Teaming up with the Hospitalists

Dear Director,

I’m having trouble working with my hospitalist leader and group.  How important is it that we “get along?”

Our interactions with the hospitalist medicine (HM) group can often make or break a shift.  I’ve worked with HM groups who were the bane of my existence, but more often, I’ve been fortunate enough to work with hospitalists who want to team up to take care of the patients and recognize that each group’s success depends on our symbiotic relationship. Here are some points/tips/pointers to help you improve your group’s interaction with hospitalists …

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What does the hospital expect?

Regardless of your employer, the hospital expects physicians to work together in the best interest of the patient and the hospital.  However, hospital administrators are generally business people, and the most important thing to most business people is … the bottom line.  One may not appreciate the impact each of us has on the other’s metrics until you’re an EM or HM medical director. In the HCAHPS world, the bottom line is directly affected by patient satisfaction — both through reimbursement and hospital reputation.

Patients typically think of the ED as part of their hospitalization and base their satisfaction ratings on their experience as both an inpatient and the ED. If the ED is not providing the patient with the bedside care and compassion that allows the patient to check the “always” box, it can negatively impact the HCAHPS scores for the admitted patients, which will impact the hospital’s bottom line and make the hospitalists look bad.

An additional cost related measure surrounds readmissions.  The Medicare Spending per Beneficiary Metric (MSPB) is defined as the mean Medicare spending per beneficiary three days prior to admission to 30 days after hospital discharge.   This makes up 25% of the value based purchasing program (VBP). You may recall that the value based purchasing program is one way CMS financially incentives hospitals for the quality of care provided to Medicare patients.  There are numerous components to VBP of which the MSPB is one component.

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Because 30-day readmissions greatly increase the cost for a patient’s spending, hospitals have been working toward reducing 30-day readmission rates for several years.  Reducing just a few readmissions a month often requires a coordinated effort with the hospitalists and a certain amount of patience on our part (because of these patients requiring a longer ED LOS).

ED LOS is a publicly reported metric that can affect a hospital’s reputation. While there’s no money attached to length of stay, the hospital also expects the EP and the hospitalists to work together to reduce ED LOS, when possible.  Towards this end, it’s reasonable for the hospital to expect a coordinated handoff and coordinated resource utilization between the EP and the hospitalist for admitted patient.  These two hit on cost, quality and patient safety.

Many hospitals see the economic benefits of having one company manage both the ED and the HM group—thus having the management company use the profits of the ED to offset the subsidies of the hospitalist group. And as one of my friends who was a leader of a national group used to say, when using one group for both the hospitalist and the ED contracts, the hospital only has one necktie to grab when it wants someone’s attention. At the end of the day, underperformance of either hospitalists or emergency physicians in the eyes of hospital leadership puts both groups at-risk in this situation.  You might think that hospitalist service dysfunction is not your issue if you don’t work for the same management company, but it might result in a new physician group being contracted that provides both HM and EM services.

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Points of friction

As emergency physicians, we see the world differently from many other specialties, so there’s no surprise that we’ll have disagreements with hospitalists.  Probably the biggest frustration is when we get pushback about admissions.  Often we take this as a personal affront of our judgment.  Then we dig our heels in and the real fights begin.  I worked with a group of hospitalists once who (at least it seemed to me) wanted to see about 80% of the patients in the ED to decide if they needed to be admitted or not.  This ground the ED to a halt and all of the EPs regularly felt disrespected.  Even when hospitalists don’t have that kind of push back, they may have a lot of push back when it comes to the “frequent flyers” we share with them.

Many of these patients have significant underlying medical issues, and while they may be easy to diagnose and make a decision to admit on, these same patients may present frustrations to the hospitalists.  Some of these patients have significant opioid abuse histories, others have a history of malingering that we may not be able to discern in a three-hour ED visit and many of these patients can be very challenging to discharge once they get admitted.

I’ve often asked hospitalists how they expect me to discharge people in three to four hours if they can’t get them out after three to four days, but I recognize that this is a reality for a small subset of patients.  Depending on the patient and how important you think an admission is, it’s certainly reasonable to have the hospitalist consult on the patient and they can certainly recommend discharging home with a particular game plan.

Along the spectrum of disagreeing over admissions are the patients the hospitalists think can go home after a more prolonged work up in the ED or with additional home resources.  The thrill of picking up a diabetic cellulitis patient who you think will be an easy admission, only to have the hospitalist suggest having IR place a picc line for home antibiotics and case management to arrange home nursing, leads to frustration because of the added work, clogging up the ED and also because you know the tough conversations that will be coming with the family.

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I’ve seen tremendous disagreement over who calls consults and whether patients have holding/bridge orders written by EPs for the hospitalists. There are clearly some consults that should be called by the EP for a stat response.  That middle of the night phone call makes us look like the bad guy.

Another friction point revolves around bridge orders.  If your hospital won’t let patients leave the ED until they have orders, waiting for the hospitalists to see the patient and write orders will likely lead to delays in patient movement.  And if your hospital allows patients to go to their floor bed without orders, not having bridge orders may delay medications and patient activity/ diet and frustrate both the patient and the floor nurse. In a recent non-scientific survey I participated in with a diverse set of EPs, about 2/3 wrote bridge orders for admissions.

Teaming up

During these meetings, we can offer to help the hospitalists by calling consults during daylight hours, which will facilitate earlier specialist input, which may lead to an overall shorter length of stay, helps the hospitalists and improves patient care.  In return, suggesting that we don’t call non-critical consults after a certain late evening hour, helps maintain relationships with the specialists, but does add to the hospitalist workload at 8 a.m.

These meetings can also be used to work through any of the typical disagreements above or others.  I’ve learned a lot from sitting with my hospitalists outside of the clinical arena.  I also better understand the hospitalist work flow and why they want the work up complete before they see the patient and write orders (they will only get one shot with the patient to fully evaluate, document, and order the work up because they’re so busy admitting the “next” patient, it’s hard for them to go back and double check returning data.  During these meetings, the hospitalists have learned about our flow, reportable metrics, bottlenecks, and challenges that impact us every day and have committed to being a partner in helping us achieve success.

At one hospital I worked in, I can trace back the improvement to the relationship with the hospitalists to a happy hour we invited them to.  For about $200 of drinks and bar food, the 90 minutes we spent comparing where our kids went to school, favorite vacations and commuting horror stories, was the first step to realizing that we’re just people trying to do the best job possible, under difficult circumstances at times.

We followed that up with a few other happy hours about every six months for a while and the relationships continued to improve.  As it turns out, having a relationship where you are comfortable enough to admit that you have a need for a social admission plays out a little easier when you’re friends.  It doesn’t mean the hospitalist won’t do the right thing without being friends, but it does typically cut down on the pushback and the added consults, before getting to the inevitable outcome.

Conclusion

We rise and fall with our hospitalist colleagues. Our patients depend on our cooperation and teamwork, as does the hospital.  Fighting against each other typically leaves both groups with mud on their faces and much more frustration than is necessary.  Regular meetings to work through our friction points, case reviews, establishing expectations of our staffs and compromising all go a long way towards improving relations and thus improving ED flow and patient care.