Dr. Kealey says the “bridge” is a point of concern for many HM groups, especially when the pressure comes from hospital administrators attempting to attract specialists. Hospitalists have the right in such situations, says Dr. Siy, to feel undersupported or that they lack crucial knowledge or skill sets. Still, Dr. Kealey sees requests from other physician groups as a positive thing for hospitalists.
“We’re going to be managing more in the future,” he says, noting his HM group first drew up a comanagement agreement with orthopedic surgeons 17 years ago. “We want to go there thoughtfully and carefully. We shouldn’t put our foot down and say no to new opportunity.”
Rules of Engagement
Nearly every hospitalist leader agrees that the key to protecting against scope creep resides with thoughtful, proactive planning. Make sure, they say, that your group is ready to manage the patients you’re being asked to manage (see “Define and Protect Your Scope of Practice,” p. 35).
—Michael Radzienda, MD, SFHM, regional chief medical officer, Sound Physicians, Boston
Michael Radzienda, MD, SFHM, regional chief medical officer at Sound Physicians in the greater Boston area, agrees with Dr. Kealey in that he sees opportunity where others might perceive burden. For example, he notes, the advent of value-based purchasing initiatives, linking payment to quality, will create “huge opportunities for hospitalists.” More than 50% of the quality core measures in these initiatives are related to the Surgical Care Improvement Project (SCIP).4
Dr. Simone
Figure 2. Services Routinely Provided: Groups Serving Adults OnlySource: 2012 State of Hospital Medicine report
“Now, more than ever, hospitalists need to align with their partners in the hospital C-suite to help them be successful around those targets,” Dr. Radzienda says. However, he adds, “it behooves the HM teams to be very methodical and not rush this.”
Crafting clear rules of engagement must be handled properly and thoughtfully at the outset, Dr. Radzienda explains, and developing mutual trust and respect between the parties is the most essential step. Logistically, this can present problems.
“Getting surgeons and hospitalists together at a table is hard work,” he says. “But I can’t underscore that more: This requires a relationship. And it’s not something that is done via email exchange or memoranda through the respective practices’ business managers.”
It’s also critical to have nursing on board, says Julie Weegman, RN, MA, OCN, director of nursing and medical surgical services at HealthPartners’ Regions Hospital in St. Paul. “Communication is key in this kind of arrangement,” she says. “Nurses could potentially be put in a bad position if there are tensions between hospitalists and the specialty departments.”
That isn’t the case at Regions, though, where the comanagement agreement between orthopedics and HM has been clearly established, Weegman says. Questions about the surgical site, activity, and weight-bearing are referred to surgeons, while chronic disease management, blood pressure, glucose monitoring, etc., usually are handled by hospitalists.
Dr. Radzienda stresses that patients must remain at the center of the equation. “At three o’clock in the morning, with the post-op ortho patient who is having pain, nausea, or bleeding, it cannot be a multistep process to decide which doc is going to take that call and deliver on the patient’s needs,” he says.
Dr. Nelson, who co-founded SHM and serves as The Hospitalist’s practice-management columnist, cautions that service agreements are not a panacea. “This won’t totally solve your problems,” he says, “because every doctor is authorized to violate agreements if they see fit and if they can prove their patient is the exception to the rule.”