stay. You've got more time to bond with that patient, address these chronic illnesses,” said Dr. Wilborn.

There also can be less time pressure during each work day. “There's a lot more need for incremental care. You don't have to see x number of patients who pop up on your list, because you see the patients who need to be seen,” Dr. Wilborn added.

Of course, the disadvantage of fewer patients needing daily care is that post-acute hospitalists have to find some way to fill their days. In many cases, that means being a regular at more than one nursing home. “There's some windshield time,” said Dr. Wilborn. “Sometimes we go to two or three or four [nursing homes] to get an aggregate volume.”

Another potential surprise for hospitalists who move into post-acute care is the limitation of resources. “Nursing facilities don't have the high level of sophistication that we're used to practicing in the hospital. We don't have the diagnostics or the therapeutics that we're used to. We have to understand that and work with the patients a little more patiently,” said Dr. Wilborn.

But there are benefits to physicians who focus on nursing home care that compensate for these challenges, experts say. “In nursing homes, the physician usually doesn't have a lot of overhead,” said Dr. Katz. “It's a little more flexible. It's very rewarding in terms of the complexity you see.” These advantages are enticing some primary care physicians, as well as recent residency graduates, into full-time nursing home practice, the experts said.

Finally, there are psychological benefits. “I enjoy working with these elderly people,” said Dr. Quinn. “They are truly the most vulnerable people in society and it's so gratifying to help them.”

Does it work?

Helping elderly patients was one of the primary goals when Dr. Gloth launched a study of post-acute hospitalist care in a Baltimore-area nursing home. “We had been looking at putting a geriatrician into one of the nursing homes, with the thought that we might be able to lower rehospitalization rates, reduce medication costs and have an overall impact in terms of better care with less cost,” he said.

In a study published in the Journal of the American Medical Directors Association in June 2011, Dr. Gloth compared outcomes in a nursing home that had recently acquired a post-acute hospitalist with outcomes before the staff change and outcomes in another facility that used community physicians.

“It did not pan out the way we had anticipated,” he said. The post-acute hospitalist system was associated with an increase in laboratory costs and no improvement in fall rates. Medication errors and pharmacy costs dropped a little, but the difference was not statistically significant.

“You had probably a lot more evaluations on patients, but when clinicians evaluate patients for whatever reason, they have a tendency to order additional tests,” said Dr. Gloth. “The conclusion you get from our study, which I think is a very helpful piece of information, is you can't universally apply the premise that everywhere you put a hospitalist you're going to get better care, even if it's a fellowship-trained geriatrician.”

The level of training required to be a post-acute hospitalist is currently a subject of discussion. Experts agree that it's unfeasible to limit the field to geriatric specialists. “There are over 15,000 SNFs alone in the United States,” said Todd Kislak, vice president of marketing and development for IPC. “There are about 7,000 geriatricians out there, but a lot of them work for hospitals or academic institutions.”

Yet physicians who practice in this field do need to have certain training and skills, according to Dr. Katz. “Just because you take care of a nursing home patient doesn't necessarily make you skilled [enough to specialize in this field],” he said.

Dr. Katz and colleagues at the American Medical Directors Association are currently developing a list of the competencies they believe a nursing home physician should have. “Once we've defined this and they're accepted, then we'll develop a curriculum around them. Eventually they may form the basis of a special recognition,” like the American Board of Internal Medicine's Focused Practice in Hospital Medicine, he said.

Post-acute hospitalists are also striving, as hospitalists have, to gather evidence to prove their value to the health care system. Dr. Katz participated in an as-yet-unpublished study of post-acute hospitalists hired by the Life Care Centers of America.

“They are going to a single-physician model in many of these homes. The physicians are given special training in nursing home care,” said Dr. Katz. “Some of the preliminary evidence suggests that the rehospitalization rates in those homes are significantly lower than before.”

He's optimistic that future research will also find benefits in this model of care. And even after his study failed to show differences versus usual care, Dr. Gloth still sees potential. He suspects that the Baltimore study may have been confounded by the expertise of the physicians in the comparator group—many of the patients were already being cared for by expert geriatricians.

Regional differences

“Putting a hospitalist in every nursing home in Baltimore may not be a good idea,” Dr. Gloth said. “Use the model where it's most needed…. In those circumstances where you're having difficulty having physicians come in as frequently as needed, identifying a single physician who has expertise in long-term care and who can spend more time—I think that's something that still has merit.”

More research is needed to prove those suspected merits, Drs. Gloth and Katz agreed. In the interim, there's some division of opinion on how fast the field should expand. “I know that some programs have not been started because there's not a clear-cut advantage in certain environments or market areas or settings,” said Dr. Gloth.

But some hospitalist groups see it differently. IPC has “a corporate objective of developing a post-acute care practice in each of our markets,” according to Mr. Kislak.

Regional differences in payment may factor into expansion decisions. “On the West Coast, where you have a much more penetrated capitation model, it makes a lot more sense…. Right now in other areas of the country with the fee-for-service environment, it can be challenging to support,” said Dr. Radzienda.

The efficiencies and continuity of combined acute/post-acute practices may make the model worthwhile, even without full capitated payment. Sound Physicians has expanded its ranks of such groups. “[Hospitalists] are discharging the patient to their partner as opposed to a physician they may have absolutely no relationship with. In that model, there is a lot of leverage to impact cost, utilization and the experience for the patient,” said Dr. Radzienda.

“Right now in many facilities, a hospitalist will discharge a patient to a post-acute facility and really have very little to no input or interaction with the patient or their post-acute provider ever again,” he added.

Both sides of the transition can contribute to better handoffs, Dr. Wilborn said. “Not a one-sheet piece of paper—to really get a good and accurate handoff, there has to be acute/post-acute provider dialogue. And vice versa, when the patient ends up being readmitted to the hospital, there needs to be some dialogue about what happened. Why did that patient need to go back?”