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									    Hospitalist Scheduling and
Work Expectations to Achieve a
  Return on Investment Model

    Hospitalist Management Resources, LLC
                             Martin B. Buser
                              MPH, FACHE, Partner
                            Roger A. Heroux
                            MHA, PhD, CHE, Partner
                                    (719) 331-7119
Presentation Objectives
   Assess needs of Hospital
   Evaluate expectations, concerns and
    issues of Medical Staff
   Develop a Hospitalist Program that is
    economically viable and meets needs of
    Hospital and Medical Staff
   Develop a sustainable model with
    business plan and ROI

                                       NAIP March 2003
Reasons Hospitalist Programs Fail
  -- ER Panel
  -- Cost Reduction
  -- Marketing
  -- Recruitment
  -- Training & Retention
  -- Leadership
  -- Clerical and Clinical Support
                                     NAIP March 2003
Reasons Hospitalist Programs Fail
  -- Resistance
  -- Burn-out
  -- Focus
  -- $ Subsidy
  -- Champion Syndrome
  -- Support Systems
  -- Data/Feedback Information
  -- Aligned Incentives
  -- ROI                         NAIP March 2003
Defining the Goals

What is the motivation?
• Define the Problem
• ED Call Panel?
• Primary Care Physicians?
• Other?
  •Managed Care
  •Market Strategy
• Establish baseline data
                                    NAIP March 2003
Staffing driven by following:
                               STAFFING MODELS
 1.   Hospital Needs
      a)   In-house coverage
      b)   Unassigned patients from ED
      c)   Assigned patients
      d)   Coordination needs with case
           management, discharge planning,
      e)   Post-acute care needs
                                        NAIP March 2003
Staffing driven by following:

2.   Medical Staff/Medical Group Needs
      a)   Increase productivity of Group
      b)   Number of capitated lives
      c)   Relief from call schedules
      d)   Need for consults
      e)   Partial coverage needs
              nights & weekends

                                            NAIP March 2003
General Guidelines
   Address the following before developing a
    specific schedule and FTE requirements:
       What does the practice want to accomplish?
          24/7 coverage?
          Only day, night, weekend or holiday coverage?

                                                     NAIP March 2003
General Guidelines
    Know your community:
         Who   are your referral sources?
         Who is your competition?
         Who else hospitalizes patients at your
         How are ED admissions handled?
         What is the acceptance of primary care
         What are policies of major insurance
          companies and HMOs?
         Any limitations (insurance coverage, privileges)
          on your ability to accept all patients referred to
          your hospital?
                                                     NAIP March 2003
General Guidelines
   Will the Hospitalists have duties other than
    seeing patients?
       Teaching?
       Out-patient rotations?
       Doing administrative work?
       Responsibility for case management?
       Hospital committee meetings (P&T, UR, QA)?
       Seasonal issues in your community?
            Seasonal influx of seniors?
            Increase in tourists?
            Flu season impact

                                                     NAIP March 2003
General Guidelines
   What are your scheduling preferences?
       10- or 12-hour shifts?
       5- or 14-day continuous shifts?
       How will salaries be determined?
          Guaranteed?

          Fee-for-service?

          Criteria for bonuses?

                                           NAIP March 2003
Staffing Coverage Models

 Weekends
 Onsite

 Nights & Weekends

 Daytime/Onsite 12 Hours

 24 Hour In-house

                            NAIP March 2003
    Staffing Models

1. Rotational* Model for a focused service
     (i.e., ED, IPA PCPs)
2. Rotational* Model for all services
3. Dedicated model without support
4. Dedicated model with full support
*Physicians rotate inpatient/outpatient responsibilities

                                                           NAIP March 2003
Hospitalist Staffing Requirements
   Each site will have different workforce needs
   Should allow for enough time to see each
    patient 2x/day
   Should also take into consideration enough time
    to do the following:
       Appropriate admissions/discharges
       Review ancillary data
       Meet with family members
       Communicate with primary care doctors
       Communicate with referring doctors
       Paperwork

                                                NAIP March 2003
Hospitalist Staffing for ED
Unassigned and Private Referrals
   Ratio of 1 Hospitalist: 15 Patients
   Additional Staff:
   Case Manager/ Clinical Coordinator
   Clerical Coordinator
   Equipped Office
   Software to track patients
   Performance Feedback

                                          NAIP March 2003
 Hospitalist Staffing for
Managed Care At-Risk Programs
      Ratio of 1 Hospitalist: 15 Patients
      Additional Staff:
      Case Manager(s)
      PA
      Clerical Coordinator
      ED Intervention
      Disease Management
      Outreach Education to members and PCPs
      Post Acute Integration
      And More!                           NAIP March 2003
Hospitalist Scheduling
   Overview:
       No one standard schedule for all hospitalists
       More after hours and weekend work than traditional
       Some Hospitalists programs may need after-hours
        help from non-Hospitalists
       Scheduling by using existing scheduling paradigms:
            Traditional primary-care practice
            Emergency Department scheduling model
            Managed Care Model

                                                     NAIP March 2003
Traditional Scheduling -
Rounder Model
  Approach similar to how PCPs might be
  Will impact efficiency of office practice
   depending on how post-call scheduling
   is handled
  Challenge of weekends

  PCP takes call on weekend for group as
   well as for Hospitalists’ patients

                                       NAIP March 2003
“Round Robin” Scheduling
   Full-time schedule - on every day
   Admit every 3rd day
   Keep patients entire course of stay
   Creates critical mass of the practice
   Sign off to partners like private practice
   Negative: lifestyle and burnout issues

                                            NAIP March 2003
Shift Work
   Analogous to ED Physician Scheduling with
    following characteristics:
      Predictable lifestyle

      Some developed by ED physicians and/or
      Shifts allowing for random scheduling of
       doctors creates continuity of care issues
      Shift Work approach should incorporate
       administrative rounds to minimize continuity
       of care issues
                                               NAIP March 2003
Block Scheduling
    Hospitalist works many days in a row, then off
     for number of days
    Blocks should be as long as possible to
     maximize continuity of care
    Shift-based scheduling can be arranged into
     block time if a given doctor works shifts on
     many consecutive days

                                             NAIP March 2003
Night-time Hospitalist
    Increased presence of doctor in hospital is benefit of
     Hospitalist Practice
    Facilitates ED admissions, consults and availability
     for in-house emergencies
    Challenge of providing night-time coverage is one of
    Need to justify value-added service to Hospital
     Medical Groups or Staff
    Assess value of night-Hospitalist on a cost-of-care
         May lower cost of care by amount that justifies subsidy
          Hospitalist group is paid -- making up night doctors’ salary

                                                                 NAIP March 2003
Staffing Ratios
Patient Census : Physician

           15                     Rounder
           10                     Dedicated
                                  Dedicated with
           0                      Full Support
            Rounder   Dedicated
                      with Full

                                         NAIP March 2003
Results of Various Staffing Models

Admit Rate/1000 Seniors

           150                          Rounder
  1000     100                          Dedicated
                                        Dedicated with
            0                           Full Support
               Low           High
             Hospital $    Hospital $
            Investment    Investment

                                                NAIP March 2003
Understand Your Economic
     Model to Predict:
   Volumes
   Payer Mix
   Staffing Requirements
   Scheduling Plan
   Systems to operate efficiently
   Productivity-based Compensation Program
   Hospital’s pay-back (ROI)

                                      NAIP March 2003
  Reimbursement Options

• Capitation with Risk Pool

• Case Rate with Risk Pool

• Fee for Service

• Fee for Service with a Hospital Supplement

                                      NAIP March 2003
Why is all of this important?
   Be Clear
   Be Prepared
   Know the expectations
   Know your next steps
   Have a Game Plan!!
   Have a Business Plan!!
   “Structure should follow Strategy”

                                         NAIP March 2003
   Recruit locally, regionally and nationally:
       Classified ads in publications
       Direct mailings
       Conferences
   Contacting/visiting residency programs
   Assess interest from local medical staff
   Retain recruiting firm
       Contingency basis
       Exclusive contract

                                                  NAIP March 2003
Program Implementation
   Program Roll Out
   Communication Systems
   Feedback
   Implementation of a “Fourth Generation

                                        NAIP March 2003
Medical Staff
Communication Techniques
• Voluntary
• Communicate benefits and options
• Protocols to keep PCP’s in loop
• Discuss sensitive areas up front
• Strong support infrastructure
• Data systems to track trends

                                     NAIP March 2003
Example of Fourth Generation
Hospitalist Program

• Dedicated Hospitalist 24/7
• Full alignment with hospital, medical
• Private Practice with proper physician
  compensation/incentive programs
• Essentials of Hospitalist program

                                      NAIP March 2003
Example of Fourth Generation
Hospitalist Programs (continued)

 • Full support systems--clerical and
   clinical support
 • Daily rounding
 • Financial management system
 • Software Tracking systems
 • Satisfaction surveys
 • Internet linked to other groups to gain
   best of practice opportunities

                                        NAIP March 2003
Hospitalist Directed Patient Care
            Acute Patient Care
            Hospitalist Physician
     On-site Hospitalist Support Team
        (Case Manager, Care Coordinator/Clerical)

         On-site Medical Director


         Benchmarking for Best Practices

                                                    NAIP March 2003
  Essentials of a Successful Hospitalist Program

                       Hospitalist            Enhanced
                        Training            Communication

                                                   Medical Center
Operations                                         Orientation &

  Hospitalist’s        Essentials                Quality
  Coordination                                 Measurements

        of Sensitive
                                                       NAIP March 2003
Develop an Information System
that defines:

• Who is the patient?

• What did you do for them?

• Did they need what you did for them?

• Did you achieve your goals?

                                  NAIP March 2003
Key Objectives for
an Information System
•Tracks Patients

•Communicate with PCP

• Benchmark Clinical Practices

• Billing & Claims Adjudication

• Quality & Financial Outcomes

• Improve Hospitalist Productivity

• Comparison with other Hospitalist sites
Examples of Feedback
and ROI Analysis

                       NAIP March 2003
 Future of the Hospitalist Specialty

• Today: 5,000             Ten years: 18,000
 Demand: 10,000
• Studies (more needed!) show higher value
hospital care provided by hospitalists than by outpatient
•Effective Support System (a.k.a. 4th Generation models) will
overcome potential flaws in the original hospitalist models.
• Effective hospitalist programs will be win (patient), win
(hospital), win (nurses), win (PCP) and win (Payers).

•Long-term success will depend on ability to prove their
worth and show a return on investment (Quality, Service & $)
                                                     NAIP March 2003

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