Hospitalists Tackle Increased Responsibilities, Mandates

An Interview With SHM President Robert W. Harrington, Jr, MD

Larry Beresford; Robert W. Harrington, Jr, MD


July 16, 2015

Editorial Collaboration

Medscape &

Robert W. Harrington, Jr, MD

Editor's Note:
Hospital medicine has been called the fastest-growing medical specialty, with nearly 50,000 clinicians practicing in this discipline across the United States. New rules placed on hospitals and hospital care by the Affordable Care Act (ACA) and the Centers for Medicare & Medicaid Services (CMS) have made the responsibilities of hospitalists, from patient management and safety to readmission prevention and post-acute care, increasingly important and complex.

Medscape recently spoke with Robert W. Harrington, Jr, MD, president of the Society of Hospital Medicine (SHM) and chief medical officer of Reliant Post-Acute Care Solutions, a Plano,Texas-based organization that provides contract therapies and other services to long-term care facilities, about the challenges facing hospitalists in the present, and what the future might hold.

Providing a New Model of Care

Medscape: We have been calling hospital medicine the fastest-growing medical specialty in history. The number of US hospitalists is approximately 48,000 now; does that sound right?

Dr Harrington: That's probably correct. We are absolutely going to continue to grow, for reasons that have to do with healthcare reform and the integration of care delivery across multiple sites. Hospitalists are by and large a young specialty trained in an environment that is conducive to and promotes team-based approaches to care.

We can no longer support the traditional model of the physician who is out on his or her own, making decisions from a silo mentality. We have to be able to care for patients longitudinally across multiple sites. Hospitalists are in a unique position to begin that process, and also to take some of the expertise that we have gained over the past 15 or 20 years in looking at systems of care and delivery and apply that expertise outside of the hospital across multiple systems.

Hospitalists' Role in Continuity of Care

Medscape: You have touched upon healthcare reform. What are your best predictions for how that evolution is going to affect front-line hospitalists in the near future?

Dr Harrington: No matter how you slice it, there are a few common, fundamental themes that run through healthcare reform. One is that we can no longer sustain the current costs of our healthcare system. Providers at the point of care are going to have to have some skin in the game as it relates to both quality and cost. From the perspective of day-to-day practice, we are going to see hospitalists being incentivized or motivated in some way for their ability to lower overall costs of the episode of care to patients. This means that hospitalists will be responsible for more than what goes on inside the four walls of the hospital.

Hospitalists will have to pay more attention to care transitions and extending themselves outside the hospital, whether that is in discharge clinics or in post-acute care environments where hospitalist practices take either a portion or a majority of the care. When it comes to quality improvement, they are going to have to find ways to link the clinical protocols that they use in the hospital with those that exist outside the hospital to provide true clinical integration.

Medscape: Can you give me an example of extending something from inside the hospital to post-hospital care?

Dr Harrington: We discharge orthopedic surgery patients on a daily basis to either inpatient rehabilitation facilities or to skilled nursing facilities for their continued recuperation. We are going to have to make sure that the protocols that we used in the hospital for antibiotic use, anticoagulant use, therapy and other modalities, and all of the pharmaceuticals that we use in the hospital, are continued in the post-acute care environment. That way, if patients were receiving three different therapy modalities, the next day in the skilled nursing facility they will get those same three therapy modalities. If they were on an anticoagulant for deep vein thrombosis prophylaxis in the hospital, they will be on that same anticoagulant in the skilled nursing facility.

Obviously, that involves a lot of integration of different members of the care team at the hospital level and in the post-acute care environment. But those are the things that we need to do, because anything less than that adds redundancy, risk, and cost to the system that we can't afford to have.

Medscape: We could say this a different way; for example, if in the hospital you are managing those issues correctly, your job isn't finished unless that correct management continues through the handoff and transition into the next setting. Would you agree?

Dr Harrington: Yes, and I would take it one step further. When we look at the system of care delivery, it's not just the next setting. It's the setting after that. Whether the patient goes to an inpatient rehabilitation unit or a skilled nursing facility, we must have partners in that post-acute care world who are aligned with us along all of those parameters—not just for the immediate post-acute care setting but also for home health or hospice.

As hospitalists, we treat both the patients and the system simultaneously, and we are in a position to look at that system of care delivery and say, "My job isn't finished when I talk to the medical director at the skilled nursing facility. My job finishes when the patient is well, off their current medications, and returned home." Those are things that our healthcare system is going to require of us in the future.

Hospitalists and Readmissions

Medscape: You have given several recent talks to physician audiences about hospital readmissions. Is it your sense that the hospitalist field is on board with the need to prevent readmissions, with the penalties that are out there, and with the need to do effective care transitioning?

Dr Harrington: There is absolutely room to learn to do it better. In fairness to most hospitalists, they are on board and are keenly aware of the readmission penalties potentially imposed upon their hospital employer or, if they are working with an outsourced contracted service, on the hospital that contracts for their services. Where they are at a disadvantage is that most hospitals and healthcare systems even today don't have preferred provider relationships outside their own walls.

The problem is that the environment outside the hospital in many places still remains a black hole. No matter how much we do for a particular patient before leaving the hospital, unless we change the system into which we discharge that patient, we are still not providing the safest and most effective care transition that we can.

When the patient ends up in another care environment, those providers have questions about the patient's care and have a lot of difficulty reaching providers on the acute care side. One thing that we are going to have to change is the availability of our providers to communicate with those post-acute care providers, whether we do that through some sort of information technology platform or through the good old-fashioned, "I'll give you my cell phone number, and you can call me even on my days off." But the mentality of being able to turn off my beeper or my cell phone when my shift ends and my responsibilities end can no longer continue—unless I have provided a way for that information to be accessed when I'm not available.

Hospitalists' Role in Lowering Costs

Medscape: You mentioned the evolving payment system. Would I be correct in saying that we are in an interesting place right now where we have these new payment models, but hospitals today are still to a significant extent operating under the old payment models?

Dr Harrington: Having hospitalists such as Pat Conway, MD, as chief medical officer of the CMS has been very good for all of us. But no matter what you want to call it, it all relates to population health and how we manage a population of patients at a higher level of quality and lower level of cost than we do today.

Bundled payments are a way that hospitals and healthcare systems can dip their toes in the water without having to jump into the pool. They can gather data, improve infrastructure, and begin to take risk. These allow hospitals, healthcare systems, and even physician groups and providers to become more comfortable with the changes, with the end game being that we are going to start to take more risk across more diagnoses and across more sites of care, to encompass the full episode of care for this particular patient or patient type.

That is where we are headed. Now is the time to become comfortable with it, because the entities that we all work for are in the process of becoming comfortable with it and looking for ways to be more successful at it. They need front-line hospitalists to help them do that.

Is a Hospitalist Still a Hospitalist?

Medscape: With the evolving role of hospital medicine, from caregiver to coordinator, do we need a different word than "hospitalist" for the physician who's part of and leading the coordinated effort? Or do we need to stretch the definition of hospitalists to include that?

Dr Harrington: I think that the front-line hospitalists are going to remain hospitalists. They are every day heavily involved in the care of hospitalized patients. I think the burden for this kind of system change is really more on the leadership, whether it's the hospital's medical director or one of the C–suite-level physicians, such as the chief medical officer, a chief quality officer, or some other officer. But by and large, those positions are quickly being filled by hospitalists because of our unique perspective in this whole system.

To answer your question, I would say no, we don't need another word. We need people who are engaged in changing the system, and those people are probably going to reside at a higher level than the front-line hospitalist.


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