A New Hospitalist Model for Managing High-Cost, High-Need Patients

A partnership between the Boston Medical Center and Commonwealth Care Alliance, a community-based health care organization, provides a promising new hospitalist model for inpatient treatment of complex care patients — patients with extensive, persistently expensive medical needs.

Complex care patients typically have complicated medical histories, functional limitations or disabilities, numerous medications prescribed by multiple outpatient providers, and social drivers of illness. Providing hospital inpatient treatment for them is challenging.

For example, the increasingly prominent hospitalist model depends on hospital-based physicians with expertise in hospital care for admitted patients. But these physicians have little to no prior experience with the patients they treat. Some data has shown that this model can lead to lower average length of stay without increasing costs, though the impact on patient-centered outcomes and total medical costs is unclear. Particularly for more complex, chronically ill patients, it is not known whether a hospital physician with expertise in complex care and understanding of an individual patient’s history could achieve better patient-centered outcomes than a traditional hospitalist.

Care delivery organizations that assume financial risk have also invested in models that improve transitions between inpatient and outpatient settings, with the goal of decreasing readmissions and other complications that come with disconnected care. For example, organizations such as CareMore have invested in “extensivists,” primary care physicians who travel to hospitals where CareMore patients are admitted and link the hospital stay with primary care. Extensivists (also known as “comprehensivists”) aim to influence the hospital course of treatment and, following discharge, the transition to outpatient care. CareMore credits this model with a 30-day hospital readmissions rate for Medicare patients that is 40% less than the national average.

Extensivists do not, however, manage the patient in the hospital and thus cede ultimate control of decision making and clinical care to their patients’ hospitalists. Most of these hospitalists do not specialize in the care of patients with complex medical and social needs and disabilities. Nevertheless, as the CareMore results indicate, extensivists do improve patient outcomes through a degree of influence over the hospital setting. Could a hospitalist service dedicated to the care of complex patients have even greater impact?

To find out, Commonwealth Care Alliance and Boston Medical Center created a hospitalist service staffed with physicians and mid-level providers who specialize in complex care. (Commonwealth Care Alliance offers health plans to individuals who are dually eligible for Medicare and Medicaid and serves patients who are significantly more medically and socially complex than the average population.) This complex care hospitalist model — which launched in July 2016 —has four fundamental, replicable components.

Communication. The complex care hospitalist team communicates frequently with patients’ primary care teams, something that conventional hospitalists do not often do. Primary care providers are contacted on admission, are given updates throughout the hospitalization, and are consulted when discharge planning begins. Communication occurs via e-mail, phone, and text and is used to verify medications, history and context of illness, and social factors that may be relevant to an admission. For example, if a new diagnosis is made during the hospitalization, the primary care team is notified and asked to help deliver the news to the patient and the family, improving both patients’ experiences and the transition out of the hospital.

Continuity of care. Patients admitted to the complex care service are co-located on the same hospital unit, with consistent nursing staff and a core rotating group of hospitalists. Since many of the patients are admitted at least annually, the inpatient nurses and providers often have familiarity with the patients, providing continuity of treatment over time. To ensure a safe discharge, a nurse-led, in-person, transitions-of-care team coordinates the discharge plan with the hospital staff, hospitalists, and primary care teams, in addition to the patients and their families or home health providers.

Social determinants of health. For complex patients, expenditures on social needs such as food and housing can have a greater impact on health outcomes and well-being than medical care. The Complex Care service trains physicians, nurses, and care transitions teams in social determinants of health and how to identify patients’ social needs. For example, a patient with diabetes may also have food insecurity, leading to difficulty accessing food that will help his medical condition and resulting in more hospitalizations for diabetes. Providers on the Complex Care service would search for underlying drivers of the patient’s diabetes hospitalizations, then coordinate with a food bank or Meals on Wheels to provide a diabetic diet when the patient returns home.

Specialists in complex care. The Complex Care hospitalist team employs physicians and mid-level providers with expertise in caring for patients with complex medical conditions and disabilities. Whether with formal training through a complex care clinical fellowship or experience working in a specialized primary care practice, the complex care hospitalists are trained in both acute care medicine and caring for the needs of this population. The nurses on the unit received training in nursing care for complex patients — for example, how to care for patients with disabilities and functional limitations.

We’ve only began to assess the effectiveness of the effort, but initial results are promising. We conducted a preliminary chart review and examined the differences in 30-day readmission rates between all of the patients from Commonwealth Care Alliance’s primary care practice, Commonwealth Community Care, admitted to BMC in one month. Ten patients were admitted to the complex care service; five were admitted to hospitalist/general medicine services. Patients discharged from the complex care service had a 20% 30-day readmission rate and 20% went to the emergency department (ED) within 30 days after discharge; those discharged from hospitalist and general medicine services had an 80% 30-day admission rate, and the remaining 20% of those patients returned to the ED within 30 days. While the population of this exploratory evaluation is small, the data support the anecdotal, qualitative experiences of patients and providers on the complex care service. We are now conducting an evaluation of more than 1,000 admissions.

These initial results also suggest that some complex patients may be better served by providers more intimately connected to the outpatient setting who specialize in caring for patients with complex medical and social needs and disabilities. Other patients may be appropriately served through an adjunct consultant, or extensivist, model. Still others, who may not need the level of expertise or intensity of either a complex care hospitalist or an extensivist can be adequately served by the traditional hospitalist model.

The challenges for value-based organizations will be how much control to exert over the inpatient hospital setting and how to triage patients to the model of inpatient care best suited to their particular needs. But in an era where hospital costs and outcomes, particularly for high-cost, high-need patients, are more relevant than ever, the complex care hospitalist model offers an achievable and replicable option for value-based hospital medicine.

The author would like to thank Sagar Raju for his research assistance.