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• W2904110135 abstract "In an exclusive interview with Caring for the Ages, Jasen Gundersen, MD, MBA, president of TeamHealth’s Hospitalist and Post-Acute Care service lines, spoke with Ian Cordes, a member of Caring’s Editorial Advisory Board, about the increasing role of hospitalists in the United States. Dr. Gundersen explained how this development has changed the practice of medicine in the acute and post-acute settings, as well as discussed the evolution of TeamHealth, the influence of electronic medical record (EMR) systems on the day-to-day, and more. Cordes: Can you provide the readers of Caring with an overview of TeamHealth’s acute and post-acute care services? Gundersen: TeamHealth is one of the nation’s largest physician management companies. Started in the 1970s as an emergency medicine company, TeamHealth entered hospital medicine in 1993 and has grown pretty aggressively over the years. I am responsible for the hospitalist and the post-acute care service lines. There are about 2,500 hospitalists on the acute side who are mostly medical, meaning they are trained in either internal or family medicine. We are in about 300 acute care facilities right now. At the end of 2015, we acquired IPC Healthcare, which provided a catalyst for our work in the post-acute space. Then, in January 2018, we separated post-acute into its own freestanding service line devoted to work in post-acute facilities — largely medical. However, we also have a fairly sizeable behavioral health component as well, and that is about 1,200 or so total clinicians, comprising roughly 50% physician and 50% advanced practice clinicians. We currently cover around 2,300 facilities in the country. In that area, one of the initiatives we are working on is putting an EMR into all of our programs, as most of the facilities don’t have any type of EMR documentation system. Cordes: Will those be compatible with the hospital’s or the skilled nursing facility’s (SNF’s) EMR or electronic health record? Gundersen: Most of those have PointClickCare, and we are working on how to build interfaces. It is a manual process; when the doctors are done with their notes, we route them via email or fax into the system and they get loaded in the record. As we get more sophisticated, we will do more with that; but from our standpoint, we wanted to have clear documentation for every doctor. It will also feed into the call center program that we are building. In other words, rather than have these facilities covered by different doctors and nurse practitioners, we are going to centralize that functionality into a call center so a team of clinicians will cover the substantial portion of our facilities. By having the EMR there, they can read the notes and know what is going on. Cordes: How has the rise of hospital medicine impacted overall health status, total cost, and the well-being of patients? Gundersen: Hospital medicine is the fastest growing specialty in the history of medicine. There are an estimated 60,000 hospitalists in the country practicing right now. From a patient care standpoint, it has really changed the care patients receive when they are in a facility. Rather than a doctor trying to manage his or her busy outpatient practice and driving in and out of the hospital, all our sites have dedicated physicians managing with a majority in the building 24/7. That has led to efficiency of care. There is a significant amount of work in the field related to EMRs and value-based measures that have made it very complicated to work in the hospital these days, and hospitalists are able to work through them more efficiently. Additionally, we have experinced a significant amount of “scope creep.” It used to be that hospital medicine doctors went to the hospital with the purpose of performing medical work. However, nowadays, the hospitalist is the quarterback for the entire hospital. Furthermore, there have been significant changes in length of stay and cost savings, two aspects of which may be a criticism. There has been an interruption in continuity for patients. It used to be that you had your general doctor who took care of everything and knew you from teenage years to old age. That change has been hard for some patients to work through. However, that has been the migration of medicine in general, so I don’t think that is a hospitalist-specific area. Cordes: Are there any strategies you are using with regards to the discontinuity in care? Gundersen: There are very few places around the country where primary care doctors are still caring for patients in the hospital. What we try to do is maintain continuity with a patient who is admitted on the hospitalist side. We strive to keep the number of providers per patient to two and work really hard to minimize handoffs within the hospitalist service. We are also constantly trying to find the best means for enhancing communication with patients’ primary care community. Cordes: Is it common for hospitalists to follow their patients into the SNF? Gundersen: In our case, we have specifically split our team so that we don’t have hospitalists who follow patients into the facility. We have made a decision that we want the folks who are working in the post-acute facility to be specialists in that area and have a scheduled presence model in which they are physically present at set times every week. Cordes: Are hospitalists becoming SNF medical directors? Gundersen: Our post-acute providers are often medical directors in their SNFs, hospices, assisted living facilities, etc. We make sure all of our medical directors are working through CME-type training so that they are trained, focused, and understand the responsibilities that come with the job. Cordes: When it comes to effective discharge and admission communication between hospital physicians and SNF physicians, do you think there is room for improvement? Gundersen: The model we are using in the post-acute setting—having a scheduled presence, a defined provider, and a facility—makes it much easier for the acute provider to know how to make the handoff and establishes what is expected on both sides. Without that, you kind of send your patients off into the night and never really know what happens. In terms of EMRs, we have run into a lot of issues with the systems, which have made it harder to communicate among providers. For example, a history and physical used to get faxed to the primary care physician, but now it goes into the EMR portal and the primary care doctor has to go look for it. And we all know that if we have to go look for things, it is not the same as if it comes in the mailbox. With regards to post-acute EMR, we try to help in cases where a patient has to go back to an emergency department or a facility by providing a clear, legible, understandable record. We make sure that the flow of information is available to whatever provider is there, at whatever time of day the patient needs something; this is really key. Overall, we have done good work on handoffs, but there is always room for improvement. Cordes: I guess part of that challenge is the interoperability of all the EMR systems. Gundersen: Yes. Unfortunately, there is no such thing as interoperability between EMR systems, despite what they all tell us. It certainly has been a challenge. I would say people spend more time in front of their keyboards clicking away than in talking and working with patients these days. Cordes: Do you think that this issue will be tackled, because it impacts everything in the continuum? Gundersen: Hospitals have spent billions of dollars on EMR systems, and I don’t know anybody who says this is the best thing we have ever done. But, ultimately, if I had to think futuristically, it would be great if people could carry their own information on the phone or in some file into which we could feed information. I work clinically in south Florida and we have a lot of snowbirds who come down and bring all their medical records. This is hugely helpful because if I tried to get their records, we would spend our entire day only to end up with an EMR output of 300 pages that is hard to decipher. Cordes: How can hospitalists and SNF-ists do a better job in partnering together to prevent avoidable hospital readmissions? Gundersen: It all starts with the admission. We need to do a better job of setting reasonable expectations of what people can expect during their hospitalization: what the course will be, what we think the downstream will be, and what they should view this as. This starts in the emergency department. Cordes: When hospitalists first emerged 20 years ago, they were considered novel, even fringe. How do you see hospital medicine evolving in the next 5 to 10 years? Gundersen: We will have to find a way to make doctors in the acute settings more efficient so they can see a higher volume of patients. In the post-acute space, we are in the Wild West. The scenario is reminiscent of where hospital medicine was 20 years ago, with only a couple of groups starting to consolidate and think of it as a specialty. However, this space will experience a significant amount of growth, evolution, and consolidation during the next 3 to 5 years. Cordes: Do you see any other physician specialties emerging? Gundersen: We are seeing growth in virtual medicine. Right now, we are paying doctors and nurse practitioners to transport themselves to different locations, whereas we could be doing a lot of that work virtually. Cordes: What would you like the readers of Caring to take away from this interview? Gundersen: The trade-off from not having one doctor who sees you in every location is that you have a dedicated group of doctors who will work with and take care of you with the best set of skills you can find in whatever setting you are in. Further, I would recommend people be advocates for their own health and well-being and bring copies of their records and a medication list. I would also recommend that families have one spokesperson who can help with coordination. We always see people during the toughest times in their lives. It is a very stressful time for everybody, and you have to work hard to build the relationship quickly during these times. This is critical for the specialty. Mr. Cordes is executive director of FMDA – The Florida Society for Post-Acute and Long-Term Care Medicine. “Board Room” is an occasional series of articles by members of the Caring for the Ages Editorial Advisory Board. Jasen Gundersen, MD, MBA, is the President of Acute and Post-Acute Care services for TeamHealth, one of the nation’s largest physician management companies. He is responsible for all hospitalist and post-acute care operations for the country with over 4,000 clinical providers practicing in approximately 300 acute and 2,300 post-acute facilities. Prior to TeamHealth, he was the Division Chief of Hospital Medicine and Clinical Associate Professor at the University of Massachusetts Memorial Medical Center. In addition, Dr. Gundersen operates his own consulting business and serves on the board of several health care IT start-up companies." @default.
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• W2904110135 title "Q&A with an Expert: The Rise of Hospital Medicine and Its Impact on Health Care Delivery" @default.
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