Hospitalist Collaboration

Coordinating Care in Hospitalist Medicine

Hospitalist Executive Leadership Summit

December 2, 2010

Michael Wagner, MD FACP
Chief, Internal Medicine and Adult Primary Care

Michael Wagner, MD FACP

Positions
• Chief, Internal Medicine and Adult Primary Care, Tufts Medical Center 2008‐
present
• Chief Executive Officer, EmCare Inpatient Services 2003‐8
• Chief, General Internal Medicine, Tufts‐New England Medical Center 1999‐2003
• Regional Medical Director, Cove Healthcare 1998‐1999
• Internal Medicine Residency Program Director and Director of Medical Education,
St. Mary’s Hospital and University of Rochester 1992‐1997
• Internist, New England Medical Center 1990‐1992
• Chief Resident, Dartmouth‐Hitchcock Medical Center 1989‐1990
• MD Georgetown University School of Medicine, 1986
Current Roles
• Associate Professor of Medicine, Tufts University School of Medicine
• Vice Chair, institutional Review Board, Tufts Medical Center and Tufts University
Health Sciences
• Physician Advisor, Information Technology Tufts Medical Center
• Chair, Managed Care and Quality Committee, Tufts Medical Center Physician
Organization

Disclosures
• None
Michael Wagner MD FACP December 2010
2

Collaboration – Goals of presentation

• Discuss broad concept of collaboration in hospitalist
medicine
• Segment collaboration into functional assessment
categories
• Discuss specific areas for collaboration and coordination
• Discuss specific strategies to enhance and hardwire
collaboration and coordination of care into a hospitalist
program


Provisos

• Focus – Day/rounding hospitalist
• Non-teaching environment


Hospitalist as a member of the team

Patient and Family
Patient and Family
Nursing
Nursing Primary Care Physician
Primary Care Physician

Care management
Care management Hospitalist Specialist Physician
Specialist Physician

Ancillary services
Ancillary services
Pharmacy
Emergency Medicine
Emergency Medicine
Pharmacy
Radiology
Radiology
Laboratory Program Coordinator
Program Coordinator
Laboratory
Respiratory
Respiratory

Rehab/LT care facility
Rehab/LT care facility Home Care Services
Home Care Services

5

Collaboration – Case

• Dr. Smith is a new graduate from a local residency
program who recently joined your hospitalist service. He
came with excellent references and interviewed very well
when he was recruited.
• After 3 months into working, you (as the medical director
of the program) perform a focused professional practice
evaluation (FPPE). You perform a chart review and
review the metrics that have been collected so far. He
seems to be doing well and his documentation is
complete and medically appropriate. Feedback from
nursing is not negative.
• When you ask around most of the staff have met him but
they say they don’t know him very well.


Collaboration – 1st order

1st order collaboration – Interactions and work involving direct
care for a specific patient

ED
ED MD ED RN

Inpatient units
Case
Primary RN Management

Ancillary Consultants

Post Hospital

PCP PCP RN
Episode of care

Collaboration – Case continued

•When you begin your block of shifts you pick up Dr.
Smith’s patients. In the process of finishing several
discharges you find several inconsistencies in the
medication lists between admission and the planned dc
med list you have from his last note.
•This prompts you to talk to the patient’s primary nurse.
“I was hoping to talk with one of you hospitalist about this patient’s med list. Dr.
Smith wasn’t available and I never had the chance to talk with him the case. In
fact sometimes I don’t even see him. I have to page him several times in the
morning just to clarify orders he has written.”


Collaboration - Engagement

Actively Engaged

Engagable

Disengaged

Actively disengaged


Collaboration – 2nd order

2nd order collaboration – Interactions and relationships
that are created and exist between the hospitalist and
other care givers

• Floor nursing
• Case management
• Specialty physicians
• ED physicians


Inpatient complexity

2000 patients

1800 patients

2500 patients

15 patients
5 doctors
with busy outside practices 1500 patients


Reducing inpatient complexity

15 patients
1 doctor with NO outside practice

Hospitalist

Reducing complexity of the inpatient enterprise
• Smaller number of “attendings”
15 patients • Higher volume/attending
5 doctors • Lower ratio of attendings:nurse
with busy outside practices



• You go and seek out Dr. Smith the next time he is on and
ask him to recount his typical day:
“I usual start in the office and start my progress notes there. I
gather the vital signs and labs that have returned so far. I then go
to the floor and see my patients. You know there really isn’t a good
place to think or write my notes so I go back to the office and finish
my notes. You know it is really annoying that the nursing staff
keep paging me, I think my orders are pretty clear. You know the
nursing staff isn’t very good here.”
• You get the sense he is not very happy in his new role
and you are not happy with his attitude.


Collaboration – 3rd order

3rd order collaboration – Interactions and relationships that are
created and exist between the hospitalist program and the other
clinical departments and outside referring physicians.

• Emergency Department
• Nurse managers
• Case management department
• Primary care practices


PATIENT
Position Interests

• Condition
• Move the patient out of
the ED ED physician • Emergent treatment
• Triage

• Disease
• Am I the best next
physician? Hospitalist • Work up completed
• Treatment initiation



• The hospital administrator calls you to complain about the
delays in transfers from the ED to the floors. He has
gotten feedback from the ED that the hospitalists are
taking forever to call back and get down to the ED for new
admissions. He also states at the last FLOW committee
the assigned hospitalist did not show up.


Collaboration – Best practices

• Recruit relaters
• Primary nurse face to face communication
• Organized daily multi-disciplinary rounds
• Deal with the ED conflict issue
• Virtually integrate with your referring PCPs
• Develop care expectations
• Leadership


Develop care expectations

• Traditional
– Pneumonia
– CHF
– Chest pain
• Service standards
– Time to see patients
– Communication
• Special populations
– Frail elderly
– Warfarin
– Poly-pharmacy
– Frequent re-admissions


Collaboration – Hospital based physicians

• 1st order
– Verbal communication about why you want the consult or
procedure done
– Make a point to touch base if you see consultant and discuss case
face to face
• 2nd order
– Introduce yourself
– Interact in MD lounge
– Eat lunch with someone new
• 3rd order
– Participate in medical staff committees
– Go to medical staff meetings
– Discuss sources of frustrations with medical director


Collaboration – Power of relating

80
70
Number of consults

60
50
Dr. Specialist new
Old specialist 3
40 Old specialist 2
Old specialist 1
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12
Quarters

Collaboration – PCPs

• 1st order
– Make an attempt to call and discuss case with PCP on admission
– Call PCP at time of DC
– Write a concise and accurate discharge summary
• 2nd order
– Go to mixers for PCP staff
• 3rd order
– Get involved in IDN/ACO committees – there will be PCPs driving
this process and discussion


Collaboration – Case conclusion

• Dr. Smith is very appreciative of your feedback and
specific suggestions on rounding with the primary nurse.
The number of pages has decreased and he is feeling
more comfortable. He agrees to participate in the Flow
committee as well.


The hospitalist’s dilemma

“Bummer of a birthmark, Dr. Hal.”

Hospitalist Collaboration

Recommended

Recommended

More Related Content

Similar to Hospitalist Collaboration

Similar to Hospitalist Collaboration (20)

Hospitalist Collaboration