Transitions of Care

When the Centers for Medicare & Medicaid Services make a significant change to the inpatient hospital rules, hospitalists are among the first to feel the effects.

You probably remember that, starting in October 2013, when a resident, nurse practitioner (NP), or physician assistant (PA) entered an inpatient admission order on your behalf, you were told to cosign that order before discharge or the hospital would forfeit payment for the entire stay. This policy was put in place by an annual piece of governmental policy known as the Inpatient Prospective Payment System (IPPS) Final Rule – the same one, in fact, that established the Two Midnight Rule.

The CMS felt that the decision to admit a Medicare beneficiary to inpatient care is such a significant event that it was appropriate to require the attending physician to complete a series of certification requirements to justify every inpatient stay. If not completed and finalized prior to discharge, the CMS would not pay for the stay. After 15 months of enforcing that policy, the CMS backed off on most of the certification requirements for most stays. However, the requirement for an authenticated inpatient order prior to discharge was kept in place for all stays. (“Authenticated” is CMS-speak for signed, or, in the case of inpatient orders initially placed by a resident/NP/PA without admitting privileges, cosigned, by a practitioner with admitting privileges.)

In the spring of 2018, the CMS proposed a change to “revise the admission order documentation requirements by removing the requirement that written inpatient admission orders are a specific requirement for Medicare Part A [inpatient hospital] payment.” The CMS also stated that it did not intend for Medicare auditors to deny hospital inpatient claims based solely on a deficiency in the inpatient order, such as a missing order or one signed after discharge, which the CMS found out was happening.

The description sounded great. In comments to the CMS, many providers assumed that they, too, would be provided similar discretion if they discovered the order defect. Are inpatient orders now optional? What rate of inpatient order technical deficiencies is acceptable to still submit inpatient claims for payment? Can 2-day observation stays where medical necessity for hospital care was present, but no inpatient order given, be billed as an inpatient now?

But these providers had not read the fine print. Consider that the annual IPPS Final Rule has a length of about 2,000 pages. Of those, only about 30 pages represent changes to a group of policies known as the Code of Federal Regulations (CFR). The CFR carries the weight of law (as long as it does not contradict law). When you appeal a Medicare denial to a judge, she will ask what portion of the CFR supports your viewpoint. The other 1,970 pages can be thought of as supporting analysis and reasoning to justify the 30 pages of changes. What changes were actually made to the CFR?

Consider the following two sentences.

• “For purposes of payment under Medicare Part A, an individual is considered an inpatient of a hospital, including a critical access hospital, if formally admitted as an inpatient pursuant to an order for inpatient admission by a physician or other qualified practitioner.”
• “This physician order must be present in the medical record and be supported by the physician admission and progress notes, in order for the hospital to be paid for hospital inpatient services under Medicare Part A.”

These are the first two sentences of 42 CFR 412.3(a), the regulation that defines the inpatient order requirement. On Oct. 1, 2018, the second sentence was removed, but the first sentence still remains. That’s the only change for this section. Does removal of the second sentence absolve providers of the requirement to document inpatient admission orders? Does it absolve providers of the requirement to cosign a resident’s admission order prior to discharge? The Medicare Benefit Policy Manual (MBPM) Chapter 1, Section 10(B) still reads “if the order is not properly documented in the medical record prior to discharge, the hospital should not submit a claim for Part A payment.”

Understanding what changed and what did not change in the CFR is key to understanding why, in this year’s IPPS Final Rule, the CMS repeatedly responded to providers that an inpatient order is still a requirement for a Part A stay and that none of the MBPM guidance regarding the inpatient order, such as the excerpt above, is changing.

At this point, we can only be reasonably certain that if a claim a hospital submits for Part A payment happens to get audited and found to have only one deficiency which is related to the inpatient order, per this guidance it probably won’t get denied. That is very different from saying the attending physician no longer has to provide a signed (or cosigned) inpatient admission order prior to discharge, or at all.

Providers actually did ask the CMS if a hospital could still submit a claim the hospital knows has a missing or incomplete inpatient admission order at the time of discharge. The CMS responded that Medicare contractors have the discretion in extremely rare circumstances to approve cases where an order to admit may be missing or defective, and yet the intent, decision, and recommendation of the ordering practitioner to admit as inpatient can be clearly derived from the medical record. However, note that the discretion belongs to the Medicare contractor, not the provider.

The American College of Physician Advisors (ACPA) asked the CMS the following question about the inpatient order policy change during the 2019 IPPS Final Rule Open Door Forum held on Sept. 11, 2018: “Can providers thus submit a claim, that the provider believes meets all other requirements for Part A payment, in the rare circumstance of an inpatient order deficiency, such as an inpatient order that was cosigned shortly after discharge?”

The CMS declined to answer the question on the call, asking us to submit the question to the Open Door Forum electronic mailbox. If the inpatient order was truly no longer being required for the CMS to pay for inpatient hospital stays, the answer would have been an easy “yes,” but it was not. Subsequently, the CMS responded in writing to the ACPA that “the responsibilities of providers regarding inpatient admission orders is unchanged.” In other words, Medicare auditors have been given discretion to overlook an inpatient order flaw, but providers have not.

At this time, our recommendation is to continue your processes to ensure that the inpatient admission order is completed and signed (or cosigned) prior to discharge by the attending physician for every Medicare patient. This will not only help make sure that the decision to make a hospitalized Medicare beneficiary an inpatient remains with the attending physician, but it will also reduce the risk of nonpayment.

Dr. Hu is executive director of physician advisor services of University of North Carolina Health Care System in Chapel Hill, N.C., and president of the ACPA. Dr. Locke is senior physician advisor at Johns Hopkins Hospital in Baltimore, and president-elect of the ACPA.

When the Centers for Medicare & Medicaid Services make a significant change to the inpatient hospital rules, hospitalists are among the first to feel the effects.

You probably remember that, starting in October 2013, when a resident, nurse practitioner (NP), or physician assistant (PA) entered an inpatient admission order on your behalf, you were told to cosign that order before discharge or the hospital would forfeit payment for the entire stay. This policy was put in place by an annual piece of governmental policy known as the Inpatient Prospective Payment System (IPPS) Final Rule – the same one, in fact, that established the Two Midnight Rule.

The CMS felt that the decision to admit a Medicare beneficiary to inpatient care is such a significant event that it was appropriate to require the attending physician to complete a series of certification requirements to justify every inpatient stay. If not completed and finalized prior to discharge, the CMS would not pay for the stay. After 15 months of enforcing that policy, the CMS backed off on most of the certification requirements for most stays. However, the requirement for an authenticated inpatient order prior to discharge was kept in place for all stays. (“Authenticated” is CMS-speak for signed, or, in the case of inpatient orders initially placed by a resident/NP/PA without admitting privileges, cosigned, by a practitioner with admitting privileges.)

In the spring of 2018, the CMS proposed a change to “revise the admission order documentation requirements by removing the requirement that written inpatient admission orders are a specific requirement for Medicare Part A [inpatient hospital] payment.” The CMS also stated that it did not intend for Medicare auditors to deny hospital inpatient claims based solely on a deficiency in the inpatient order, such as a missing order or one signed after discharge, which the CMS found out was happening.

The description sounded great. In comments to the CMS, many providers assumed that they, too, would be provided similar discretion if they discovered the order defect. Are inpatient orders now optional? What rate of inpatient order technical deficiencies is acceptable to still submit inpatient claims for payment? Can 2-day observation stays where medical necessity for hospital care was present, but no inpatient order given, be billed as an inpatient now?

But these providers had not read the fine print. Consider that the annual IPPS Final Rule has a length of about 2,000 pages. Of those, only about 30 pages represent changes to a group of policies known as the Code of Federal Regulations (CFR). The CFR carries the weight of law (as long as it does not contradict law). When you appeal a Medicare denial to a judge, she will ask what portion of the CFR supports your viewpoint. The other 1,970 pages can be thought of as supporting analysis and reasoning to justify the 30 pages of changes. What changes were actually made to the CFR?

Consider the following two sentences.

• “For purposes of payment under Medicare Part A, an individual is considered an inpatient of a hospital, including a critical access hospital, if formally admitted as an inpatient pursuant to an order for inpatient admission by a physician or other qualified practitioner.”
• “This physician order must be present in the medical record and be supported by the physician admission and progress notes, in order for the hospital to be paid for hospital inpatient services under Medicare Part A.”

These are the first two sentences of 42 CFR 412.3(a), the regulation that defines the inpatient order requirement. On Oct. 1, 2018, the second sentence was removed, but the first sentence still remains. That’s the only change for this section. Does removal of the second sentence absolve providers of the requirement to document inpatient admission orders? Does it absolve providers of the requirement to cosign a resident’s admission order prior to discharge? The Medicare Benefit Policy Manual (MBPM) Chapter 1, Section 10(B) still reads “if the order is not properly documented in the medical record prior to discharge, the hospital should not submit a claim for Part A payment.”

Understanding what changed and what did not change in the CFR is key to understanding why, in this year’s IPPS Final Rule, the CMS repeatedly responded to providers that an inpatient order is still a requirement for a Part A stay and that none of the MBPM guidance regarding the inpatient order, such as the excerpt above, is changing.

At this point, we can only be reasonably certain that if a claim a hospital submits for Part A payment happens to get audited and found to have only one deficiency which is related to the inpatient order, per this guidance it probably won’t get denied. That is very different from saying the attending physician no longer has to provide a signed (or cosigned) inpatient admission order prior to discharge, or at all.

Providers actually did ask the CMS if a hospital could still submit a claim the hospital knows has a missing or incomplete inpatient admission order at the time of discharge. The CMS responded that Medicare contractors have the discretion in extremely rare circumstances to approve cases where an order to admit may be missing or defective, and yet the intent, decision, and recommendation of the ordering practitioner to admit as inpatient can be clearly derived from the medical record. However, note that the discretion belongs to the Medicare contractor, not the provider.

The American College of Physician Advisors (ACPA) asked the CMS the following question about the inpatient order policy change during the 2019 IPPS Final Rule Open Door Forum held on Sept. 11, 2018: “Can providers thus submit a claim, that the provider believes meets all other requirements for Part A payment, in the rare circumstance of an inpatient order deficiency, such as an inpatient order that was cosigned shortly after discharge?”

The CMS declined to answer the question on the call, asking us to submit the question to the Open Door Forum electronic mailbox. If the inpatient order was truly no longer being required for the CMS to pay for inpatient hospital stays, the answer would have been an easy “yes,” but it was not. Subsequently, the CMS responded in writing to the ACPA that “the responsibilities of providers regarding inpatient admission orders is unchanged.” In other words, Medicare auditors have been given discretion to overlook an inpatient order flaw, but providers have not.

At this time, our recommendation is to continue your processes to ensure that the inpatient admission order is completed and signed (or cosigned) prior to discharge by the attending physician for every Medicare patient. This will not only help make sure that the decision to make a hospitalized Medicare beneficiary an inpatient remains with the attending physician, but it will also reduce the risk of nonpayment.

Dr. Hu is executive director of physician advisor services of University of North Carolina Health Care System in Chapel Hill, N.C., and president of the ACPA. Dr. Locke is senior physician advisor at Johns Hopkins Hospital in Baltimore, and president-elect of the ACPA.

When the Centers for Medicare & Medicaid Services make a significant change to the inpatient hospital rules, hospitalists are among the first to feel the effects.

You probably remember that, starting in October 2013, when a resident, nurse practitioner (NP), or physician assistant (PA) entered an inpatient admission order on your behalf, you were told to cosign that order before discharge or the hospital would forfeit payment for the entire stay. This policy was put in place by an annual piece of governmental policy known as the Inpatient Prospective Payment System (IPPS) Final Rule – the same one, in fact, that established the Two Midnight Rule.

The CMS felt that the decision to admit a Medicare beneficiary to inpatient care is such a significant event that it was appropriate to require the attending physician to complete a series of certification requirements to justify every inpatient stay. If not completed and finalized prior to discharge, the CMS would not pay for the stay. After 15 months of enforcing that policy, the CMS backed off on most of the certification requirements for most stays. However, the requirement for an authenticated inpatient order prior to discharge was kept in place for all stays. (“Authenticated” is CMS-speak for signed, or, in the case of inpatient orders initially placed by a resident/NP/PA without admitting privileges, cosigned, by a practitioner with admitting privileges.)

In the spring of 2018, the CMS proposed a change to “revise the admission order documentation requirements by removing the requirement that written inpatient admission orders are a specific requirement for Medicare Part A [inpatient hospital] payment.” The CMS also stated that it did not intend for Medicare auditors to deny hospital inpatient claims based solely on a deficiency in the inpatient order, such as a missing order or one signed after discharge, which the CMS found out was happening.

The description sounded great. In comments to the CMS, many providers assumed that they, too, would be provided similar discretion if they discovered the order defect. Are inpatient orders now optional? What rate of inpatient order technical deficiencies is acceptable to still submit inpatient claims for payment? Can 2-day observation stays where medical necessity for hospital care was present, but no inpatient order given, be billed as an inpatient now?

But these providers had not read the fine print. Consider that the annual IPPS Final Rule has a length of about 2,000 pages. Of those, only about 30 pages represent changes to a group of policies known as the Code of Federal Regulations (CFR). The CFR carries the weight of law (as long as it does not contradict law). When you appeal a Medicare denial to a judge, she will ask what portion of the CFR supports your viewpoint. The other 1,970 pages can be thought of as supporting analysis and reasoning to justify the 30 pages of changes. What changes were actually made to the CFR?

Consider the following two sentences.

• “For purposes of payment under Medicare Part A, an individual is considered an inpatient of a hospital, including a critical access hospital, if formally admitted as an inpatient pursuant to an order for inpatient admission by a physician or other qualified practitioner.”
• “This physician order must be present in the medical record and be supported by the physician admission and progress notes, in order for the hospital to be paid for hospital inpatient services under Medicare Part A.”

These are the first two sentences of 42 CFR 412.3(a), the regulation that defines the inpatient order requirement. On Oct. 1, 2018, the second sentence was removed, but the first sentence still remains. That’s the only change for this section. Does removal of the second sentence absolve providers of the requirement to document inpatient admission orders? Does it absolve providers of the requirement to cosign a resident’s admission order prior to discharge? The Medicare Benefit Policy Manual (MBPM) Chapter 1, Section 10(B) still reads “if the order is not properly documented in the medical record prior to discharge, the hospital should not submit a claim for Part A payment.”

Understanding what changed and what did not change in the CFR is key to understanding why, in this year’s IPPS Final Rule, the CMS repeatedly responded to providers that an inpatient order is still a requirement for a Part A stay and that none of the MBPM guidance regarding the inpatient order, such as the excerpt above, is changing.

At this point, we can only be reasonably certain that if a claim a hospital submits for Part A payment happens to get audited and found to have only one deficiency which is related to the inpatient order, per this guidance it probably won’t get denied. That is very different from saying the attending physician no longer has to provide a signed (or cosigned) inpatient admission order prior to discharge, or at all.

Providers actually did ask the CMS if a hospital could still submit a claim the hospital knows has a missing or incomplete inpatient admission order at the time of discharge. The CMS responded that Medicare contractors have the discretion in extremely rare circumstances to approve cases where an order to admit may be missing or defective, and yet the intent, decision, and recommendation of the ordering practitioner to admit as inpatient can be clearly derived from the medical record. However, note that the discretion belongs to the Medicare contractor, not the provider.

The American College of Physician Advisors (ACPA) asked the CMS the following question about the inpatient order policy change during the 2019 IPPS Final Rule Open Door Forum held on Sept. 11, 2018: “Can providers thus submit a claim, that the provider believes meets all other requirements for Part A payment, in the rare circumstance of an inpatient order deficiency, such as an inpatient order that was cosigned shortly after discharge?”

The CMS declined to answer the question on the call, asking us to submit the question to the Open Door Forum electronic mailbox. If the inpatient order was truly no longer being required for the CMS to pay for inpatient hospital stays, the answer would have been an easy “yes,” but it was not. Subsequently, the CMS responded in writing to the ACPA that “the responsibilities of providers regarding inpatient admission orders is unchanged.” In other words, Medicare auditors have been given discretion to overlook an inpatient order flaw, but providers have not.

At this time, our recommendation is to continue your processes to ensure that the inpatient admission order is completed and signed (or cosigned) prior to discharge by the attending physician for every Medicare patient. This will not only help make sure that the decision to make a hospitalized Medicare beneficiary an inpatient remains with the attending physician, but it will also reduce the risk of nonpayment.

Dr. Hu is executive director of physician advisor services of University of North Carolina Health Care System in Chapel Hill, N.C., and president of the ACPA. Dr. Locke is senior physician advisor at Johns Hopkins Hospital in Baltimore, and president-elect of the ACPA.

Hospitalists have focused much attention on reducing 30-day readmission rates, at a time when 15-20% of health care dollars spent on those readmissions is considered potentially preventable.

But until very recently, no study has explored patient perceptions of the likelihood of readmission during index admission. Now, that’s changed.

Reference

Carter J et al. The association between patient experience factors and likelihood of 30-day readmission: A prospective cohort study. BMJ Qual Saf. 16 Nov 2017. Accessed Feb 2, 2018.

Hospitalists have focused much attention on reducing 30-day readmission rates, at a time when 15-20% of health care dollars spent on those readmissions is considered potentially preventable.

But until very recently, no study has explored patient perceptions of the likelihood of readmission during index admission. Now, that’s changed.

Reference

Carter J et al. The association between patient experience factors and likelihood of 30-day readmission: A prospective cohort study. BMJ Qual Saf. 16 Nov 2017. Accessed Feb 2, 2018.

Hospitalists have focused much attention on reducing 30-day readmission rates, at a time when 15-20% of health care dollars spent on those readmissions is considered potentially preventable.

But until very recently, no study has explored patient perceptions of the likelihood of readmission during index admission. Now, that’s changed.

Reference

Carter J et al. The association between patient experience factors and likelihood of 30-day readmission: A prospective cohort study. BMJ Qual Saf. 16 Nov 2017. Accessed Feb 2, 2018.

Clinical question: Does patient experience correlate with specific hospital care coordination and transition strategies, and if so, which strategies most strongly correlate with higher patient experience scores?

Background: Patient experience is an increasingly important measure in value-based payment programs. However, progress has been slow in improving patient experience, and little empirical data exist regarding which strategies are effective. Care transitions are critical times during a hospitalization, with many hospitals already implementing measures to improve the discharge process and prevent readmission of patients. It is not known whether those measures also influence patient experience scores, and if they do improve scores, which measures are most effective at doing so.

Study design: An analytic observational survey design.

Setting: Hospitals eligible for the Hospital Readmissions Reduction Program (HRRP) between June 2013 and December 2014.

Synopsis: A survey was developed and given to chief medical officers at 1,600 hospitals between June 2013 and December 2014; the survey assessed care coordination strategies employed by these institutions. 992 hospitals (62% response rate) were subsequently categorized as “low-strategy,” “mid-strategy,” or “high-strategy” hospitals. Patient satisfaction scores from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey in 2014 were correlated to the number of strategies and the specific strategies each hospital employed. In general, the higher-strategy hospitals had significantly higher HCAHPS survey scores than did low-strategy hospitals (+2.23 points; P less than .001). Specifically, creating and sharing a discharge summary prior to discharge (+1.43 points; P less than .001), using a discharge planner (+1.71 points; P less than .001), and calling patients 48 hours post discharge (+1.64 points; P less than .001) all resulted in overall higher hospital ratings by patients.
 

One limitation of this study is that no causal inference can be made between the specific strategies associated with higher HCAHPS scores and care coordination strategies.

Bottom line: Hospital-led care transition strategies with direct patient interactions led to higher patient satisfaction scores.

Citation: Figueroa JF et al. Hospital-level care coordination strategies associated with better patient experience. BMJ Qual Saf. 2018 Apr 4. doi: 10.1136/bmjqs-2017-007597.

Dr. Tsien is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.

Clinical question: Does patient experience correlate with specific hospital care coordination and transition strategies, and if so, which strategies most strongly correlate with higher patient experience scores?

Background: Patient experience is an increasingly important measure in value-based payment programs. However, progress has been slow in improving patient experience, and little empirical data exist regarding which strategies are effective. Care transitions are critical times during a hospitalization, with many hospitals already implementing measures to improve the discharge process and prevent readmission of patients. It is not known whether those measures also influence patient experience scores, and if they do improve scores, which measures are most effective at doing so.

Study design: An analytic observational survey design.

Setting: Hospitals eligible for the Hospital Readmissions Reduction Program (HRRP) between June 2013 and December 2014.

Synopsis: A survey was developed and given to chief medical officers at 1,600 hospitals between June 2013 and December 2014; the survey assessed care coordination strategies employed by these institutions. 992 hospitals (62% response rate) were subsequently categorized as “low-strategy,” “mid-strategy,” or “high-strategy” hospitals. Patient satisfaction scores from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey in 2014 were correlated to the number of strategies and the specific strategies each hospital employed. In general, the higher-strategy hospitals had significantly higher HCAHPS survey scores than did low-strategy hospitals (+2.23 points; P less than .001). Specifically, creating and sharing a discharge summary prior to discharge (+1.43 points; P less than .001), using a discharge planner (+1.71 points; P less than .001), and calling patients 48 hours post discharge (+1.64 points; P less than .001) all resulted in overall higher hospital ratings by patients.
 

One limitation of this study is that no causal inference can be made between the specific strategies associated with higher HCAHPS scores and care coordination strategies.

Bottom line: Hospital-led care transition strategies with direct patient interactions led to higher patient satisfaction scores.

Citation: Figueroa JF et al. Hospital-level care coordination strategies associated with better patient experience. BMJ Qual Saf. 2018 Apr 4. doi: 10.1136/bmjqs-2017-007597.

Dr. Tsien is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.

Clinical question: Does patient experience correlate with specific hospital care coordination and transition strategies, and if so, which strategies most strongly correlate with higher patient experience scores?

Background: Patient experience is an increasingly important measure in value-based payment programs. However, progress has been slow in improving patient experience, and little empirical data exist regarding which strategies are effective. Care transitions are critical times during a hospitalization, with many hospitals already implementing measures to improve the discharge process and prevent readmission of patients. It is not known whether those measures also influence patient experience scores, and if they do improve scores, which measures are most effective at doing so.

Study design: An analytic observational survey design.

Setting: Hospitals eligible for the Hospital Readmissions Reduction Program (HRRP) between June 2013 and December 2014.

Synopsis: A survey was developed and given to chief medical officers at 1,600 hospitals between June 2013 and December 2014; the survey assessed care coordination strategies employed by these institutions. 992 hospitals (62% response rate) were subsequently categorized as “low-strategy,” “mid-strategy,” or “high-strategy” hospitals. Patient satisfaction scores from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey in 2014 were correlated to the number of strategies and the specific strategies each hospital employed. In general, the higher-strategy hospitals had significantly higher HCAHPS survey scores than did low-strategy hospitals (+2.23 points; P less than .001). Specifically, creating and sharing a discharge summary prior to discharge (+1.43 points; P less than .001), using a discharge planner (+1.71 points; P less than .001), and calling patients 48 hours post discharge (+1.64 points; P less than .001) all resulted in overall higher hospital ratings by patients.
 

One limitation of this study is that no causal inference can be made between the specific strategies associated with higher HCAHPS scores and care coordination strategies.

Bottom line: Hospital-led care transition strategies with direct patient interactions led to higher patient satisfaction scores.

Citation: Figueroa JF et al. Hospital-level care coordination strategies associated with better patient experience. BMJ Qual Saf. 2018 Apr 4. doi: 10.1136/bmjqs-2017-007597.

Dr. Tsien is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.

ATLANTA – Patient sharing among hospital facilities contributed substantially to the overall Clostridium difficile infection rate, an analysis of interhospital contamination effects showed.

In fact, 7.6% of all Clostridium difficile infection (CDI) cases at the nearly 400 California hospitals included in the study were directly attributable to the patient-sharing network, Daniel Sewell, PhD, reported at the International Conference on Emerging Infectious Diseases.

“The methods that we employed allowed us to estimate the expected increase in CDI cases due to transfers as a function of the CDI rate at the hospital from which those patients were brought. These transfer patients were responsible for about 3.06 times the number of CDI cases as a normal patient,” said Dr. Sewell, a biostatistician at the University of Iowa, Iowa City.

The findings, which underscored the importance of regional (rather than local) efforts to minimize the spread of health care–associated infections, are based on an analysis of 27,200,873 hospital admissions and 532,320 same-day patient transfers identified from the Healthcare Cost and Utilization Project California State Inpatient Database for 2005-2011.

Transfer networks based on the monthly average number of patients discharged from one hospital and admitted to another on the same day were constructed, and the monthly average number of CDI cases per hospital were considered, along with hospital-level characteristics such as patient length of stay, age, and number of diagnoses. Network autocorrelation models that help eliminate bias were then used to assess the contamination effects between hospitals, he explained.

This led to development of an equation that can be used to determine the expected number of CDI cases in a hospital as a function of the number of transfers coming in and the contamination level of the source hospitals. The ability to calculate the expected number of CDI cases in this fashion is an important factor for the success of regional versus local intervention efforts, which are increasingly thought to be important for reducing health care–associated infections.

“If we want to design a coordinated or regional approach, we’ve got to have a much better understanding of the role that patient transfers have in these diseases,” Dr. Sewell said.

As most hospitals included in the study had a low CDI rate and a low transfer rate, the CDIs attributable to transfers represent a minority of cases, but they are a substantial minority, he said, noting that the main concern is with the “perfect storm” of high CDI rate plus high transfer rate.

The methodological approach used in this study to estimate CDI rates can be used for any health care–associated infection of interest, he added.

Dr. Sewell reported that he had no disclosures.

sworcester@mdedge.com

ATLANTA – Patient sharing among hospital facilities contributed substantially to the overall Clostridium difficile infection rate, an analysis of interhospital contamination effects showed.

In fact, 7.6% of all Clostridium difficile infection (CDI) cases at the nearly 400 California hospitals included in the study were directly attributable to the patient-sharing network, Daniel Sewell, PhD, reported at the International Conference on Emerging Infectious Diseases.

“The methods that we employed allowed us to estimate the expected increase in CDI cases due to transfers as a function of the CDI rate at the hospital from which those patients were brought. These transfer patients were responsible for about 3.06 times the number of CDI cases as a normal patient,” said Dr. Sewell, a biostatistician at the University of Iowa, Iowa City.

The findings, which underscored the importance of regional (rather than local) efforts to minimize the spread of health care–associated infections, are based on an analysis of 27,200,873 hospital admissions and 532,320 same-day patient transfers identified from the Healthcare Cost and Utilization Project California State Inpatient Database for 2005-2011.

Transfer networks based on the monthly average number of patients discharged from one hospital and admitted to another on the same day were constructed, and the monthly average number of CDI cases per hospital were considered, along with hospital-level characteristics such as patient length of stay, age, and number of diagnoses. Network autocorrelation models that help eliminate bias were then used to assess the contamination effects between hospitals, he explained.

This led to development of an equation that can be used to determine the expected number of CDI cases in a hospital as a function of the number of transfers coming in and the contamination level of the source hospitals. The ability to calculate the expected number of CDI cases in this fashion is an important factor for the success of regional versus local intervention efforts, which are increasingly thought to be important for reducing health care–associated infections.

“If we want to design a coordinated or regional approach, we’ve got to have a much better understanding of the role that patient transfers have in these diseases,” Dr. Sewell said.

As most hospitals included in the study had a low CDI rate and a low transfer rate, the CDIs attributable to transfers represent a minority of cases, but they are a substantial minority, he said, noting that the main concern is with the “perfect storm” of high CDI rate plus high transfer rate.

The methodological approach used in this study to estimate CDI rates can be used for any health care–associated infection of interest, he added.

Dr. Sewell reported that he had no disclosures.

sworcester@mdedge.com

ATLANTA – Patient sharing among hospital facilities contributed substantially to the overall Clostridium difficile infection rate, an analysis of interhospital contamination effects showed.

In fact, 7.6% of all Clostridium difficile infection (CDI) cases at the nearly 400 California hospitals included in the study were directly attributable to the patient-sharing network, Daniel Sewell, PhD, reported at the International Conference on Emerging Infectious Diseases.

“The methods that we employed allowed us to estimate the expected increase in CDI cases due to transfers as a function of the CDI rate at the hospital from which those patients were brought. These transfer patients were responsible for about 3.06 times the number of CDI cases as a normal patient,” said Dr. Sewell, a biostatistician at the University of Iowa, Iowa City.

The findings, which underscored the importance of regional (rather than local) efforts to minimize the spread of health care–associated infections, are based on an analysis of 27,200,873 hospital admissions and 532,320 same-day patient transfers identified from the Healthcare Cost and Utilization Project California State Inpatient Database for 2005-2011.

Transfer networks based on the monthly average number of patients discharged from one hospital and admitted to another on the same day were constructed, and the monthly average number of CDI cases per hospital were considered, along with hospital-level characteristics such as patient length of stay, age, and number of diagnoses. Network autocorrelation models that help eliminate bias were then used to assess the contamination effects between hospitals, he explained.

This led to development of an equation that can be used to determine the expected number of CDI cases in a hospital as a function of the number of transfers coming in and the contamination level of the source hospitals. The ability to calculate the expected number of CDI cases in this fashion is an important factor for the success of regional versus local intervention efforts, which are increasingly thought to be important for reducing health care–associated infections.

“If we want to design a coordinated or regional approach, we’ve got to have a much better understanding of the role that patient transfers have in these diseases,” Dr. Sewell said.

As most hospitals included in the study had a low CDI rate and a low transfer rate, the CDIs attributable to transfers represent a minority of cases, but they are a substantial minority, he said, noting that the main concern is with the “perfect storm” of high CDI rate plus high transfer rate.

The methodological approach used in this study to estimate CDI rates can be used for any health care–associated infection of interest, he added.

Dr. Sewell reported that he had no disclosures.

sworcester@mdedge.com

Presenter

Elisabeth Schainker, MD, MSc
 

Session title

Making the referral and navigating “A Whole New World” of care
 

Session summary

By describing different types of post-acute care clinical services, Dr. Schainker empowered the HM18 audience to rethink how to best identify patients and conditions appropriate for transitions of care, from short-term acute care environments to long-term acute care places, inpatient rehabs, or skilled nursing facilities.

With increasing numbers of pediatric patients with medical complexity, who are dependent on technology devices and complicated care needs, hospitalists need to be knowledgeable about the rules of engagement for prolonged or enhanced recoveries, families’ needs, and insurance qualifications. The role of the hospitalist is to make sure that things are in place for safe and successful discharges, keeping in mind patients’ complexity, resources available within family and community, and fair assessments of readmission risks.

Whether rehab needs pertain to pulmonary, medical, or post NICU stays – length of stay averaging 70-80 days – hospitalists still need to ensure that patients have a clear potential to do better and transition to home eventually. There are inadequate numbers of such pediatric post-acute care facilities, 36 hospitals to be precise. Franciscan Children’s, where Dr. Schainker practices, was beautifully represented in a short movie played during the session at the annual meeting of the Society of Hospital Medicine. The protagonists in the movie were children: Mae and Luke.

Key takeaways for HM

1. Knowledge: Post-acute care services facilitate safe discharges of complex medical patients that eventually get home.

2. Attitude: Hospitalists need to identify what would benefit their patients and counsel families, as well as make proper and timely referrals.

3. Behavior: Hospitalists should be familiar with local resources and engage with available providers of post-acute care services.
 

Dr. Giordano is a pediatric neurosurgery hospitalist at Columbia University Medical Center in New York.

Presenter

Elisabeth Schainker, MD, MSc
 

Session title

Making the referral and navigating “A Whole New World” of care
 

Session summary

By describing different types of post-acute care clinical services, Dr. Schainker empowered the HM18 audience to rethink how to best identify patients and conditions appropriate for transitions of care, from short-term acute care environments to long-term acute care places, inpatient rehabs, or skilled nursing facilities.

With increasing numbers of pediatric patients with medical complexity, who are dependent on technology devices and complicated care needs, hospitalists need to be knowledgeable about the rules of engagement for prolonged or enhanced recoveries, families’ needs, and insurance qualifications. The role of the hospitalist is to make sure that things are in place for safe and successful discharges, keeping in mind patients’ complexity, resources available within family and community, and fair assessments of readmission risks.

Whether rehab needs pertain to pulmonary, medical, or post NICU stays – length of stay averaging 70-80 days – hospitalists still need to ensure that patients have a clear potential to do better and transition to home eventually. There are inadequate numbers of such pediatric post-acute care facilities, 36 hospitals to be precise. Franciscan Children’s, where Dr. Schainker practices, was beautifully represented in a short movie played during the session at the annual meeting of the Society of Hospital Medicine. The protagonists in the movie were children: Mae and Luke.

Key takeaways for HM

1. Knowledge: Post-acute care services facilitate safe discharges of complex medical patients that eventually get home.

2. Attitude: Hospitalists need to identify what would benefit their patients and counsel families, as well as make proper and timely referrals.

3. Behavior: Hospitalists should be familiar with local resources and engage with available providers of post-acute care services.
 

Dr. Giordano is a pediatric neurosurgery hospitalist at Columbia University Medical Center in New York.

Presenter

Elisabeth Schainker, MD, MSc
 

Session title

Making the referral and navigating “A Whole New World” of care
 

Session summary

By describing different types of post-acute care clinical services, Dr. Schainker empowered the HM18 audience to rethink how to best identify patients and conditions appropriate for transitions of care, from short-term acute care environments to long-term acute care places, inpatient rehabs, or skilled nursing facilities.

With increasing numbers of pediatric patients with medical complexity, who are dependent on technology devices and complicated care needs, hospitalists need to be knowledgeable about the rules of engagement for prolonged or enhanced recoveries, families’ needs, and insurance qualifications. The role of the hospitalist is to make sure that things are in place for safe and successful discharges, keeping in mind patients’ complexity, resources available within family and community, and fair assessments of readmission risks.

Whether rehab needs pertain to pulmonary, medical, or post NICU stays – length of stay averaging 70-80 days – hospitalists still need to ensure that patients have a clear potential to do better and transition to home eventually. There are inadequate numbers of such pediatric post-acute care facilities, 36 hospitals to be precise. Franciscan Children’s, where Dr. Schainker practices, was beautifully represented in a short movie played during the session at the annual meeting of the Society of Hospital Medicine. The protagonists in the movie were children: Mae and Luke.

Key takeaways for HM

1. Knowledge: Post-acute care services facilitate safe discharges of complex medical patients that eventually get home.

2. Attitude: Hospitalists need to identify what would benefit their patients and counsel families, as well as make proper and timely referrals.

3. Behavior: Hospitalists should be familiar with local resources and engage with available providers of post-acute care services.
 

Dr. Giordano is a pediatric neurosurgery hospitalist at Columbia University Medical Center in New York.

Clinical question: Does prompting hospitalists during interdisciplinary rounds to discontinue lab orders on patients nearing discharge result in a decrease in lab testing?

Background: The Society of Hospital Medicine, as part of the Choosing Wisely campaign, has recommended against “repetitive complete blood count and chemistry testing in the face of clinical and lab stability.” Repeated phlebotomy has been shown to increase iatrogenic anemia and patient discomfort. While past interventions have been effective in decreasing lab testing, this study focused on identifying and intervening on patients who were clinically stable and nearing discharge.

Study design: Prospective, observational study.

Setting: Tertiary care teaching hospital in New York.

Synopsis: As part of structured, bedside, interdisciplinary rounds, over the course of a year, this study incorporated an inquiry to identify patients who were likely to be discharged in the next 24-48 hours; the unit medical director or nurse manager then prompted staff to discontinue labs for these patients when appropriate. This was supplemented by education of clinicians and regular review of lab utilization data with hospitalists.

The percentage of patients with labs ordered in the 24 hours prior to discharge decreased from 50.1% in the preintervention period to 34.5% in the postintervention period (P = .004). The number of labs ordered per patient-day dropped from 1.96 to 1.83 (P = .01).

Bottom line: An intervention with prompting during structured interdisciplinary rounds decreased the frequency of labs ordered for patients nearing hospital discharge.

Citation: Tsega S et al. Bedside assessment of the necessity of daily lab testing for patients nearing discharge. J Hosp Med. 2018 Jan 1;13(1):38-40.
 

Dr. Huang is associate chief of the division of hospital medicine at UC San Diego Health and an associate professor of medicine at the University of California, San Diego.

Clinical question: Does prompting hospitalists during interdisciplinary rounds to discontinue lab orders on patients nearing discharge result in a decrease in lab testing?

Background: The Society of Hospital Medicine, as part of the Choosing Wisely campaign, has recommended against “repetitive complete blood count and chemistry testing in the face of clinical and lab stability.” Repeated phlebotomy has been shown to increase iatrogenic anemia and patient discomfort. While past interventions have been effective in decreasing lab testing, this study focused on identifying and intervening on patients who were clinically stable and nearing discharge.

Study design: Prospective, observational study.

Setting: Tertiary care teaching hospital in New York.

Synopsis: As part of structured, bedside, interdisciplinary rounds, over the course of a year, this study incorporated an inquiry to identify patients who were likely to be discharged in the next 24-48 hours; the unit medical director or nurse manager then prompted staff to discontinue labs for these patients when appropriate. This was supplemented by education of clinicians and regular review of lab utilization data with hospitalists.

The percentage of patients with labs ordered in the 24 hours prior to discharge decreased from 50.1% in the preintervention period to 34.5% in the postintervention period (P = .004). The number of labs ordered per patient-day dropped from 1.96 to 1.83 (P = .01).

Bottom line: An intervention with prompting during structured interdisciplinary rounds decreased the frequency of labs ordered for patients nearing hospital discharge.

Citation: Tsega S et al. Bedside assessment of the necessity of daily lab testing for patients nearing discharge. J Hosp Med. 2018 Jan 1;13(1):38-40.
 

Dr. Huang is associate chief of the division of hospital medicine at UC San Diego Health and an associate professor of medicine at the University of California, San Diego.

Clinical question: Does prompting hospitalists during interdisciplinary rounds to discontinue lab orders on patients nearing discharge result in a decrease in lab testing?

Background: The Society of Hospital Medicine, as part of the Choosing Wisely campaign, has recommended against “repetitive complete blood count and chemistry testing in the face of clinical and lab stability.” Repeated phlebotomy has been shown to increase iatrogenic anemia and patient discomfort. While past interventions have been effective in decreasing lab testing, this study focused on identifying and intervening on patients who were clinically stable and nearing discharge.

Study design: Prospective, observational study.

Setting: Tertiary care teaching hospital in New York.

Synopsis: As part of structured, bedside, interdisciplinary rounds, over the course of a year, this study incorporated an inquiry to identify patients who were likely to be discharged in the next 24-48 hours; the unit medical director or nurse manager then prompted staff to discontinue labs for these patients when appropriate. This was supplemented by education of clinicians and regular review of lab utilization data with hospitalists.

The percentage of patients with labs ordered in the 24 hours prior to discharge decreased from 50.1% in the preintervention period to 34.5% in the postintervention period (P = .004). The number of labs ordered per patient-day dropped from 1.96 to 1.83 (P = .01).

Bottom line: An intervention with prompting during structured interdisciplinary rounds decreased the frequency of labs ordered for patients nearing hospital discharge.

Citation: Tsega S et al. Bedside assessment of the necessity of daily lab testing for patients nearing discharge. J Hosp Med. 2018 Jan 1;13(1):38-40.
 

Dr. Huang is associate chief of the division of hospital medicine at UC San Diego Health and an associate professor of medicine at the University of California, San Diego.

Long continues the debate on what impact hospitalists have on inpatient outcomes. This issue has been playing out in the medical literature for 20 years, since the coining of the term in 1997. In a recent iteration of the debate, a study was published in JAMA Internal Medicine entitled “Comparison of Hospital Resource Use and Outcomes Among Hospitalists, Primary Care Physicians, and Other Generalists.”

The study retrospectively evaluated health care resources and outcomes from over a half-million Medicare beneficiaries hospitalized in 2013 for 20 common diagnosis-related groups, by type of physician provider (hospitalist, their primary care physician, or other generalist). The study found that nonhospitalists used more consultations and had longer lengths of stays, compared with hospitalists. In addition, relative to hospitalists, PCPs were more likely to discharge patients to home, had similar readmission rates, and lower 30-day mortality rates, but generalists were less likely to discharge patients home, had higher readmission rates, and higher mortality rates.

Also on The Hospital Leader …

• Locums vs. F/T Hospitalists: Do Temps Stack Up? by Brad Flansbaum, DO, MPH, MHM

• Rounds: Are We Spinning Our Wheels? by Vineet Arora, MD, MPP, MHM

• Up Your Game in APP Integration by Tracy Cardin, ACNP-BC, SFHM

Long continues the debate on what impact hospitalists have on inpatient outcomes. This issue has been playing out in the medical literature for 20 years, since the coining of the term in 1997. In a recent iteration of the debate, a study was published in JAMA Internal Medicine entitled “Comparison of Hospital Resource Use and Outcomes Among Hospitalists, Primary Care Physicians, and Other Generalists.”

The study retrospectively evaluated health care resources and outcomes from over a half-million Medicare beneficiaries hospitalized in 2013 for 20 common diagnosis-related groups, by type of physician provider (hospitalist, their primary care physician, or other generalist). The study found that nonhospitalists used more consultations and had longer lengths of stays, compared with hospitalists. In addition, relative to hospitalists, PCPs were more likely to discharge patients to home, had similar readmission rates, and lower 30-day mortality rates, but generalists were less likely to discharge patients home, had higher readmission rates, and higher mortality rates.

Also on The Hospital Leader …

• Locums vs. F/T Hospitalists: Do Temps Stack Up? by Brad Flansbaum, DO, MPH, MHM

• Rounds: Are We Spinning Our Wheels? by Vineet Arora, MD, MPP, MHM

• Up Your Game in APP Integration by Tracy Cardin, ACNP-BC, SFHM

Long continues the debate on what impact hospitalists have on inpatient outcomes. This issue has been playing out in the medical literature for 20 years, since the coining of the term in 1997. In a recent iteration of the debate, a study was published in JAMA Internal Medicine entitled “Comparison of Hospital Resource Use and Outcomes Among Hospitalists, Primary Care Physicians, and Other Generalists.”

The study retrospectively evaluated health care resources and outcomes from over a half-million Medicare beneficiaries hospitalized in 2013 for 20 common diagnosis-related groups, by type of physician provider (hospitalist, their primary care physician, or other generalist). The study found that nonhospitalists used more consultations and had longer lengths of stays, compared with hospitalists. In addition, relative to hospitalists, PCPs were more likely to discharge patients to home, had similar readmission rates, and lower 30-day mortality rates, but generalists were less likely to discharge patients home, had higher readmission rates, and higher mortality rates.

Also on The Hospital Leader …

• Locums vs. F/T Hospitalists: Do Temps Stack Up? by Brad Flansbaum, DO, MPH, MHM

• Rounds: Are We Spinning Our Wheels? by Vineet Arora, MD, MPP, MHM

• Up Your Game in APP Integration by Tracy Cardin, ACNP-BC, SFHM

As the field of hospital medicine continues to grow, it is experiencing more requests for assistance with pre- and posthospital care. These increasing demands will be the focus of today’s session “Addressing the Expanding Scope of Practice in Hospital Medicine.”

“As hospital medicine continues to advance, we are being asked to help hospitals and health care systems with challenges that extend beyond the hospital,” presenter Nick Fitterman, MD, SFHM, vice chair of hospital medicine of Northwell Health in Long Island, N.Y., explained in an interview. “Sometimes, this is a natural extension of hospital medicine; other times, it may reflect gaps in primary care or the health care system in general. Hospital medicine can be supportive, but our course must be deliberate and not extend beyond our scope of practice.

“The health care system is facing a variety of challenges, which, in turn, make an impact on hospital medicine,” stated Dr. Fitterman. “Factors that result in increased demands on the field include lack of access to posthospitalization care, high-acuity patients in subacute rehabilitation, rising health care costs, and value-based payments that include ‘bundles’ of care stretching beyond hospitalization. Finally, the nation has a population that’s aging,” he continued, “thanks to the ‘silver tsunami’ of baby boomers.”

The session will include presentations by leaders in the fields of post-acute clinics and hospitals at home. Lauren Doctoroff, MD, FHM, of Beth Israel Deaconess Medical Center in Boston will discuss post-acute care clinics; David Levine, MD, of Brigham and Women’s Hospital and Harvard Medical School, both in Boston, will cover some hospital-at-home developments; and Efren Manjarrez, MD, SFHM, of the University of Miami Health System will speak about preoperative care. Dr. Fitterman will provide examples of the expanded scope of practice issues that can arise in a large health care system.

“There are a finite number of beds in any given hospital and extending our reach into pre- or posthospitalization care is an avenue to expand our book of business, cultivate new skills, and engage patients and colleagues in new settings,” Dr. Fitterman explained. “Done with a clear vision and plan and within our scope of practice, this can be quite rewarding. Executed only to meet a demand but without proper resources, this can pose a new challenge and become frustrating.”

“HM18 participants who attend the session will receive some insights into what works and what doesn’t work regarding extrahospital care for hospital medicine,” continued Dr. Fitterman. “And we hope it will help hospital medicine practitioners and groups as they determine where to focus their efforts.”

Addressing the Expanding Scope of Practice in Hospital Medicine
Wednesday, 7:30-8:30 a.m.
​Grand Ballroom 7B

As the field of hospital medicine continues to grow, it is experiencing more requests for assistance with pre- and posthospital care. These increasing demands will be the focus of today’s session “Addressing the Expanding Scope of Practice in Hospital Medicine.”

“As hospital medicine continues to advance, we are being asked to help hospitals and health care systems with challenges that extend beyond the hospital,” presenter Nick Fitterman, MD, SFHM, vice chair of hospital medicine of Northwell Health in Long Island, N.Y., explained in an interview. “Sometimes, this is a natural extension of hospital medicine; other times, it may reflect gaps in primary care or the health care system in general. Hospital medicine can be supportive, but our course must be deliberate and not extend beyond our scope of practice.

“The health care system is facing a variety of challenges, which, in turn, make an impact on hospital medicine,” stated Dr. Fitterman. “Factors that result in increased demands on the field include lack of access to posthospitalization care, high-acuity patients in subacute rehabilitation, rising health care costs, and value-based payments that include ‘bundles’ of care stretching beyond hospitalization. Finally, the nation has a population that’s aging,” he continued, “thanks to the ‘silver tsunami’ of baby boomers.”

The session will include presentations by leaders in the fields of post-acute clinics and hospitals at home. Lauren Doctoroff, MD, FHM, of Beth Israel Deaconess Medical Center in Boston will discuss post-acute care clinics; David Levine, MD, of Brigham and Women’s Hospital and Harvard Medical School, both in Boston, will cover some hospital-at-home developments; and Efren Manjarrez, MD, SFHM, of the University of Miami Health System will speak about preoperative care. Dr. Fitterman will provide examples of the expanded scope of practice issues that can arise in a large health care system.

“There are a finite number of beds in any given hospital and extending our reach into pre- or posthospitalization care is an avenue to expand our book of business, cultivate new skills, and engage patients and colleagues in new settings,” Dr. Fitterman explained. “Done with a clear vision and plan and within our scope of practice, this can be quite rewarding. Executed only to meet a demand but without proper resources, this can pose a new challenge and become frustrating.”

“HM18 participants who attend the session will receive some insights into what works and what doesn’t work regarding extrahospital care for hospital medicine,” continued Dr. Fitterman. “And we hope it will help hospital medicine practitioners and groups as they determine where to focus their efforts.”

Addressing the Expanding Scope of Practice in Hospital Medicine
Wednesday, 7:30-8:30 a.m.
​Grand Ballroom 7B

As the field of hospital medicine continues to grow, it is experiencing more requests for assistance with pre- and posthospital care. These increasing demands will be the focus of today’s session “Addressing the Expanding Scope of Practice in Hospital Medicine.”

“As hospital medicine continues to advance, we are being asked to help hospitals and health care systems with challenges that extend beyond the hospital,” presenter Nick Fitterman, MD, SFHM, vice chair of hospital medicine of Northwell Health in Long Island, N.Y., explained in an interview. “Sometimes, this is a natural extension of hospital medicine; other times, it may reflect gaps in primary care or the health care system in general. Hospital medicine can be supportive, but our course must be deliberate and not extend beyond our scope of practice.

“The health care system is facing a variety of challenges, which, in turn, make an impact on hospital medicine,” stated Dr. Fitterman. “Factors that result in increased demands on the field include lack of access to posthospitalization care, high-acuity patients in subacute rehabilitation, rising health care costs, and value-based payments that include ‘bundles’ of care stretching beyond hospitalization. Finally, the nation has a population that’s aging,” he continued, “thanks to the ‘silver tsunami’ of baby boomers.”

The session will include presentations by leaders in the fields of post-acute clinics and hospitals at home. Lauren Doctoroff, MD, FHM, of Beth Israel Deaconess Medical Center in Boston will discuss post-acute care clinics; David Levine, MD, of Brigham and Women’s Hospital and Harvard Medical School, both in Boston, will cover some hospital-at-home developments; and Efren Manjarrez, MD, SFHM, of the University of Miami Health System will speak about preoperative care. Dr. Fitterman will provide examples of the expanded scope of practice issues that can arise in a large health care system.

“There are a finite number of beds in any given hospital and extending our reach into pre- or posthospitalization care is an avenue to expand our book of business, cultivate new skills, and engage patients and colleagues in new settings,” Dr. Fitterman explained. “Done with a clear vision and plan and within our scope of practice, this can be quite rewarding. Executed only to meet a demand but without proper resources, this can pose a new challenge and become frustrating.”

“HM18 participants who attend the session will receive some insights into what works and what doesn’t work regarding extrahospital care for hospital medicine,” continued Dr. Fitterman. “And we hope it will help hospital medicine practitioners and groups as they determine where to focus their efforts.”

Addressing the Expanding Scope of Practice in Hospital Medicine
Wednesday, 7:30-8:30 a.m.
​Grand Ballroom 7B

Background: The acuity of many patients recently discharged from an acute care facility is high. Some of these patients are being transferred to a SNF upon hospital discharge. Currently existing SNF care systems may not be prepared sufficiently for the challenges that arise with the admission of such patients to the SNFs after hospital discharge, resulting in readmissions.

Study design: Observational, retrospective cohort analysis.

Setting: Collaborative effort among a large, urban, acute care center, interdisciplinary clinical team, 124 community physicians, and eight SNFs.

Synopsis: In addition to standard care, the Enhanced Care Program (ECP) included a team of nurse practitioners participating in the care of SNF patients, a pharmacist-driven medication reconciliation at the time of transfer, and educational in-services for SNF nursing staff. Following introduction of the three ECP interventions, 30-day readmission rates were compared for both ECP and non-ECP patient groups. After adjustment for sociodemographic and clinical characteristics, ECP patients had 29% lower odds of being readmitted within 30 days (P less than .001). Multivariate analyses confirmed similar results. Major caveats include that this was a single-hospital study and that selection of the enrolled patients was not random, but rather, was determined by their primary care providers, potentially leading to some confounding.

Bottom line: For patients discharged to SNFs, an interdisciplinary care approach may reduce 30-day hospital readmissions.

Citation: Rosen BT et al. The Enhanced Care Program: Impact of a care transition program on 30-day hospital readmissions for patients discharged from an acute care facility to skilled nursing facilities. J Hosp Med. 2017 Oct 4:E1-E7. doi: 10.12788/jhm.2852

Dr. Burklin is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.

Background: The acuity of many patients recently discharged from an acute care facility is high. Some of these patients are being transferred to a SNF upon hospital discharge. Currently existing SNF care systems may not be prepared sufficiently for the challenges that arise with the admission of such patients to the SNFs after hospital discharge, resulting in readmissions.

Study design: Observational, retrospective cohort analysis.

Setting: Collaborative effort among a large, urban, acute care center, interdisciplinary clinical team, 124 community physicians, and eight SNFs.

Synopsis: In addition to standard care, the Enhanced Care Program (ECP) included a team of nurse practitioners participating in the care of SNF patients, a pharmacist-driven medication reconciliation at the time of transfer, and educational in-services for SNF nursing staff. Following introduction of the three ECP interventions, 30-day readmission rates were compared for both ECP and non-ECP patient groups. After adjustment for sociodemographic and clinical characteristics, ECP patients had 29% lower odds of being readmitted within 30 days (P less than .001). Multivariate analyses confirmed similar results. Major caveats include that this was a single-hospital study and that selection of the enrolled patients was not random, but rather, was determined by their primary care providers, potentially leading to some confounding.

Bottom line: For patients discharged to SNFs, an interdisciplinary care approach may reduce 30-day hospital readmissions.

Citation: Rosen BT et al. The Enhanced Care Program: Impact of a care transition program on 30-day hospital readmissions for patients discharged from an acute care facility to skilled nursing facilities. J Hosp Med. 2017 Oct 4:E1-E7. doi: 10.12788/jhm.2852

Dr. Burklin is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.

Background: The acuity of many patients recently discharged from an acute care facility is high. Some of these patients are being transferred to a SNF upon hospital discharge. Currently existing SNF care systems may not be prepared sufficiently for the challenges that arise with the admission of such patients to the SNFs after hospital discharge, resulting in readmissions.

Study design: Observational, retrospective cohort analysis.

Setting: Collaborative effort among a large, urban, acute care center, interdisciplinary clinical team, 124 community physicians, and eight SNFs.

Synopsis: In addition to standard care, the Enhanced Care Program (ECP) included a team of nurse practitioners participating in the care of SNF patients, a pharmacist-driven medication reconciliation at the time of transfer, and educational in-services for SNF nursing staff. Following introduction of the three ECP interventions, 30-day readmission rates were compared for both ECP and non-ECP patient groups. After adjustment for sociodemographic and clinical characteristics, ECP patients had 29% lower odds of being readmitted within 30 days (P less than .001). Multivariate analyses confirmed similar results. Major caveats include that this was a single-hospital study and that selection of the enrolled patients was not random, but rather, was determined by their primary care providers, potentially leading to some confounding.

Bottom line: For patients discharged to SNFs, an interdisciplinary care approach may reduce 30-day hospital readmissions.

Citation: Rosen BT et al. The Enhanced Care Program: Impact of a care transition program on 30-day hospital readmissions for patients discharged from an acute care facility to skilled nursing facilities. J Hosp Med. 2017 Oct 4:E1-E7. doi: 10.12788/jhm.2852

Dr. Burklin is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.

Transitions of care can be rife with communications issues – and subsequent adverse events. They are also a place where hospitalists can take the lead in making improvements.

“They are the team leaders, typically,” said Ana Pujols McKee, MD, the executive vice president and chief medical officer for The Joint Commission. “The hospitalist really owns this process of the transfer of this accurate information.”

To help, The Joint Commission has issued a new Sentinel Event Alert, which provides seven recommendations to improve the communication failures that can occur when patients are transitioned from one caregiver to another, as well as a Targeted Solutions Tool to put the recommendations into action.

“Every organization is challenged in communicating accurate and timely information regarding patients,” Dr. McKee said. “One of the riskiest transitions that patients go through is when they change levels of care from ICU to med-surg, or from the ER to ICU, OR to ICU, med-surg to home, and home to home care. All of those transitions inherently carry a certain amount of risk and are deeply reliant on the transfer of the right information at the right time to the right person.”

Transitions of care can be rife with communications issues – and subsequent adverse events. They are also a place where hospitalists can take the lead in making improvements.

“They are the team leaders, typically,” said Ana Pujols McKee, MD, the executive vice president and chief medical officer for The Joint Commission. “The hospitalist really owns this process of the transfer of this accurate information.”

To help, The Joint Commission has issued a new Sentinel Event Alert, which provides seven recommendations to improve the communication failures that can occur when patients are transitioned from one caregiver to another, as well as a Targeted Solutions Tool to put the recommendations into action.

“Every organization is challenged in communicating accurate and timely information regarding patients,” Dr. McKee said. “One of the riskiest transitions that patients go through is when they change levels of care from ICU to med-surg, or from the ER to ICU, OR to ICU, med-surg to home, and home to home care. All of those transitions inherently carry a certain amount of risk and are deeply reliant on the transfer of the right information at the right time to the right person.”

Transitions of care can be rife with communications issues – and subsequent adverse events. They are also a place where hospitalists can take the lead in making improvements.

“They are the team leaders, typically,” said Ana Pujols McKee, MD, the executive vice president and chief medical officer for The Joint Commission. “The hospitalist really owns this process of the transfer of this accurate information.”

To help, The Joint Commission has issued a new Sentinel Event Alert, which provides seven recommendations to improve the communication failures that can occur when patients are transitioned from one caregiver to another, as well as a Targeted Solutions Tool to put the recommendations into action.

“Every organization is challenged in communicating accurate and timely information regarding patients,” Dr. McKee said. “One of the riskiest transitions that patients go through is when they change levels of care from ICU to med-surg, or from the ER to ICU, OR to ICU, med-surg to home, and home to home care. All of those transitions inherently carry a certain amount of risk and are deeply reliant on the transfer of the right information at the right time to the right person.”