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Imagine having at your disposal a group of physicians whose goals mirror yours, who are as committed as you are to creating efficiencies in patient care, and who support case management efforts with more than lip service. For case managers who’ve endured years of adversarial relationships with attending physicians, that description may sound like a fantasy. But in a growing number of facilities, hospital-employed inpatient physicians, or hospitalists, are bucking the old trend of physician resistance to case management tools and concepts.
Many hospitals have found that establishing a partnership between case managers and hospitalists can help lower length of stay (LOS), cut costs, and increase patient satisfaction. Since coming onto the scene in the early 1980s, hospitalists have changed the way many facilities practice acute inpatient care and have aligned the physician’s goals better with those of the hospital case manager, says Toni G. Cesta, PhD, RN, FAAN, director of case management at Saint Vincents Medical Center in New York City.
"There’s a better alignment between case management and the hospitalist than with an outside attending physician," she explains. "Sometimes with a private attending [physician], his income is generated by how many times he visits the patient in the hospital, so you have a mismatch of incentives: The case manager’s trying to shorten [LOS], and the attending [physician is] not. It can be kind of a war with them.
"The other thing that plays into a private attending [physician] is that he may have a long-standing relationship with the family or the patient," Cesta says. While that can be a good thing in many instances, it also can stand in the way of a case manager’s initiatives if the family says, "Oh, can’t Mom stay just one more day?" The private attending physician might allow it, to avoid jeopardizing the relationship, Cesta says.
But case managers working with hospitalist physicians can be a natural fit, according to Mark Williams, MD, FACP, president-elect of the National Association of Inpatient Physicians (NAIP), and director of the hospital medicine unit at Emory University School of Medicine in Atlanta. "Both [case management and the hospitalist movement] came into being to improve patient care overall and to improve quality of care, as well as efficiency in the hospital," he explains. "We’re all targeted toward the same thing: making sure the patient gets in and out of the hospital, gets properly educated, and gets efficient care."
Perhaps the only obstacle between the two, in Williams’ estimation, is one that happens across the board in acute care — physicians thinking the patient needs to stay in the hospital longer for medical or social reasons. "But the case managers have tremendous pressure placed on them by administration to get patients out. I don’t think that conflict is unique to hospitalists; it’s a conflict of physicians and managed care," he adds.
Robert Saulters, MD, director of the Jackson (MS) Medical Clinic and a hospitalist at Mississippi Baptist Medical, part of the Baptist Health System, says he entered the practice as a way to take care of sick people, "instead of the worried well" in his private practice. His 500-bed facility employs three inpatient physicians, whose goals for the hospital include reduced LOS and more efficient use of resources. "Also, there’s a decrease in the lag time between the test result and the next step," he says.
Saulters says his relationship with case managers works well. Patients at Baptist who will be under the hospitalist’s care are admitted to the same ward or unit if possible, and a specific case manager is dedicated to each floor. "We want our own case managers," he explains. "We have started a conference once a week where we go over all the patients in a meeting with the case manager. We’re working on a model where we work a little more closely with them."
In their model, the case manager serves as an information source, notes Jessylen Jackson, RN, BSN, CCRN, a nurse case manager at Baptist. Her work strategy involves an initial assessment "to identify what’s wrong, and figure out what to do for discharge planning," she says. "Then I try to follow the labs and X-rays so I can let the doctor know, when he comes up [to the floor]. It helps them, because as hospitalists, they do have a lot of patients."
Often, they have other patients not on Jackson’s floor; however, she explains, unlike working with a private attending physician, "I know I’m going to see him during the morning for some extended period of time." At the same time, Jackson says case management’s diligence "keeps [the doctors] on their toes because they know someone’s watching their practice. Medicine has become specialized, and some things can fall through the cracks — for example, if a patient’s diet hasn’t advanced after surgery. Those are the kinds of things I think case management can be an asset to."
Williams and Saulters agree that the main function of the case manager in such a partnership is to be a communicator. "There is always a risk when you have someone who’s been cared for by a physician for 10 or 15 years, and then [the patient is] handed off [to the hospitalist], that you’ll lose the continuity of care," Williams notes. Case managers can help ease the transition. "They’re another communication link for the hospitalist, especially if they’re around frequently. The emphasis needs to be on ensuring that there’s adequate communication at the time of admission and discharge to avoid this sort of loss," he says.
Jackson has seen that loss of continuity happen at her facility with patients who come from nearby rural towns to be hospitalized at Baptist. Chances are, they don’t know who their hospital doctor is going to be, she explains, and many times, they don’t know who their local physician is, either. The challenge for the case manager, she says, is to make sure they know whom to follow up with, once they return home. "The majority of our responsibility is discharge planning," she says.
"This [system] works well because there’s a person in the hospital who’s always available, who’s an expert in the care of hospitalized patients," Williams says. "So you’re getting optimum quality of care delivery." It’s true there’s an interruption, he notes. "But you don’t expect primary care physicians to do surgery on patients. Hospitals are beginning to enforce the requirement that there be a site’ specialty," just like any other medical specialty. "And the case managers love it because they don’t have to contact 16 different doctors anymore," he adds.
More health systems are adopting the practice of using inpatient physicians, according to NAIP’s current statistics. Williams says there already are about 5,000 hospitalists practicing in the United States; that’s more than there are infectious disease specialists. "Projections show that there will be 20,000 by 2010 — as many as there are cardiologists."
Williams, a practicing hospitalist, says that his top wish-list item is that the case manager go on rounds with him. The secondary role, as he sees it, is to drive the communication with important ancillary hospital staff such as nutritionists, respiratory therapists, nursing staff, and so forth. "That’s critical for care delivery," he says — but it’s not new to case management. The difference is that after you’ve done all the communicating and have something to tell about the patient’s next step, the person you need to talk to might be only a few footsteps away.
[For more information, contact:
• Toni G. Cesta, PhD, RN, FAAN, Director of Case Management, Saint Vincents Hospital and Medical Center, New York City. Telephone: (212) 604-7992.
• Jessylen Jackson, RN, BSN, CCRN, Nurse Case Manager, Mississippi Baptist Medical Center, 1225 N. State St., Jackson, MS 39202. Telephone: (601) 292-4665.
• Robert Saulters, MD, Director of Inpatient Medicine, Jackson (MS) Medical Clinic. Telephone: (601) 352-2273.
• Mark Williams, MD, FACP, Director, Hospital Medicine Unit, Emory University School of Medicine, 1440 Clifton Road, Atlanta, GA 30322. Telephone: (404) 616-5287.]