A new place between the hospital and the office
Hospitalist group branches out into ‘extensivist’ care
By Stacey Butterfield
Where: Holston Medical Group, a multispecialty practice including hospitalists, based in northeastern Tennessee and southwestern Virginia.
The issue: Providing inpatient-level care while avoiding the negative effects of hospitalization.
When hospitalist Christopher Neglia, MD, first read about post-hospital syndrome, a concept proposed by cardiologist Harlan Krumholz, MD, in the Jan. 10, 2013, New England Journal of Medicine (and covered in the March 2013 ACP Hospitalist), it hit home.
“That really rang true with everything we do,” said Dr. Neglia. “Patient deconditioning—they're put in a bed and they will lay in that bed for 3 or 4 days until they go home. Also, the sleep deprivation—a patient will be awoken sometimes 15-20 times. And most importantly, many elderly patients suffer cognitive disturbances while hospitalized.”
Dr. Neglia and his colleagues at Holston Medical Group, which includes both hospitalists and outpatient practices, started considering how to reduce their patients' risk of these and other consequences of hospitalization. “We thought, how can we do this better? Maybe we should try taking care of patients outside the hospital setting, but providing all the things that the hospital provides, other than the overnight stay,” he said.
How it works
Using some available space in one of the group's infusion centers, Dr. Neglia and colleagues opened what they call an “extensivist clinic” in early 2013. The clinic includes 5 patient rooms with reclining chairs and is staffed 12 hours a day by emergency or ICU-trained nurses and 1 hospitalist.
“This isn't something you walk off the street and say, ‘Can I be seen?’” said Dr. Neglia, who is the lead physician of the clinic. “[Referring clinicians] feel the patient has enough illness to warrant hospitalization and would traditionally direct that patient to the ER or to our hospitalist team directly.”
Patients are referred to the extensivist clinic from the urgent care center next door (also run by Holston Medical Group) or by primary care clinicians who work with the hospitalist group. The concept is explained to patients as an alternative to hospitalization.
“They'll say to the patient, ‘You need to go to the hospital, but we have an extensivist clinic that can do many of the same things, if you'd be willing to go there.’ The patient has a say in this,” said Dr. Neglia.
The clinic doesn't provide all the same services as a hospital, he noted. They don't take stroke or chest pain patients, but treat a lot of the other conditions typical of a hospitalist service, including pneumonia, exacerbations of heart failure or chronic obstructive pulmonary disease, refractory cellulitis, sepsis, delirium, renal failure, dehydration and ileus.
“We have telemetry monitors, access to labs, basic radiology, IV fluids, IV antibiotics, IV drips. We have breathing treatments, oxygen, even [bilevel positive airway pressure]. Pretty much our resources in the clinic are equivalent to a general medical floor,” said Dr. Neglia.
Care begins with a 3-way phone conversation among the referring clinician, the extensivist and the extensivist nurse. Once the patient arrives, the extensivist physician does a full work-up, including history and physical. Treatment is initiated, and then the extensivist returns to see the patient as many as 5 or 6 times during the day.
“It's very intense, focused treatment. You see the patient frequently throughout the course of the day to monitor their progress,” said Dr. Neglia. Patients can stay up to 12 hours, until the clinic closes at 8 p.m.
Before closing time, patients are evaluated to determine whether they go home or to the hospital. “If you don't see the patient progressing, or you don't think they will do well at home, at that point, you…strongly recommend this patient be watched overnight [in the hospital],” said Dr. Neglia. Or if the patient is uncomfortable with being sent home, or the patient's caregiver doesn't feel capable of providing overnight support, the patient is admitted.
Patients who are sent home overnight may be set up with a home health visit during the night, and they can be scheduled for ongoing treatment the next day at the extensivist clinic.
In the clinic's first 7 months of operation, most patients were successfully kept out of the hospital. “Of the patients treated in our extensivist clinic, 80% do go home, and only 20% are directly admitted,” reported Dr. Neglia.
Even the patients who are admitted benefit from their stay in the extensivist clinic. “Admitting the patient is like a hospital-to-hospital transfer. I call the transfer coordinator of our hospital, I admit the patient to myself, I put the orders in before the patient arrives, and then one of my partners who is at the hospital will tuck the patient in,” Dr. Neglia said. This process avoids the wait and duplicate testing often associated with admission through an emergency department.
The concept has also been successful in gaining patient acceptance. “Surprisingly, we haven't had to sell this at all to patients. People are more than willing to avoid the hospital,” Dr. Neglia said. Patients have opted to travel as long as 35 minutes to the extensivist clinic rather than be admitted to closer hospitals. “The patients and the families that have gone through it have been in the hospital before and they've seen the problems. They're willing to watch over Mom or Dad through the night,” he said.
The data aren't gathered yet, but Dr. Neglia believes that the model can prevent admissions and readmissions, as well as shorten length of stay. The extensivists also see some patients immediately after hospital discharge, referred by the group's hospitalists.
“They can be discharged sometimes a little bit earlier, because we can do the same IV therapies in our clinic the next day, and cut off the hospitalization,” Dr. Neglia said. Patients whose post-discharge primary care visit is expected to be complex are also referred. “To take care of these patients in hospital follow-up, sometimes 1 hour is not sufficient,” he said. “Any patient who is going to be very complex and bog down a primary care provider, we'll send.”
Not having to worry about being bogged down is one of the greatest benefits of this form of practice, according to Dr. Neglia. “We're given the luxury of time,” he said. “Patients were getting admitted for a lot of things that could be handled outpatient just given a little more time.”
Of course, time is money, and currently, the extensivist clinic has more of the former than the latter.
“Our only reimbursement for this is a high-level office visit, which does not cover the time, because some of these patients we keep 10 or 12 hours,” said Dr. Neglia, adding that the practice is also reimbursed for infusions. “We're not charging any kind of hospital charge, even observation, because we're not a hospital.”
If the extensivist clinic reduces insurers' expenditures for hospitalizations, however, the clinicians might be able to profit from the savings. “We have a patient panel. If we can show that we can treat the patients more cheaply than the national average, Medicare will reimburse some of that difference,” said Dr. Neglia. “We are talking to private insurers who are very interested in this model.”
Under the current payment system, any reduction in hospitalizations achieved by the clinic could have a negative effect on hospitals' finances. The hospitals that Holston Medical Group works with are aware of the clinic but haven't commented on its presence.
“Certainly, we're taking patients out of their beds. However, we are also shortening the hospitals' patient length-of-stay and decreasing their readmission rates with the extensivist clinic,” said Dr. Neglia. “Most hospitalist groups are employed by the hospital, and the hospital systems would rather keep these patients in [observation] or at least in their building. I don't think every hospitalist group could do this.”
The model of care also doesn't suit every hospitalist. Currently, 5 members of Dr. Neglia's 12-person team rotate through the extensivist clinic, and some of the others are reluctant to try it out. “We're trying to push them all to at least rotate through a couple times to get an idea of what you can do and who are the patients to send to the clinic,” he said. “Just like the extensivist clinic is not for every patient, it's not for every hospitalist either.”
If a financing model can be developed for the extensivist clinic, Dr. Neglia and his colleagues hope to build additional facilities in their practice area. “We're looking to set up another clinic in one of our areas that has a high number of elderly with multiple comorbidities, so that they don't have to travel 30 minutes to this clinic,” he said.
One success story
To provide an example of how the Holston Medical Group's new extensivist clinic works, lead physician Christopher Neglia, MD, offered a patient anecdote.
A 90-year-old farmer who lived alone was brought to the clinic by his daughters with bilateral pneumonia, nausea and vomiting and some delirium. On arrival, he had an oxygen saturation of 85%, sepsis and newly diagnosed atrial fibrillation.
“He had 5 different diagnoses. Each one would be enough to qualify for inpatient hospitalization,” said Dr. Neglia. The extensivist put the patient on oxygen, IV fluids, IV antibiotics and a telemetry monitor.
“We cultured him up. We did everything that we do that first day in a hospital. We kept him there on a monitor until the end of the day,” said Dr. Neglia. At the end of the day, the patient was somewhat improved.
“We came to the daughters and said, ‘Look, he meets all inpatient criteria. We can directly admit through the night, or he can go home with you two with supplemental oxygen and you'll need to keep an eye on him,’” Dr. Neglia said. “He had received all the treatments he needed during the day anyway.”
Having seen their father become confused and spend a week in intensive care during a previous hospitalization for a urinary tract infection, the daughters opted to take him home.
The patient came back at 9 a.m. and received more IV antibiotics, and then an anticoagulant for his atrial fibrillation once he was able to keep oral medication down. On the third day, he stayed home under his family's care on oral antibiotics. The fourth day, he came back to the clinic for a final checkup. “He was doing better,” said Dr. Neglia. “We released him back to his regular doctor.”
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