Hospitalists take charge in the post-acute world
Twenty-five years after the first hospitalist programs began, the hospitalist model of dedicated, site-specific care is starting to make its way into post-acute care settings.
They may be called SNFists or post-acute care hospitalists, but whatever the name, physicians are staking out more of a physical presence in skilled nursing facilities (SNFs), inpatient rehabilitation facilities, long-term acute care hospitals, and other post-acute care settings.
In some cases, hospitalists are migrating into post-acute facilities part-time. Under this hybrid model, traditional hospitalists are continuing their work in the hospital, but may also care for patients in a nearby skilled nursing facility.
The other model that has been developing over the past 3-4 years looks more like the traditional hospitalist model of care, but may not always involve hospitalists. Under this dedicated model, physicians work exclusively in the post-acute care setting, providing coverage to these facilities anywhere from 3 to 7 days a week. Some of the physicians working under this model are former hospitalists, but others are geriatricians, intensivists, internists, and family physicians.
Nearly 27% of hospitalist medical groups provide services in either inpatient rehabilitation facilities, psychiatric facilities, or long-term acute care hospitals. And nearly 10% provide services in SNFs or extended-care facilities, according to the 2012 State of Hospital Medicine survey released by the Society of Hospital Medicine (SHM).
One reason for the shift in care is that the old model isn’t working, said Dr. Jerome Wilborn, the national medical director for post-acute care services at IPC The Hospitalist Company.
"Unfortunately, you look around the country, and doctors just don’t go to the nursing facility setting often enough to make an impact," Dr. Wilborn said. "How do we know that? A quarter of the patients who come here, bounce back to the hospital."
Beefing up the physician presence at SNFs and other post-acute care facilities has the potential to bring down those hospital readmission numbers, Dr. Wilborn said. In the post-acute care hospitalist programs that he oversees, the number of patient visits is driven by clinical acuity.
For example, in the first week, when patients are most vulnerable to bouncing back to the hospital, they may be seen by a physician three or four times. Some of that time is spent counseling family members, working on reducing medications, and coordinating care with the discharging physician, Dr. Wilborn said.
"It’s not so much the number of touches as it is the presence of the clinical team that’s there," Dr. Wilborn said. "You don’t know who you’re going to see, or who you should see, if you only go once a week."
IPC The Hospitalist Company recently made a big entrance into the post-acute care market. Over the past 4 years, they have begun practicing in about 650 post-acute care facilities. The facilities are mostly SNFs, but also include long-term acute care hospitals, inpatient rehabilitation facilities, assisted living facilities, and others, according to Todd Kislak, the vice president of marketing for IPC. This is in addition to the traditional hospital practices that the company has in about 350 acute care hospitals and long-term acute care hospitals around the country.
The IPC executives saw the holes in care in the post-acute care setting and saw an opportunity to use their experience with hospitalist programs, electronic health record technology, and advanced communications systems to surge ahead in the market, Mr. Kislak said. "IPC is playing an influential role in the organization and consolidation of these doctors in the post-acute space," he said.
IPC and other acute care hospitalist groups follow a fee-for-service business model. But there are other, more complex financial drivers that appear to be moving this model forward.
One driver is the Medicare 30-day readmission penalty, which went into effect on Oct. 1, 2012. Under the new policy, the Centers for Medicare and Medicaid Services is cutting Medicare payments to hospitals with excess readmissions in heart failure, pneumonia, and acute myocardial infarction.
The readmission policy incentivizes short-term acute care hospitals to use post-acute care services efficiently, safely, and effectively, said Dr. Sean R. Muldoon, the senior vice president and chief medical officer at Kindred Healthcare’s Hospital Division, which is a national network of long-term acute care hospitals headquartered in Louisville, Ky.
"Managing the transition and assuring that the patients go into settings that are likely to continue the patients’ improvement are in [the hospitals’] best patient, payment, and policy interests," said Dr. Muldoon, who cochairs the SHM Post-Acute Care Task Force.
And the movement by Medicare toward bundling payments for an entire episode of care means that hospitals will have another financial incentive to move patients into a less costly setting, while also ensuring that the quality of care is maintained.
