Driving continuity of care at a private hospitalist group
Hung Davis, M.D., CMD, co-founder and CEO, Adfinitas Health
Continuity of care across acute and post-acute settings is an important part of delivering quality care in today's increasingly value-based healthcare system. The experience hospitalist physicians can bring from the hospital to the post-acute setting is uniquely valuable in this scenario. These hospitalists can proactively address problems before patients reach post-acute care, discharge patients to the most appropriate type of post-acute facility, and better coordinate care for medically complex cases.
Yet, only about 10% of hospitalist groups provide services in skilled nursing facilities or extended care facilities. This is unfortunate because partnering across care settings can dramatically improve clinical outcomes and hospital readmission rates.
Growing roots in post-acute care
When Adfinitas Health (formerly MDICS) was founded in 2007, we quickly started working with both hospitals and post-acute facilities. Our subsequent hospital contracts had significant patient flow between the hospital and skilled nursing and long-term care facilities, as well as rehabilitation centers and nursing homes. As a two-person team starting out, my partner, Douglas Mitchell, M.D., and I were the ones following our patients from the acute to post-acute setting. Because we were a small business, it made sense for us to build these relationships and support the transitions of care. Families felt better about the care their loved ones received when they knew the physician from the hospital was going to check in on the patient in the post-acute facility.
The post-acute part of our business has always been very important to me, and as we evolved, I took the reins of the Adfinitas Health Post-Acute Services team. Although the 43 post-acute facilities in which we work receive patients from hospitals outside our partner facilities, we always try to establish and maintain some degree of coordination of patient and information flow, and implement best practices focused on quality of care. As a result of these relationships, we find ourselves well positioned to deal with the extra pressures that the Readmissions Reduction Program, introduced by CMS in 2012, brings to our partner hospitals and post-acute facilities, with its penalties for high readmissions.
Staffing for success across care settings
At Adfinitas Health, we've been pairing highly-qualified and trained physician assistants (PAs) and nurse practitioners (NPs), collectively referred to as advanced practice providers (APPs), with physicians for nearly a decade. Our APPs and doctors work at the top of their credentials in a collaborative model. This frees up hospitalist doctors to treat higher acuity patients and, at times, to move between acute and post-acute facilities to support transitioning patients. While this kind of expanded APP model is not new to post-acute care, in hospital medicine, it's a game changer—albeit one that's not always readily accepted despite its many benefits.
We've worked for years to develop and continually improve our rigorous APP training program to make sure these providers are clinically capable for the widest scope of responsibilities allowed by law and the facility. Our six-month program combines classroom learning based on core competencies from The Society for Hospitalist medicine, and on-the-job learning where APPs work closely with our experienced clinical instructors and medical staff. Over the training period, they are given escalating responsibilities and are closely monitored. While we cannot claim we are the only hospitalist group employing an expanded APP staffing model, the extent of our training program and use of APPs is not established industry practice. This model delivers high-quality care and high patient satisfaction in a more cost-effective manner compared to a more tradition physician-centric model.
We recently took advantage of an opportunity to study the quality of care this staffing model provides. The study, co-written by one of our partners, Timothy Capstack, M.D., and published in the Journal of Clinical Outcomes Management last October, compares the two hospitalist staffing models at a 384-bed community hospital in Maryland. It examined PAs working collaboratively with physicians to see a large proportion of patients, rather than relying mainly or exclusively on physicians, as was the case in the conventional group. The PAs in the conventional group saw nine patients a day on average, while the expanded PA group saw 14 patients each per day. Both groups organized their collaboration with PAs similarly—all PA patients were discussed with the physician daily, and were seen by a physician at least every third day. Of patient visits by the conventional group, 5.89% were conducted by only the PA, while 35.73% of the expanded-PA group's visits had that structure. After adjusting for variables like patient age, insurance status, severity of illness, risk of mortality, and consultant use, no statistically significant differences in measures like mortality, readmissions, consultant use or length of stay was found between the groups. The exception was cost of treatment, which was lower in the expanded PA group.
Considering full-time hospitalists earn more than $280,000 in salary on average, it was not surprising to us that the results showed the expanded APP model resulted in equal quality outcomes at a lower cost.
We hope this study demonstrates that the expanded APP framework is an effective model in the acute care setting. It can help hospitals achieve their clinical and financial goals, and is one possible way to address the shortage of physician labor in rural areas.
Caring for patients across acute and post-acute care has given us a window to see both the challenges and opportunities that come with transitions in care. As a learning organization focused on quality and continuous improvement, we are well positioned to help our acute and post-acute partners drive positive outcomes and protect the bottom line without sacrificing quality.
Hung Davis, M.D., CMD, WCC, is co-founder and CEO of Adfinitas Health (formerly MDICS). He leads Adfinitas Health's Post-Acute Services program, and currently serves as the Interim Medical Director for the University of Maryland Rehabilitation and Orthopaedic Institute.