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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
                               www.HMRLLC.com
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
           STOP:
Reasons Hospitalist Programs Fail
Expectations
  -- ER Panel
  -- Cost Reduction
  -- Marketing
Execution
  -- Recruitment
  -- Training & Retention
  -- Leadership
  -- Clerical and Clinical Support
                                     NAIP March 2003
           STOP:
Reasons Hospitalist Programs Fail
Evolution
  -- Resistance
  -- Burn-out
  -- Focus
  -- $ Subsidy
  -- Champion Syndrome
 Evaluation
  -- Support Systems
  -- Data/Feedback Information
  -- Aligned Incentives
  -- ROI                         NAIP March 2003
Defining the Goals
                             FOUNDATION


What is the motivation?
• Define the Problem
• ED Call Panel?
• Primary Care Physicians?
• Other?
  •Education
  •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,
           etc.
      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
          hospital?
         How are ED admissions handled?
         What is the acceptance of primary care
          groups?
         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
        practices
       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
   scheduled
  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
    model
   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
       companies
      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
Coverage
    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
     economics
    Need to justify value-added service to Hospital
     Medical Groups or Staff
    Assess value of night-Hospitalist on a cost-of-care
     basis
         May lower cost of care by amount that justifies subsidy
          Hospitalist group is paid -- making up night doctors’ salary
          shortfall.


                                                                 NAIP March 2003
Staffing Ratios
Patient Census : Physician

           25
           20
           15                     Rounder
Patients
           10                     Dedicated
           5
                                  Dedicated with
           0                      Full Support
            Rounder   Dedicated
                      with Full
                       Support



                                         NAIP March 2003
Results of Various Staffing Models

Admit Rate/1000 Seniors

           250
           200
           150                          Rounder
 Admits/
  1000     100                          Dedicated
           50
                                        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
Recruitment
   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
    Program”




                                        NAIP March 2003
Medical Staff
Communication Techniques
                             STRATEGY
• 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
  groups.
• Private Practice with proper physician
  compensation/incentive programs
• Essentials of Hospitalist program
  implemented

                                      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

                   Supportive
                  Infrastructure


         Benchmarking for Best Practices


                                                    NAIP March 2003
  Essentials of a Successful Hospitalist Program

       Recruit
                       Hospitalist            Enhanced
      Qualified
                        Training            Communication
      Physicians


                                                   Medical Center
Operations                                         Orientation &
                                                     Training

                       Hospitalist
  Hospitalist’s        Essentials                Quality
  Coordination                                 Measurements



        Management
                                     Information
        of Sensitive
                                       Systems
           Issues
                                                       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
PCPs.
•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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