Staffing
The CHC Hospital Medicine Program is a 24-hour in-house service that operates in a shift-based (7a-7p) block model. There is one nocturnalist that covers 15 night shifts per month. Hospitalists are scheduled 15-18 12-hour shifts per month and are paid for additional shift coverage. Sign-in/out is face-to-face at 7 a.m. and 7 p.m. Day-time shifts are covered by two physicians 7 days per week, with an additional 0.5 FTE available M-F (medical director). Night shifts have single-physician coverage. Beginning in January 2005, day-time coverage will expand by one FTE.
Compensation/Benefits
All physicians are salaried. An annual bonus of up to 10% base salary is available at each physician’s anniversary date. The bonus is based heavily upon quality/FCCS certification (30%), team and referral physician satisfaction (20%), Press Ganey Patient-Physician Satisfaction scores (15%), and operational efficiency/organizational benefit (35%).
Standard benefits are provided, including malpractice coverage with tail, health, dental, vision, life insurance, 403b and 457b plans, short- and long-term disability. CME/Professional fee allowances of $3000 are provided. Initially, all physicians received 37 days of paid time off while contracting for 18 shifts/month. This has evolved into a 15-shifts/month schedule with no additional PTO.
Patient Census/Population
Patients are admitted to the Covenant HealthCare Hospital Medicine Service from three main avenues: unassigned emergency department admissions, private admitting relationships, and direct regional referrals. The hospitalists cover approximately 85% off all ED unassigned admissions. In addition, the service admits exclusively (all-or-none) for 35 local and regional primary care physicians. Covenant HealthCare serves as the tertiary referral for a number of small rural and critical access hospitals. These regional partners have ease of access with a “one pager” call number for the admitting hospitalist. Additionally, the hospitalists co-manage patients with various surgical specialties (orthopedics, neurosurgery, general surgery) and offer a medical consultation service. All of the Covenant Hospitalists have ACLS and Fundamentals of Critical Care Support certification, allowing them to serve as intensivist extenders (ICUs are open). As such, the service acts as Code Blue attending and the Medical Response Team for pre-code emergencies.
The average daily census is 30 with an average of 8-10 admissions per day. The Case Mix Index is 1.2617.
Communication Strategies
Communication was emphasized as a priority with the development of this new program. The position of a hospitalist support associate was created to serve as the point person for all external and internal communication. This is a full-time equivalent Monday through Friday. Hospitalist dictations are expedited via medical records transcription and faxed to the hospitalist office. All primary care physicians receive a notification of patient admission by fax on the morning following admission. This notification identifies the hospitalist attending, accompanies the dictated history and physical, and makes a request for pertinent outpatient information. Follow-up appointments are arranged by the hospitalist support associate prior to patient discharge. Discharge summaries are completed in real-time and faxed to the primary care office at the time of discharge.
Each hospitalist carries their own designated pager. A universal pager is passed between day and night physicians and is the “one call” direct contact for both the hospitalists’ private admitting relationships and regional referrals. Primary care physicians also have the opportunity to identify their preferred subspecialty consultants on enrollment to the hospitalist service. Laboratory and Radiology also utilize the universal pager for communication of critical values.
In conjunction with business development, primary care physician enrollment packets, patient brochures, hospitalist fliers, a regional referral manual, and DVD have all been compiled to assist in the education of patients, staff, and physicians.
Challenges
The greatest challenge to our program has been the facilitation of a culture of direct communication between the hospitalists and the medical staff consultants. Additionally, in our system the emergency department physicians routinely write admitting orders (“bridging orders”) for the private medical staff attending admissions. It has been a shift in culture to request the emergency physicians not to write bridging orders for the hospitalist admissions but to allow the hospitalist physician the opportunity to evaluate and admit hospitalist patients in real time in the emergency department.