Background: Prolonged hospitalizations of patients who are medically ready for discharge are highly prevalent in the current acute care environment.1 Patients who remain in the hospital beyond resolution of their acute medical needs often have high medical, social and psychiatric complexity and are poorly served remaining in an environment that is not designed for their needs. In our large academic medical center, the care of these patients is also complicated by the number of providers rotating through teams.

Purpose: Implement a new physician staffing model to improve the continuity of care for patients with prolonged hospitalizations.

Description: Prior to our redesign, patients with prolonged hospitalizations were primarily cared for on general medical teams of our Hospitalist service. As part of a prior test of change, we had one small team staffed by an independent advanced practice provider (APP) that cared specifically for this population of patients. Provider scheduling on all teams was done in our group’s standard fashion, which does not specifically prioritize continuity. We chose to tailor our new team design to geriatric and medically complex patients with prolonged hospitalizations. Parallel work at our institution to improve the care of patients with prolonged hospitalization in the setting of substance use disorder was already in process. Through discussions with hospital medicine physicians, nursing, care management, social work, subspecialty physicians and leadership, we identified key barriers and opportunities as noted in the accompanying Figure. In January 2023, we established two Enhanced Continuity (EC) teams dedicated to the care of patients who are medically ready for discharge but with major barriers to discharge. EC teams are staffed by physicians and have a higher target census than other teams. Patients are seen for full formal visits twice weekly in accordance with our Medical Staff bylaws with additional visits for new concerns and social support. Weekend coverage for both teams is provided by one physician. Day shifts are nine hours, rather than our typical twelve-hour days and the schedule prioritizes weekday continuity. In general, each team has two dedicated hospitalists assigned for two months at a time. The hours saved by shortened shifts and reduced weekend coverage allowed for the addition of a noon-8pm admitter shift that supports the general medical teams. At our planned assessment of the EC pilot, the feedback was highly favorable. Our team has identified the following advantages to the change: improved continuity with patients with perceived benefits to quality of care, better teamwork, perception that additional admission coverage maintained an even workload for general medical teams, and improved physician wellness through schedule regularity and the opportunity to form relationships with patients over time.

Conclusions: We were able to implement a new team structure to optimize provider continuity in the care of patients with prolonged hospitalizations who do not have ongoing acute care needs. This care model was well-received by our physicians who highlighted benefits to patients, families and the care team. We plan to complete a formal assessment of the impact of this change in the coming year.

IMAGE 1: Figure. Diagram outlining the project aim, opportunities and barriers to change as well as the strategies we employed in developing our new service.