Under the same umbrella

Pros and cons of integrated hospitalist/ED staffing.

When patients make the transition from the ED to the hospital medicine unit, they may assume that the 2 teams are talking to each other and have a similar plan of care. This is not always the case. “Especially if programs are not coordinated, there can be a disconnect between different specialties, and they may be at odds with each other,” says hospitalist Kenneth R. Epstein, MD, MBA, FACP.

“From a patient and family viewpoint, there's the expectation that they work together,” added Dr. Epstein, chief medical officer for Hospitalist Consultants, a division of Michigan-based ECI Healthcare Partners, which also provides emergency medicine staffing.

As a potential solution to this issue, models in which hospitalists and ED physicians are employed by the same company are becoming increasingly common.

Photo by Thinkstock
Photo by Thinkstock

In August 2015, for example, hospital and emergency medicine staffing companies Hospital Physician Partners and Schumacher Group merged, resulting in Schumacher Clinical Partners, which in June went on to acquire ECI Healthcare Partners. Another major merger between physician staffing giants TeamHealth and IPC Healthcare became final last November.

“I would say it is a trend, but I would also say that my suspicion is...this is still a relatively small percentage that have the ED and the hospital medicine groups managed by the same manager or entity,” said Christopher Frost, MD, national medical director of hospital-based services at Tennessee-based LifePoint Health.

Of course, comanaged groups do not have the market on ED/hospitalist collaboration cornered. Arizona-based Apogee Physicians has elected to stay focused exclusively on hospital medicine but still encourages collaboration with colleagues in the ED, said chief medical officer Steve Cervi-Skinner, MD. “I think [being hospitalist-only] does distinguish us, especially now that you're seeing a lot of consolidation,” he said.

Whether one model or another results in greater collaboration between the service lines is still a matter of debate. Some administrators say a comanaged, or integrated, staffing model may help the process along while others, like Dr. Cervi-Skinner, aren't so convinced. “To do collaborative care, I don't think you have to put everybody under one employment umbrella,” he said.

Collaboration through integration

One potential benefit of integrated staffing is improved ED throughput. “When both groups are aligned from a management perspective, there's an opportunity to codify the expectation of each group and how they'll work together, and hardwire processes that facilitate a more streamlined process,” Dr. Frost said, offering the example of a warm handoff, where the ED physician physically hands a patient off to the hospitalist.

The rise of value-based payment will make this integration increasingly appealing to hospitals and clinicians, he predicted.

An integrated staffing model also offers an opportunity to improve the patient experience, Dr. Epstein said. “The more that the hospitalists can help get people out of the ED and up to the floor and free up beds, the more quickly patients in the waiting room can get seen, which improves patient satisfaction and quality of care,” he said.

For integrated groups, interactions between the service lines are often not optional. Regularly scheduled joint meetings and social events can help each group understand the other's perspective, reducing tension and disagreements, Dr. Epstein said.

“I think when hospitalists first hear it, they may think that we'll just put more pressure on them to get people out of the ED and admitted quickly,” he said. “Actually, it's just the opposite: You're working together as colleagues and reducing that stressful relationship.”

Those social gatherings are usually enjoyable for physicians, according to Dr. Frost. “Oftentimes, [this] is embraced because there's a social aspect, as well as an opportunity to solicit feedback and share information so they don't feel like this is just being driven by leadership,” he said.

Washington-based Sound Physicians last year launched an ED service line in addition to its hospitalist business, said Femi Adewunmi, MD, Sound Physicians' chief medical officer for its Eastern states. “Some of the programs I manage now have both the hospitalist and ED service lines under Sound....We're committed to increase collaboration around patient care delivery and outcome goals,” he said.

Leaders of integrated groups tend to get positive reviews of the system from the participating physicians, Dr. Frost said, drawing from his own experience. “Where there's little coordination between independent ED and hospital medicine groups or where the management teams that might be the same for the groups don't oversee or lead their teams to work together, it's much more often that there's finger-pointing and the blame game rather than positive feedback,” he said.

At Sound, each service line has a medical director, and these leaders attend quarterly joint operating committee meetings and frequently review progress and priorities with hospital administrators, Dr. Adewunmi said. “Part of what we did initially was get both sides on the same page, understanding initiatives and quality metrics and exploring how one can support the other,” he said.

The specialties have what some experts have called competing incentives: Whereas ED doctors want to see patients and quickly and efficiently move them to the next location of care, hospitalists particularly want to make sure that patients meet the criteria for admission. “Our shared goal, as much as possible, is to support the ED's efforts to move patients through the system efficiently while ensuring the appropriateness of the need for hospitalization,” Dr. Adewunmi said.

At one small hospital, for example, the ED physicians had typically been responsible for writing all the admission orders, Dr. Adewunmi said. “We were able to take that responsibility off their hands and establish protocols around having bridge admission orders to support patients moving directly to the floors even more efficiently,” he said. “These changes have helped support the ED's goals of improved patient flow.”

Dr. Adewunmi also had to coordinate discussions with the ED team about how some patients might not need to be admitted but could be discharged home with additional services, such as home health care or a prompt follow-up primary care visit. Arranging and coordinating the services needed may require additional time but is the right thing to do for patients, he said. “I think that's part of the conversations that have to keep going on,” Dr. Adewunmi said. “We're no longer siloed as hospitalists or emergency physicians; we're jointly looking at the metrics both teams are held accountable for and discussing how we can support each other in achieving the best possible care and outcomes.”

Some hospital administrators also see advantages to the integrated model, Dr. Adewunmi added. “If you have an organization with proven competencies in driving performance across multiple complementary service lines, the organization is able to operate more cost-effectively and efficiently. Working with a single partner that is accountable for patient care and performance results is advantageous over managing multiple provider groups,” he said.

Good partnerships are still feasible in hospitals where both service lines aren't under the same management, he said. “There's definitely an advantage of being together under a single organization, but it isn't a prerequisite.”


As with any change in management, there are certainly challenges in moving to this model, Dr. Adewunmi said, noting the hospitalists' reaction when they were initially approached to take over the ED's admission order entries. “Part of the discussion we had was around helping the team understand that taking over and putting in admission orders was better for patient care and mutually beneficial for both provider groups. With changes and transitions, it is always important to have discussions with the team about potential workflow changes and their impact, solicit their input, and get their buy-in,” he said.

And closer collaboration doesn't appeal to everyone, especially physicians who are have an “us-versus-them mentality,” which can be ingrained during residency training, according to Denise Brown, MD, chief strategy officer for California-based CEP America, which provides integrated hospitalist and ED programs, as well as urgent care and telepsychiatry. Physician ownership in the company helps break down that us-versus-them mentality, but there are still issues for the industry to address, she said.

“You're considered a strong medicine resident if you can block admissions from the ED,” Dr. Brown said. “You get credit for something for your entire residency that, then when you're actually out in the practice community, would be [more widely] considered somewhat deleterious to the health of the hospital.”

Another challenge is dealing with the innate differences between the physician specialties. ED doctors and hospitalists “have their own set of distinct challenges,” said Dr. Cervi-Skinner. “Recruiting is different, staffing is different, the resources that are necessary are different. I think when you put that all together, you still need to manage an independent hospitalist group, and you still need to manage an independent ED group, even if you have both service lines. I don't think there's as many cost or business synergies as it might initially appear.”

Leaders of nonintegrated ED and hospitalist groups can also meet and work together to achieve both independent goals and mutual goals, he added. “Regardless of whether the ED physicians and the hospitalist physicians work for the same group or a different group, in the trenches, it really boils down to what that relationship is like,” Dr. Cervi-Skinner said.

Those with good relationships typically find many points of commonality. “I think it's all tied together. HCAHPS scores, length of stay, all that kind of stuff starts in the ED but then ultimately, hospitalists are held accountable for a lot of those data points,” he said. “I think regardless of where the paycheck comes from, it really falls on us collectively to address those issues and make sure that we're performing at the best level possible.”

Dr. Brown believes that efforts toward optimal performance will lead to even more integration among services. “I anticipate over the next 10 years more consolidation with ED, hospital medicine, and most ICU practices, with the addition of anesthesia to that triad, which creates a stable base for hospitals to do well in a value-based bundle world,” she said.

In contrast, Dr. Cervi-Skinner is skeptical of the continuation of even ED-hospitalist mergers. “I think it's clearly a trend right now, but I'm not sure that it's a viable trend,” he said.

Employing everyone involved in bundled care payments could feasibly extend to case management, social services, or even outpatient physicians. “When you take it to that level, it becomes unrealistic. That's not a model that's really possible. At the end of the day, I think collaborative care is absolutely a top priority, and when hospitals have been successful in pulling in all the stakeholders, transitions of care and patient care improve, and metrics follow,” Dr. Cervi-Skinner said.

Whether it's a mandate from above or a desire for better outcomes that causes hospitalists to meet the ED outside the silo, collaborative care is the way of the future, experts agreed. “The advice would be: Embrace this. It'll make your life, as well as the lives of your patients, a better setting. This collaborative care model is the new reality—there's no going back,” Dr. Frost said.