Clearly defined roles are crucial when establishing a co-management program
Co-management continues to evolve as hospital leaders and hospitalists find the best ways to use skills and expertise from various specialties, including their own, to benefit patient care. Orthopedic surgery, neurosurgery, and other surgical specialties are commonly part of hospitalist co-management programs.
Dr. Shaughnessey
“These surgical specialty teams are often less familiar with managing medical complexity, and allowing the surgical team to provide excellent surgical care and the hospitalist to manage medical issues results in the best of both worlds,” said Erin E. Shaughnessy MD, MSHCM, director and Beth Gordy Dubina Endowed Chair of pediatric hospital medicine in the department of pediatrics at the Heersink School of Medicine at the University of Alabama in Birmingham, Ala.
Dr. Giordano
Co-management with these areas is common in pediatric medicine and adult medicine because evidence shows better outcomes when clinicians with varied experiences collaborate within these areas, said Mirna Giordano, MD, FHM, pediatric hospitalist and associate professor of pediatrics at Columbia University Medical Center in New York.
Dr. Mgbojikwe
Yet other specialties can be part of a co-management agreement, said Nkemdilim Mgbojikwe, MD, SFHM, associate professor, department of medicine, and associate chief medical officer at Fox Chase Cancer Center in Philadelphia.
At Dr. Shaughnessy’s hospital, it’s common for pediatric hospitalists to co-manage patients with significant medical needs with their pediatric physical medicine and rehabilitation partners, but infectious disease, dentistry, and ophthalmology often are in consultant roles. “The primary differentiation between a consultation and [a] co-management model is: a consultant makes recommendations and does not place orders, whereas co-managing services make decisions related to their practice area and enter orders,” she explained.
Benefits and defining roles
Dr. Meyer
Besides better patient care, potential benefits of co-management include increased professional satisfaction through collaborative working relationships and better allocation of medical staff expertise among patients, said Daniel A. Meyer, MD, vice chair for clinical affairs and quality in the department of medicine at Maine Medical Center in Portland.
“The value proposition suggests that it is better for patients, providers, and healthcare systems alike to engage in these partnerships,” Dr. Meyer said.
Dr. Meyer said that co-management within orthopedics may be so common and successful because there is easy delineation of roles. “The orthopedist can manage the surgery and the surgery-specific post-op care, and the hospitalist will typically manage everything else,” he said. “This clear role definition allows the two groups to partner effectively and easily, in a sense because there is not a ton of partnership required to make it work.”
He contrasts this with cardiology or oncology, where there may be more overlap in role definition. For instance, will the cardiologist or the hospitalist optimize hypertension? “It may be hard to define roles and responsibilities clearly ahead of time, but it is likely time well spent to iron out these questions as clearly as possible before entering into a co-management arrangement,” he said.
When co-management arrangements happen organically due to staffing or resource limitations, hospitalists should still be deliberate in their role definition.
Dr. Pyke
O’Neil J. Pyke, MD, MBA, SFHM, chief medical officer at Jackson North Medical Center, of Jackson Health System in Miami, supports more formal co-management arrangements but says it’s common for them to develop organically. “Unfortunately, sometimes it’s building the plane as we start flying,” he said. One challenge he has seen is getting surgeons to take part in patient follow-ups postoperatively, especially on the weekends. “The hospitalist is left to guess or scramble to actually figure out what the surgeon is thinking because it’s not adequately delineated in their progress notes,” he said.
This led to a pilot protocol at one of the hospitals in the Jackson system that says when a patient is admitted with a primary surgical issue, the surgeon is not allowed to sign off the case until they have a distinct conversation with the hospitalist team to confirm the patient is doing well and that the surgeon can be reached for any follow-up questions.
Co-management evolution
SHM published a White Paper on co-management in 2017, noting that co-management was associated with better patient care, improved patient safety, better pain scores, and lowered costs per patient hospitalization.1
The paper presented two possible models for co-management: one that assigns the hospitalist to be the patient’s primary attending with the subspecialist as a consultant, and the second with the hospitalist as a consultant with the subspecialist as the patient’s primary attending.
Although either model can work well with agreement and support from the involved parties, misinterpretations from other medical staff members and co-managers can occur if the co-management structure is not clearly defined.1
The report’s content remains relevant today, hospitalists said—the only real change is an expanded role for co-management. “There is no doubt that we have moved away from the days where hospitalists only provided hospital coverage for primary care providers,” Dr. Meyer said. “Today, hospitalists are managing or co-managing patients with a far wider range of medical and surgical conditions and medical complexity.”
Dr. Pyke, one of the co-authors of the paper believes it reasonably states challenges with co-management and some possible solutions. What he’s seen in recent years is hospitals trending toward specific co-management patterns based on the number of specialists available in a given area.
Best practices
Whether you’re looking to start a co-management arrangement for the first time or want to maximize your current structure, here are a few tips for best practices:
Examine your current hospital dynamics. “The easiest place to start is by looking at your local environment to see where hospitalist partnerships can add the most value,” Dr. Meyer said. “When in doubt, starting with an area like orthopedics or a similar surgical specialty may be the easiest way to go.” However, examine your reasons for co-management. If your hospital orthopedic service’s length of stay is longer than expected due to surgeons who are in the operating room and unable to address patient-flow needs, co-management may be useful. If orthopedic performance on length of stay already exceeds benchmarks, there may be fewer benefits of a co-management arrangement.
When getting started, make sure to discuss the financials of co-management with your chief executive officer and chief financial officer, to be clear on which type of practitioner is better to admit versus consult, Dr. Pyke advised.
Create detailed policies related to co-management. Although hospitalists acknowledge that co-management agreements sometimes happen organically, it’s a better idea to have agreements in place. Be as detailed as possible so it’s clear about who does what, where, and when. Make sure to outline any protocols used for shared decision-making as well, including medical and surgical checklists, Dr. Giordano recommended.
“One of the ways co-management programs break down is when a hospitalist or specialist feels they are being asked to practice out of scope, such as the hospitalist determining the timing of a surgery or a specialist needing to manage chronic medical condition outside of their training and experience,” Dr. Mgbojikwe said. “The discussion about the scope of practice, including the level of engagement, cannot be emphasized enough in its importance for patients and medical teams.” And, share these policies when onboarding new medical staff.
Vet your policies with members of surgical teams across the spectrum. “Even though the patient is at the center, we definitely want to make sure we hear all [clinician] voices,” Dr. Pyke said. In a small hospital, that could mean speaking with every single proceduralist, but that also can help get support and feedback to create realistic co-management policies.
Link co-management to institutional or quality goals. For example, you could connect it with reaching a lower length of stay or improved patient experiences. “It still stands true from a quality perspective that the patient is getting the best care because you are structuring your co-management. It’s making sure there are no gaps in the care that is delivered to the patient. Quality has to be at the top,” Dr. Pyke said.
Have a plan in place to address conflict. Even with the best-laid policies, it still may happen. Plan to have a clearly identified individual or committee who can help handle conflict as well, Dr. Mgbojikwe recommended.
Aim for great communication and co–rounding when possible. “The best practice will always bring the two providers together to the bedside to make sure the patient perceives the togetherness of the service, and to feel more comfortable that no stones are left unturned in their care,” Dr. Pyke said. In terms of better communication, that can be as simple as an exchange of phone numbers with fellow co-managers and having secure text messaging available, Dr. Shaughnessy said.
Foster a culture of mutual respect among specialties. “We are all professionals with important knowledge to contribute to patient care,” Dr. Meyer said. “Respect each other’s skills.” One way to develop this is to have faculty who are active across divisions, he suggested.
Consider any special circumstances if you work in pediatrics. The American Academy of Pediatrics’ section on hospital medicine, surgical care subcommittee, has a pediatric surgical co-management listserv that Dr. Giordano recommends to any practitioners who co-manage children and teenagers. If you’re not sure how to join, she welcomes SHM members to contact her directly at [email protected]. This same subcommittee has several templates for clinicians who may want to start a co-management program, Dr. Giordano said. Another good resource for pediatric co-management is an article published earlier this year in Pediatrics.2
Vanessa Caceres is a medical writer in Bradenton, Fla.
SHM’s Practice Management Team will debut additional co-management resources next month at hospitalmedicine.org/comanagement.
References
- Society of Hospital Medicine, Co-Management Workgroup. The Evolution of Co-management. SHM website. https://www.hospitalmedicine.org/globalassets/practice-management/practice-management-pdf/pm-19-0004-co-management-white-paper_minor-update-m.pdf. Published 2017. Accessed August 29, 2024.
- Rosenberg RE, Pressel DM, et al. Comanagement of surgical pediatric patients in the acute care inpatient setting. Pediatrics. 2024;153:e2023064775. doi: 10.1542/peds.2023-064775.