Psychiatry Hospitalist Model Allows for More Patient, Family Time

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The importance of a consistent delivery of a high level of care has become a hot topic for more and more hospitals.
The importance of a consistent delivery of a high level of care has become a hot topic for more and more hospitals.

During the last several years, hospital inpatient wards nationwide have undergone significant changes with the initiation of "hospitalist" programs, using dedicated inpatient physicians who work exclusively in a hospital.1 Although these models were initiated with internal medicine, hospitalist programs have expanded into other disciplines, are now are prevalent in such specialties as obstetrics and gynecology, and have moved into inpatient psychiatry as well. Psychiatrists are currently being hired by hospitals and physician provider organizations across the United States to participate in psychiatric hospitalist divisions.

In the early 2000s, very few programs were using the hospitalist model, with the exception of academic centers and some hospital systems.2 Even now, many psychiatric hospitals and inpatient units still use psychiatrists who intersperse visits for inpatient responsibilities amidst the maintenance of an outpatient office practice.

In recent years, hospitals have started taking a closer look at metrics, patient satisfaction, and experience. The importance of a consistent delivery of a high level of care has become a hot topic for more and more hospitals. Many hospitals rely on scoring from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), a patient satisfaction survey required by the Centers for Medicare & Medicaid Services for all hospitals in the United States.

Lower HCAHPS scores have been correlated with the "traditional model," in which private practice physicians round on their hospital patients while spending the majority of the day at their busy outpatient offices.3 Commonly, in this model, the physicians would round early in the day or late in the evening, fitting in hospital responsibilities where they could, leaving the main part of the day for scheduled outpatient appointments. A recurrent complaint by hospital administrators about this model was that the attending physicians were frequently rushed and not readily available for staffing, multidisciplinary rounding, complex care conference, or family meetings.

One key difference between the hospitalist model and the traditional model is that hospitalists are dedicated solely to the hospitalized patients, and thus will have the opportunity to spend more time with the patient, family, and significant others. An area in both the HCAHPS scores and the Press-Ganey patient satisfaction surveys (which include inpatient psychiatry) that directly benefits from this approach is the patient's report of the time spent with the physician.4

Today, patients are more informed and knowledgeable about healthcare issues. They understand many aspects of healthcare and demand a higher level of attention and care. And as pressures mount to improve patient satisfaction for both regulatory and compensation reasons, meeting the needs of the informed patient population has led to significant influence on how hospitals shape their care.5

Recognizing these changing demands, Palomar Health, a multiple campus medical center and healthcare system in northern San Diego County, California, switched to a psychiatry hospitalist model in 2011, hoping to improve the delivery of high-quality care to its mental health inpatient population. At Palomar Health, the hospitalist psychiatrists work full time in the hospital. As a result, they are readily available to patients, staff, and other providers. Psychiatrists regularly participate in, and lead, inpatient unit multidisciplinary team meetings, providing an integrated approach to caring for their patients.

Oftentimes, with the traditional model, patients in the most acute setting who were decompensated saw their psychiatrist for briefer periods of time than a patient who was stable and being seen at their outpatient clinic. With the hospitalist model, this is quite different, as patients have thorough evaluations and are observed repeatedly throughout the course of the day. The hospitalist psychiatrists are always available for recommendations, treatment interventions, and input with nursing and clinical staff concerning the management of the patient.

Since the implementation of the hospitalist program at the Palomar Health, patient satisfaction scores have improved dramatically. The physicians now consistently perform well above the national benchmarks. Initiatives such as improving discharge times were realized and helped with emergency department throughput and shorter emergency department wait times. In addition, improved access to psychiatry services resulted in more effective emergency department disposition and decreased boarding times. In addition, the psychiatric providers reported higher job satisfaction and better work-life balance.

Hospitals are inviting more and more physicians to actively participate and collaborate in initiatives that focus on quality improvement and leadership.6 This is being affected by a shift from volume-based to value-based systems.7

The hospitalist model aligns well with healthcare systems' mission to engage and involve physicians in leadership and management. This in turn creates better outcomes for patient care and safety, moving the dial to higher reliability and accountability with a focus on "what's best for the patient."8

The psychiatry hospitalist model is here to stay. With its effective implementation, it will continue to contribute to the better use of scarce healthcare resources. Addressing population health needs has resulted in clinically integrated networks that focus on collaboration of hospitalist models with the continuum of care in communities while focusing on value and cutting costs.9

References

1. Rachoin JS, Skaf J, Cerceo E, et al. The impact of hospitalists on length of stay and costs: systematic review and meta-analysis. Am J Manag Care. 2012;18(1):23-30.

2. Hamrin V, Iennaco J, Olsen D. A review of ecological factors affecting inpatient psychiatric unit violence: implications for relational and unit cultural improvements [published online July 9, 2009]. Issues Ment Health Nurs. doi: 10.1080/01612840802701083

3. Chen LM, Birkmeyer JD, Saint S, Jha AK. Hospitalist staffing and patient satisfaction in the national Medicare population [published online January 3, 2013]. J Hospital Med. doi: 10.1002/jhm.2001

4. Bleustein C, Rothschild DB, Valen A, Valatis E, Schweitzer L, Jones R. Wait Times, Patient Satisfaction Scores, and the Perception of Care. Am J Manag Care. 2014;20(5):393-400

5. Zgierska A, Rabago D, Miller MM. Impact of patient satisfaction ratings on physicians and clinical care [published online April 3, 2014]. Patient Prefer Adherence. doi: 10.2147/PPA.S59077

6. Berwick D, Feeley D, Loehrer S. Change from the inside out health care leaders taking the helm. JAMA. 2015;313(17):1707-1708. doi: 10.1001/jama.2015.2830

7. Angood, P. The value of physician leadership. Physician Exec. 2014;40:6-20.

8. Silbaugh BR, Leider HL. Physician leadership is key to creating a safer, more reliable health care system. Physician Exec. 2009;35:12-16.

9. Swensen S Pugh M. High Impact Leadership: Improve care, improve the health of populations, and reduce costs. Cambridge, MA: Institute of Healthcare Improvement; 2013.


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