CINDY SANDERS

Mark McGinnis

In an era of medical specialties and sub-specialties, a growing number of acute care facilities and primary care physicians are opting to rely on those that specialize in hospital medicine.

Advocates of this model cite quality, convenience, cost efficiency and patient-centered care among the pluses of relinquishing control of inpatient stays to a hospitalist.

This relatively new specialty — the term “hospitalist” was coined in 1996, and the Society of Hospital Medicine was established the following year — is typically composed of internal medicine practitioners but also incorporates other specialties as suits the acute care facility’s needs.

Saint Thomas Hospital is home to a successful program that now numbers 26 hospitalists on staff including teams specializing in cardiology, neurology and orthopedics. Well ahead of the national trend, the hospital launched its program in 1998 but has recently undergone expansion.

“We have grown dramatically in the last year. We went from 12 last year to the 26 we now have,” said Mark McGinnis, vice president of operations and finance for Saint Thomas Hospital.

“At any one time, we have 80-130 patients assigned to the hospitalist service,” he continued, adding that this typically represents between one-fourth to one-third of the patient load.

Saint Thomas has seen some efficiencies in terms of length of stay for those assigned to a hospitalist, which mirrors national trends.

Although Saint Thomas has opted to manage its program internally, several large firms … including Nashville-based Cogent Healthcare … set up and run hospitalist programs nationally. For Dr. Rusty Holman, chief operating officer for Cogent, it all boils down to creating a very strong partnership between facilities and physicians.

“We take painstaking measures to make sure we understand the short- and long-term goals of the hospital before we put anything in place,” he said. “It’s important for us to customize our program to the unique setting … every hospital has a unique culture.”

Holman added that his company, one of the earliest adopters of the hospitalist strategy, was created by a group of physicians in the mid-1990s “on the basis of improving the quality of care for hospitalized patients and improving efficiencies for physicians practicing in that model.”

Holman, who is also president of the national Society of Hospital Medicine, said the 1999 Institute of Medicine Report, “To Err is Human” and the 2001 follow-up, “Crossing the Quality Chasm,” had a major impact on the young field as hospitals around the country began to focus sharply on quality and safety issues.

Today, he noted, hospitals operate in an environment of increasing federal regulations and government scrutiny requiring exacting quality reporting, transparency and adherence to approved care guidelines. Hospitalists, he said, serve as one way to standardize care.

“We believe investing in a very robust infrastructure that includes training, information technology, quality assurance programs, physician coaching and mentoring, and onsite personnel is a way to lead to the best outcomes, results and value for a program,” Holman continued.

Whether contracting with an outside company like Cogent or creating an in-house group such as the Saint Thomas Hospital program, the focus of the hospitalist care model is evidence-based medicine and processes. Holman explained that those processes not only include coordinated activities during the patient’s stay but encompass effective communication with the primary care physician to ensure smooth transitions of care, as well as direct follow-up with patients to maximize compliance.

One example of evidence-based process implementation, Holman said, is a follow-up call within 48 hours of discharge to every patient seen by a Cogent hospitalist to ensure all necessary equipment or prescriptions are in place and to answer any lingering questions. Despite intensive patient education before discharge, Holman said that about 20 percent of patients will have unresolved issues.

“We have a process where we can intervene immediately to either mitigate or resolve the problem to prevent unnecessary readmissions to the hospital,” he noted.

Once a primary care physician opts to refer patients to the hospitalist, most programs require the referring physician to step back and allow the hospitalist to oversee and manage the inpatient care plan. That isn’t to say, however, that referring physicians aren’t encouraged to visit their hospitalized patients to maintain contact. Most programs also welcome any specific insight regarding a patient’s needs.

Despite the “hands off” approach, Holman said that in many cases the primary care physicians are the actual drivers for a hospitalist program to be established. He pointed out that by taking the inpatient burden off of referring physicians, they are free to spend more time in the outpatient setting.

McGinnis echoed the sentiment, saying, “It’s a real benefit for recruiting primary care physicians. It allows the primary care physician to focus on their clinics.”

He added that there is also a lifestyle benefit for both the referring physician, who doesn’t have to be on call all the time, and for the hospitalist, who tends to work longer shifts but fewer days.

Both men stressed that physician participation with a hospitalist program is purely voluntary. McGinnis said that about half of Saint Thomas Hospital’s referring physicians use a hospitalist while the remaining 50 percent choose not to participate.

While physicians on both sides of the equation seem to benefit, so, too, does the patient. Satisfaction levels are typically high among patients and families because of the onsite availability of the hospitalist.

“By everyone’s estimation, this is the fastest-growing specialty in the history of medicine,” Holman said of the field’s rising popularity.

“Hospitals are facing unrelenting cost pressures, and the hospitalist model is well-proven to show improvements in costs and efficiency,” he said of one of the key drivers behind the rapid expansion.

“Our best estimates are that there are 20,000 hospitalists practicing in the U.S. today,” Holman continued. “Our projection is that there will be 40,000 or more when it begins to plateau.”

He concluded, “I think hospitalists will become the major provider of inpatient care in the United States.”


National Hospitalist Firm Cogent Moves HQ to Nashville

Cogent Healthcare, a major national provider of hospitalist services, expects to put the finishing touches on its corporate relocation to Nashville by month’s end.

Formally founded in 1997, Cogent was created by a group of Los Angeles physicians and headquartered in Irvine, California. As the firm grew, executive offices were also established in Nashville, and a service center was added in Daytona, Florida. This past spring, the company announced it would relocate its headquarters and service center to Middle Tennessee.

Cogent officials cited Nashville’s large number of healthcare companies and entrepreneurial climate as influencing their decision to consolidate services to what they termed “the epicenter of the healthcare industry.”

“Nashville is a logical choice for a centralized operation and will offer our company and our employees an exceptional business environment and quality of life,” Gene Fleming, CEO of Cogent Healthcare, said in a statement announcing the move.

After a decade of growth — the last four years at an average rate of 35 percent annually — the leadership team had become largely decentralized.

“The move to Nashville was an effort to put everyone under one roof and to allow for greater speed of communication and quality of decision-making,” explained Dr. Rusty Holman, Cogent COO, who relocated from Raleigh, North Carolina, this past summer.

Geographic desirability also factored into the equation. Holman noted, “Many of our programs are located in the Midwest as well as the Southeast and East Coast.” He added that the move to Nashville brings the executive team closer to the company’s client base.

Other influences included the area’s healthcare climate and experienced workforce, along with an anticipated savings in operational costs and high quality of life for employees.

Holman said the company has a national workforce of about 350, plus more than 100 part-time physicians serving clients in 16 states. He expects the corporate move to generate approximately 75 new jobs in the Nashville area.



November 2007