Scripps Clinic: Continuity issue valid?
Scripps Clinic: Continuity issue valid?
Hospitalist as quarterback
Scripps Clinic in La Jolla, CA, has employed a hospitalist configuration since August 1992. The program began in response to what doctors perceived as inefficiencies in their practices. When a doctor had only one or two patients hospitalized and the distance between office and hospital was sizeable, the doctor spent too much time traveling. Scripps sought to correct this by having an on-site doctor do all the hospital work.
"That person could read laboratory tests in real time, make real-time decisions, and get the patient along to the next spectrum of care," explains Dan Dworsky, MD, an inpatient internist at Scripps.
Today there are about a dozen primary care physicians who are hospitalists at Scripps. Each physician takes turns being a "dedicated admitting physician" for week-long tours of duty. "Initially, outpatient doctors were definitely skeptical," says Dworsky, "both primary care physicians and specialists. But we’ve been doing this now for a while, and the system’s become accepted."
Care coordinators work with Scripps' hospitalists, and the focus of those professionals is to clinch the diagnosis that’s keeping the patient in the hospital and start therapy. "Patients are not kept there while we look at lots of other diagnostic tests that are possibly unrelated to their hospitalization," says Dworsky. "Those are in the purview of the outpatient doctor."
Hospital Peer Review asked Dworsky whether continuity of care is an issue when the hospitalist may be less familiar with the patient than the primary doctor.
"The continuity-of-care argument doesn’t hold water in today’s health care arena," he says. "The important thing is good communication. But the communication has to be three-way, and include the patient."
In today’s world, only the very sick are admitted to the hospital. The needs of hospitalized patients are distinct from those who present at the office. "You can look at this two ways," Dworsky says. "First, continuity of care has very little to do with patients being in the hospital today. People typically are there for less than two or three days. The brief acute intervention doesn’t impact the continuity of care anymore. If a patient has had a stroke, for example, I treat that condition. I don’t have to know details about the patient’s family life. Years ago, when patients were in the hospital longer and for less clear indications and had lower levels of acuity, that argument held. But not today."
Update outpatient physicians daily
Dworsky’s second point is that for complex problems that require longer hospitalizations, an excellent communication system has to be established.
"We make sure we update the outpatient physicians on their patients’ progress daily," says Dworsky. Whether by phone, fax, or hallway consultation, this communication is essential. "In addition, you have to assure the patient that his doctors are communicating daily. If you don’t do that, you’re in trouble from two standpoints: You may not be facilitating adequate communication, and you have an unhappy patient."
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