Care transitions between hospitals, nursing homes, and home are a vulnerable time for patients. Given the increasing elderly population and the shortage of primary care physicians with training in geriatrics or nursing home care, there is a growing need to identify organizational systems to optimize physician practice, enhance quality of care and increase educational opportunities in nursing homes.
Purpose:
There is evidence to suggest that greater physician presence in nursing homes may impact the care delivered. We describe an innovative staffing model where hospitalist physicians rotate between acute and sub-acute care.
Description:
Our healthcare system includes a 400-bed acute care hospital and a 112-bed sub-acute/long-term care facility. The organizational structure consists of hospitalist physicians who rotate between: 1) the acute inpatient medical service with teaching and supervisory responsibilities of internal medicine residents from various affiliated medicine programs, and 2) the sub-acute service with direct patient care and supervisory teaching roles for psychiatry residents on general medicine rotations and physician assistant students. The sub-acute service is also staffed with a portion of full-time clinicians to provide continuity of care. There is a range of FTE for these physicians with additional time for teaching and quality improvement responsibilities. Close partnership and regular communication exist between leaders of the acute and sub-acute service.
The organizational model has been in effect for 18 months, with resultant growth in quality improvement (QI), system redesign, and educational programming. QI projects include admissions process redesign, improving handoff processes from inpatient to sub-acute care, standardizing shift-handoff processes, and participation in a national study in medication reconciliation. The educational programs have also expanded, establishing the sub-acute service as a training site for general medicine rotations for psychiatry residents and physician assistant students, a clinical site for transitions-in-care internal medicine resident curricula and monthly academic conferences. There has been high satisfaction with a multidisciplinary staff (n = 24 [response rate 85.7%], scale 1 [very negatively] to 5 [very positively] with mean reported) in terms of impact on clinical skills and knowledge (4.4), interprofessional relationships (4.0), development of education opportunities (4.6) and overall satisfaction with the rotation model (4.1).
Conclusions:
This innovative organizational staffing bridges the spectrum of healthcare delivery between acute and sub-acute care. This model has been received with high satisfaction from multidisciplinary staff. This unique organizational structure offers the opportunity to optimize care transitions and increase quality improvement and educational opportunities in sub-acute care and nursing homes.