際際滷

際際滷Share a Scribd company logo

Hospitalist Collaboration

Michael Wagner, MD FACP
Michael Wagner, MD FACP

The document discusses coordination of care in hospitalist medicine. It provides background on Michael Wagner and his positions. It then discusses collaboration at different levels - 1st order collaboration involves direct patient care, 2nd order collaboration are relationships between hospitalists and other providers, and 3rd order collaboration is between hospitalist programs and other departments. Specific areas of collaboration discussed include communication with nurses, multi-disciplinary rounds, relationships with ED physicians, standardizing care expectations, and coordinating with primary care physicians. The presentation provides examples and best practices for enhancing collaboration at each level.

1 of 23
Downloaded 13 times
Coordinating Care in Hospitalist Medicine Hospitalist Executive Leadership Summit December 2, 2010 Michael Wagner, MD FACP Chief, Internal Medicine and Adult Primary Care
珂庄界鞄温艶鉛油安温乙稼艶姻,油珂禽油酷粥遺永 Positions Chief,InternalMedicineandAdultPrimaryCare,TuftsMedicalCenter2008 present ChiefExecutiveOfficer,EmCareInpatientServices20038 Chief,GeneralInternalMedicine,TuftsNewEnglandMedicalCenter19992003 RegionalMedicalDirector,CoveHealthcare19981999 InternalMedicineResidencyProgramDirectorandDirectorofMedicalEducation, St.MarysHospitalandUniversityofRochester19921997 Internist,NewEnglandMedicalCenter19901992 ChiefResident,DartmouthHitchcockMedicalCenter19891990 MDGeorgetownUniversitySchoolofMedicine,1986 CurrentRoles AssociateProfessorofMedicine,TuftsUniversitySchoolofMedicine ViceChair,institutionalReviewBoard,TuftsMedicalCenterand TuftsUniversity HealthSciences PhysicianAdvisor,InformationTechnologyTuftsMedicalCenter Chair,ManagedCareandQualityCommittee,TuftsMedicalCenterPhysician Organization Disclosures None MichaelWagnerMDFACPDecember2010 2
Collaboration Goals of presentation Discuss broad concept of collaboration in hospitalist medicine Segment collaboration into functional assessment categories Discuss specific areas for collaboration and coordination Discuss specific strategies to enhance and hardwire collaboration and coordination of care into a hospitalist program MichaelWagnerMDFACPDecember2010
Provisos Focus Day/rounding hospitalist Non-teaching environment MichaelWagnerMDFACPDecember2010
Hospitalist as a member of the team Patient and Family Patient and Family Nursing Nursing Primary Care Physician Primary Care Physician Care management Care management Hospitalist Specialist Physician Specialist Physician Ancillary services Ancillary services Pharmacy Emergency Medicine Emergency Medicine Pharmacy Radiology Radiology Laboratory Program Coordinator Program Coordinator Laboratory Respiratory Respiratory Rehab/LT care facility Rehab/LT care facility Home Care Services Home Care Services 5 MichaelWagnerMDFACPDecember2010
Collaboration Case Dr. Smith is a new graduate from a local residency program who recently joined your hospitalist service. He came with excellent references and interviewed very well when he was recruited. After 3 months into working, you (as the medical director of the program) perform a focused professional practice evaluation (FPPE). You perform a chart review and review the metrics that have been collected so far. He seems to be doing well and his documentation is complete and medically appropriate. Feedback from nursing is not negative. When you ask around most of the staff have met him but they say they dont know him very well. MichaelWagnerMDFACPDecember2010
Collaboration 1st order 1st order collaboration Interactions and work involving direct care for a specific patient ED ED MD ED RN Inpatient units Case Primary RN Management Ancillary Consultants Post Hospital PCP PCP RN Episode of care MichaelWagnerMDFACPDecember2010
Collaboration Case continued When you begin your block of shifts you pick up Dr. Smiths patients. In the process of finishing several discharges you find several inconsistencies in the medication lists between admission and the planned dc med list you have from his last note. This prompts you to talk to the patients primary nurse. I was hoping to talk with one of you hospitalist about this patients med list. Dr. Smith wasnt available and I never had the chance to talk with him the case. In fact sometimes I dont even see him. I have to page him several times in the morning just to clarify orders he has written. MichaelWagnerMDFACPDecember2010
Collaboration - Engagement ActivelyEngaged Engagable Disengaged Activelydisengaged MichaelWagnerMDFACPDecember2010
Collaboration 2nd order 2nd order collaboration Interactions and relationships that are created and exist between the hospitalist and other care givers Floor nursing Case management Specialty physicians ED physicians MichaelWagnerMDFACPDecember2010
Inpatient complexity 2000 patients 1800 patients 2500 patients 15 patients 5 doctors with busy outside practices 1500 patients MichaelWagnerMDFACPDecember2010
Reducing inpatient complexity 15patients 1doctorwithNOoutsidepractice Hospitalist Reducingcomplexityoftheinpatiententerprise Smallernumberofattendings 15patients Highervolume/attending 5doctors Lowerratioofattendings:nurse withbusyoutsidepractices MichaelWagnerMDFACPDecember2010
Collaboration Case continued You go and seek out Dr. Smith the next time he is on and ask him to recount his typical day: I usual start in the office and start my progress notes there. I gather the vital signs and labs that have returned so far. I then go to the floor and see my patients. You know there really isnt a good place to think or write my notes so I go back to the office and finish my notes. You know it is really annoying that the nursing staff keep paging me, I think my orders are pretty clear. You know the nursing staff isnt very good here. You get the sense he is not very happy in his new role and you are not happy with his attitude. MichaelWagnerMDFACPDecember2010
Collaboration 3rd order 3rd order collaboration Interactions and relationships that are created and exist between the hospitalist program and the other clinical departments and outside referring physicians. Emergency Department Nurse managers Case management department Primary care practices MichaelWagnerMDFACPDecember2010
PATIENT Position Interests Condition Move the patient out of the ED EDphysician Emergent treatment Triage Disease Am I the best next physician? Hospitalist Work up completed Treatment initiation MichaelWagnerMDFACPDecember2010
Collaboration Case continued The hospital administrator calls you to complain about the delays in transfers from the ED to the floors. He has gotten feedback from the ED that the hospitalists are taking forever to call back and get down to the ED for new admissions. He also states at the last FLOW committee the assigned hospitalist did not show up. MichaelWagnerMDFACPDecember2010
Collaboration Best practices Recruit relaters Primary nurse face to face communication Organized daily multi-disciplinary rounds Deal with the ED conflict issue Virtually integrate with your referring PCPs Develop care expectations Leadership MichaelWagnerMDFACPDecember2010
Develop care expectations Traditional Pneumonia CHF Chest pain Service standards Time to see patients Communication Special populations Frail elderly Warfarin Poly-pharmacy Frequent re-admissions MichaelWagnerMDFACPDecember2010
Collaboration Hospital based physicians 1st order Verbal communication about why you want the consult or procedure done Make a point to touch base if you see consultant and discuss case face to face 2nd order Introduce yourself Interact in MD lounge Eat lunch with someone new 3rd order Participate in medical staff committees Go to medical staff meetings Discuss sources of frustrations with medical director MichaelWagnerMDFACPDecember2010
Collaboration Power of relating 80 70 Number of consults 60 50 Dr. Specialist new Old specialist 3 40 Old specialist 2 Old specialist 1 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 Quarters MichaelWagnerMDFACPDecember2010
Collaboration PCPs 1st order Make an attempt to call and discuss case with PCP on admission Call PCP at time of DC Write a concise and accurate discharge summary 2nd order Go to mixers for PCP staff 3rd order Get involved in IDN/ACO committees there will be PCPs driving this process and discussion MichaelWagnerMDFACPDecember2010
Collaboration Case conclusion Dr. Smith is very appreciative of your feedback and specific suggestions on rounding with the primary nurse. The number of pages has decreased and he is feeling more comfortable. He agrees to participate in the Flow committee as well. MichaelWagnerMDFACPDecember2010
Thehospitalists dilemma Bummer of a birthmark, Dr. Hal. MichaelWagnerMDFACPDecember2010

More Related Content

Hospitalist Collaboration

  • 1. Coordinating Care in Hospitalist Medicine Hospitalist Executive Leadership Summit December 2, 2010 Michael Wagner, MD FACP Chief, Internal Medicine and Adult Primary Care
  • 2. 珂庄界鞄温艶鉛油安温乙稼艶姻,油珂禽油酷粥遺永 Positions Chief,InternalMedicineandAdultPrimaryCare,TuftsMedicalCenter2008 present ChiefExecutiveOfficer,EmCareInpatientServices20038 Chief,GeneralInternalMedicine,TuftsNewEnglandMedicalCenter19992003 RegionalMedicalDirector,CoveHealthcare19981999 InternalMedicineResidencyProgramDirectorandDirectorofMedicalEducation, St.MarysHospitalandUniversityofRochester19921997 Internist,NewEnglandMedicalCenter19901992 ChiefResident,DartmouthHitchcockMedicalCenter19891990 MDGeorgetownUniversitySchoolofMedicine,1986 CurrentRoles AssociateProfessorofMedicine,TuftsUniversitySchoolofMedicine ViceChair,institutionalReviewBoard,TuftsMedicalCenterand TuftsUniversity HealthSciences PhysicianAdvisor,InformationTechnologyTuftsMedicalCenter Chair,ManagedCareandQualityCommittee,TuftsMedicalCenterPhysician Organization Disclosures None MichaelWagnerMDFACPDecember2010 2
  • 3. Collaboration Goals of presentation Discuss broad concept of collaboration in hospitalist medicine Segment collaboration into functional assessment categories Discuss specific areas for collaboration and coordination Discuss specific strategies to enhance and hardwire collaboration and coordination of care into a hospitalist program MichaelWagnerMDFACPDecember2010
  • 4. Provisos Focus Day/rounding hospitalist Non-teaching environment MichaelWagnerMDFACPDecember2010
  • 5. Hospitalist as a member of the team Patient and Family Patient and Family Nursing Nursing Primary Care Physician Primary Care Physician Care management Care management Hospitalist Specialist Physician Specialist Physician Ancillary services Ancillary services Pharmacy Emergency Medicine Emergency Medicine Pharmacy Radiology Radiology Laboratory Program Coordinator Program Coordinator Laboratory Respiratory Respiratory Rehab/LT care facility Rehab/LT care facility Home Care Services Home Care Services 5 MichaelWagnerMDFACPDecember2010
  • 6. Collaboration Case Dr. Smith is a new graduate from a local residency program who recently joined your hospitalist service. He came with excellent references and interviewed very well when he was recruited. After 3 months into working, you (as the medical director of the program) perform a focused professional practice evaluation (FPPE). You perform a chart review and review the metrics that have been collected so far. He seems to be doing well and his documentation is complete and medically appropriate. Feedback from nursing is not negative. When you ask around most of the staff have met him but they say they dont know him very well. MichaelWagnerMDFACPDecember2010
  • 7. Collaboration 1st order 1st order collaboration Interactions and work involving direct care for a specific patient ED ED MD ED RN Inpatient units Case Primary RN Management Ancillary Consultants Post Hospital PCP PCP RN Episode of care MichaelWagnerMDFACPDecember2010
  • 8. Collaboration Case continued When you begin your block of shifts you pick up Dr. Smiths patients. In the process of finishing several discharges you find several inconsistencies in the medication lists between admission and the planned dc med list you have from his last note. This prompts you to talk to the patients primary nurse. I was hoping to talk with one of you hospitalist about this patients med list. Dr. Smith wasnt available and I never had the chance to talk with him the case. In fact sometimes I dont even see him. I have to page him several times in the morning just to clarify orders he has written. MichaelWagnerMDFACPDecember2010
  • 9. Collaboration - Engagement ActivelyEngaged Engagable Disengaged Activelydisengaged MichaelWagnerMDFACPDecember2010
  • 10. Collaboration 2nd order 2nd order collaboration Interactions and relationships that are created and exist between the hospitalist and other care givers Floor nursing Case management Specialty physicians ED physicians MichaelWagnerMDFACPDecember2010
  • 11. Inpatient complexity 2000 patients 1800 patients 2500 patients 15 patients 5 doctors with busy outside practices 1500 patients MichaelWagnerMDFACPDecember2010
  • 12. Reducing inpatient complexity 15patients 1doctorwithNOoutsidepractice Hospitalist Reducingcomplexityoftheinpatiententerprise Smallernumberofattendings 15patients Highervolume/attending 5doctors Lowerratioofattendings:nurse withbusyoutsidepractices MichaelWagnerMDFACPDecember2010
  • 13. Collaboration Case continued You go and seek out Dr. Smith the next time he is on and ask him to recount his typical day: I usual start in the office and start my progress notes there. I gather the vital signs and labs that have returned so far. I then go to the floor and see my patients. You know there really isnt a good place to think or write my notes so I go back to the office and finish my notes. You know it is really annoying that the nursing staff keep paging me, I think my orders are pretty clear. You know the nursing staff isnt very good here. You get the sense he is not very happy in his new role and you are not happy with his attitude. MichaelWagnerMDFACPDecember2010
  • 14. Collaboration 3rd order 3rd order collaboration Interactions and relationships that are created and exist between the hospitalist program and the other clinical departments and outside referring physicians. Emergency Department Nurse managers Case management department Primary care practices MichaelWagnerMDFACPDecember2010
  • 15. PATIENT Position Interests Condition Move the patient out of the ED EDphysician Emergent treatment Triage Disease Am I the best next physician? Hospitalist Work up completed Treatment initiation MichaelWagnerMDFACPDecember2010
  • 16. Collaboration Case continued The hospital administrator calls you to complain about the delays in transfers from the ED to the floors. He has gotten feedback from the ED that the hospitalists are taking forever to call back and get down to the ED for new admissions. He also states at the last FLOW committee the assigned hospitalist did not show up. MichaelWagnerMDFACPDecember2010
  • 17. Collaboration Best practices Recruit relaters Primary nurse face to face communication Organized daily multi-disciplinary rounds Deal with the ED conflict issue Virtually integrate with your referring PCPs Develop care expectations Leadership MichaelWagnerMDFACPDecember2010
  • 18. Develop care expectations Traditional Pneumonia CHF Chest pain Service standards Time to see patients Communication Special populations Frail elderly Warfarin Poly-pharmacy Frequent re-admissions MichaelWagnerMDFACPDecember2010
  • 19. Collaboration Hospital based physicians 1st order Verbal communication about why you want the consult or procedure done Make a point to touch base if you see consultant and discuss case face to face 2nd order Introduce yourself Interact in MD lounge Eat lunch with someone new 3rd order Participate in medical staff committees Go to medical staff meetings Discuss sources of frustrations with medical director MichaelWagnerMDFACPDecember2010
  • 20. Collaboration Power of relating 80 70 Number of consults 60 50 Dr. Specialist new Old specialist 3 40 Old specialist 2 Old specialist 1 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 Quarters MichaelWagnerMDFACPDecember2010
  • 21. Collaboration PCPs 1st order Make an attempt to call and discuss case with PCP on admission Call PCP at time of DC Write a concise and accurate discharge summary 2nd order Go to mixers for PCP staff 3rd order Get involved in IDN/ACO committees there will be PCPs driving this process and discussion MichaelWagnerMDFACPDecember2010
  • 22. Collaboration Case conclusion Dr. Smith is very appreciative of your feedback and specific suggestions on rounding with the primary nurse. The number of pages has decreased and he is feeling more comfortable. He agrees to participate in the Flow committee as well. MichaelWagnerMDFACPDecember2010
  • 23. Thehospitalists dilemma Bummer of a birthmark, Dr. Hal. MichaelWagnerMDFACPDecember2010