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Hospital Medicine: Improving Quality Care One Patient at a Time

Hospital medicine – provided by physicians who specialize in delivering comprehensive medical care to hospitalized patients – is significantly changing processes and outcomes for patients throughout the United States. Here’s how The University of Kansas Health System is working to improve outcomes and smooth transitions for hospitalized patients.

Hospitalist model used exclusively

The University of Kansas Health System began using the hospitalist model in 2000 and now has 26 numerous hospitalists on staff to supervise the care of all inpatients.

Following medical school, specialists of hospital medicine typically undergo residency training in general internal medicine, general pediatrics or family practice and may also receive training in other medical disciplines. More than 80% of hospitalists specialize in internal medicine.

Hospitalists are focused around a location of care rather than an organ, disease or age group. Unlike medical specialists in the emergency department or critical care units, hospitalists help manage patients through the continuum of hospital care, often seeing them in the emergency room, following them to a specialized care unit and organizing post-acute care.

They are typically involved in patient care, teaching, research and leadership related to hospital care. These physicians have made a deliberate choice to make the hospital their primary care environment. They care for patients in the hospital, work within the patients’ larger social and family context and transition them through the continuum of care and back to their primary care providers. Because of their singular focus on hospitalized patients, hospitalists have an exceptional understanding of hospital systems and can play a strong role in making consistent process and quality improvements in patient care.

Trends support specialty growth

Hospital medicine is one of the fastest-growing specialties in the history of medicine. In the last decade, the number of hospitals with a dedicated group of hospitalists doubled to nearly 60 percent (almost 90 percent for hospitals with 200+ beds). The specialty’s proliferation is paying off. Studies have shown hospitalists can reduce the average length of stay by up to 30% and the average cost of hospitalization by 20%.

Healthcare reform and the ongoing effort to provide measurably more efficient, less expensive and better care is underlining and reinforcing the critical role that hospitalists play as part of the healthcare team. Specific trends driving the practice right now are improvements in medication reconciliation, patient education and communication – all significant factors in ensuring a smooth transition into and out of hospital care and back to the community.

Medication reconciliation: Many readmissions can be attributed to medication problems such as adverse effects, errors and omissions. We find patients often have a very low level of understanding about their medications, especially as they transition from hospital to home, and medication reconciliation efforts are aimed at correcting this problem. Pharmacists are an integral part of our inpatient practice, meeting with the physician, patient and family at the time of admission and again at discharge to reconcile medications. High-risk patients are identified and provided with additional counseling including a medication calendar. We also are looking at the possibility of calling each patient to check on medication and other discharge instructions 48-72 hours after discharge.

Patient education: Our hospital is among the second wave of hospitals participating in the Society of Hospital Medicine’s Project BOOST (Better Outcomes for Older adults through Safe Transitions). The project aims to reduce 30-day readmissions, increase patient satisfaction and improve the information flow between inpatient and outpatient providers optimizing the discharge process, by identifying high-risk patients and targeting them with interventions. One intervention is a “teach-back” session, in which a nurse educator and pharmacist work with the patient and family or other caregiver at the time of discharge to:

  • Review the reason for hospitalization and treatment
  • Discuss follow-up treatment
  • Review medication instructions
  • Ensure patients understand what’s been taught.

Early results of the effort show significant increases in patient satisfaction with the discharge process.

Communication: The introduction of a new physician to the mix at the time of hospitalization increases the risk for fragmentation of care, duplication of efforts and other misunderstandings. That means we have to ramp up our communication. We understand, as hospitalists, that we are taking a second look at a patient who most often is already cared for by a community physician. Recognizing the practice demands of primary care physicians, we do our best to ensure we touch base at admission and discharge.

  • We notify the primary care physician of the admission and discharge via the electronic medical record or fax.
  • We try to have a phone conversation with the primary care provider, especially when we are dealing with a new diagnosis, new medication regimen or complex transition of care.
  • Like many academic centers, we recently instituted daily huddles that include the attending physicians, case managers, social workers, pharmacists and bedside rounding nurses. We plan to expand this successful practice and embed care teams on each unit.

Melissa Parkhurst

MD, FHM, hospital-based medicine specialist

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