I. Problem / Challenge.
Consultation is an essential part of providing healthcare to complex patients with multiple comorbidities and to patients whose treatment involves a team of subspecialists. Defining the relationship (that is, consultation versus co-management) between different physicians is important for coding, billing, and coordinated delivery of healthcare to inpatients.
Traditional medical consultation is a service provided by physicians, whose advice or opinion regarding a specific problem is requested by another physician or provider. The key word in defining the consult is that the hospitalist performs medical consultation upon request of the referring physician and gives an assessment and recommendation after evaluating the patient. The hospitalist might follow the patient once or until the end of patient’s hospitalization.
Co-management is a service provided by physicians who manage a particular condition. According to Society of Hospital Medicine (SHM) survey data from 2005, 85% of hospitalist groups are involved in some kind of co-management. Co-management requires clearly defined roles, shared responsibility, authority and accountability for care of a hospitalized patient, and collaborative professional relationships, typically between hospitalists and surgeons and other specialties. When co-managing inpatients, hospitalists are typically more involved and take greater responsibility to make sure that medical conditions are actively and proactively managed. While previous studies have shown inconsistent benefits of co-management programs, a recent large scale analysis of a surgical co-management hospitalist program showed improvement in medical complications, length of stay, 30-day readmissions, number of consultants, and cost of care.
When delivering medical consults or co-management, hospitalists frequently manage diabetes, congestive heart failure, hypertension, and deep venous thrombosis (DVT). Consultation and co-management includes delivering preoperative care, managing perioperative medical complications, postpartum complications, procedures and complications of surgery (orthopedic, neurosurgery, ear, nose and throat [ENT], urology, etc.), caring for hospitalized adolescents, and providing recommending further consultation with medical subspecialties (cardiology, gastroenterology, oncology/hematology, dermatology) and neuropsychiatric specialties.
II. Identify the Goal Behavior.
Hospitalist programs are diverse in their organization, structure, and leadership. Thus, the success of consultation and co-management varies from program to program and continues to evolve. In most instances, the hospitalist is a general internist or pediatrician. However, in some instances, the hospitalist may be a specialist such as a nephrologist, neurologist, obstetrician/gynecologist, geriatrician, or infectious disease specialist.
In order for consultation to be successful, it is important to adhere to basic principles of defining the question to be addressed, establishing the urgency of consultation, analyzing primary data, being succinct, being specific, providing contingency plans, defining co-management, teaching with tact, emphasizing direct communication, and providing daily follow-up.
In order for co-management to be a success, it is important to first elucidate what needs to be fixed:
Are hospitalists the right resource to address the problem?
Are they staffed appropriately to do it?
If the answers are positive, it is important to establish a clear understanding and clarify expectations with the surgeons and other specialists who call on hospitalists to manage their hospitalized patients’ medical care needs. Clear understanding is established by creating a formal co-management agreement before jumping into co-management practice. Otherwise, inappropriate utilization of the hospital medicine service may become a problem.In the case of co-management of surgical patients, it is important to spell out clearly that the patients’ surgeons manage treatments related to surgery and hospitalists manage treatments related to the patients’ medical conditions.
III. Describe a Step-by-Step approach/method to this problem.
Establishing a successful consult service
1. Establish consult service goals
2. Communicate vision and mission of the program in order to develop buy-in.
3. Train hospitalists to provide exceptional consultative skills:
a. Promptness: timely response to a request for consultation.
b. Effective communication:
Clarify reason for consult.
c. Written report of clinical findings and recommendations:
Thorough assessment of the patient.
Consistency in management recommendations.
Outlined contingency plans.
d. Appropriate follow-up, until the day of discharge if needed.
Establishing a successful co-management service (adapted from SHM)
1. Identify obstacles and challenges.
a. Who are the stakeholders?
Hospital – leadership, operational departments, etc.
Surgeons and specialists.
Other physicians – emergency, primary care, etc.
Other care professionals – nurses, case managers.
Trainees – residents.
b. What are the goals of the co-management program? Identify goals in the context of each stakeholder, understand the potential conflicting goals, and determine the metrics that can be tracked to evaluate the success or failure of the program:
Length of stay reduction.
Process and outcome quality improvement.
Physician and staff satisfaction.
Improved clinical outcomes.
c. What are the potential concerns of implementing the co-management program?
Clinical – appropriate training, concordance of treatment standards between hospitalists and surgeons, availability of surgeons/specialists and hospitalists to each other.
Legal – clinical risks may increase vulnerability to malpractice.
Service – capacity to staff and support the co-management service.
Stakeholder satisfaction – financial viability (does length of stay decrease?), patient satisfaction, nursing awareness of who to call, hospitalist and surgeon/specialist relationship, physician autonomy and meaningful work.
2. Plan and document a clear written service agreement or memorandum of understanding.
Clearly define roles.
Establish shared responsibility.
Define mutual goals and expectations.
Define accountability for the care of hospitalized patients (including what happens on nights and weekends.)
Establish collaborative professional relationships, communication channels and how conflicts will be addressed.
3. Identify a champion who will be engaged and supportive.
Hospitalist – acts as a partner with the co-management team to determine roles and responsibilities.
Surgeon / Specialist – according to the SHM task force, a surgeon / specialist is a necessary champion for a successful co-management program.
Hospital Administration – especially helpful for financial support.
4. Address financial issues.
Revenue – who bills what, periodic review of revenue.
Expenses – in relation to patient volume, coverage, mid-level usage, and workload.
Deficit funding – staffing expenses usually exceed billing revenue.
5. Measure performance.
Volume and case mix of patients.
Length of stay.
Hospital utilization and cost of care.
Provider / professional satisfaction.
In-hospital morbidity and mortality rates.
Quality / patient safety metrics.
IV. Common Pitfalls.
One of the main pitfalls is jumping into co-management without clearly identifying obstacles and challenges and without clearly defined service agreement. Failure to clearly define most common obstacles and/or challenges may result in:
Disagreement on how to treat patients.
Inability to adequately measure performance and service.
V. National Standards, Core Indicators and Quality Measures.
Effective January 1 2010, Centers for Medicare and Medicaid Services (CMS) eliminated the use of all consultation current procedural terminology (CPT) codes, including inpatient codes (99251-99255), and office outpatient codes (99241-99245). Instead of consultation codes, providers are instructed to bill:
Initial hospital care (99221-99223).
Initial nursing facility fee (99304-99306),
Initial office visits (99201-99205) as applicable,
Documentation requirements for consultations are no longer applicable. Instead, hospitalists only need to meet the evaluation and management (E / M) documentation requirements for the initial visit code as applicable. Hospitalists no longer need to name the requesting provider or provide a written consultation report (unless when medically appropriate). For medical co-management of surgical or specialty patients, hospitalists bill an initial visit code and subsequent hospital care codes.
VI. What's the Evidence?
Siegal, EM. “Just because you can, doesn’t mean that you should: A call for the rational application of hospitalist co-management”. J Hosp Med. vol. 3. 2008. pp. 398-402.
Auerbach, AD, Wachter, RM, Cheng, HQ, Maselli, J, McDermott, M, Vittinghoff, E, Burger, MS. “Co-management of surgical patients between neurosurgeons and hospitalists”. Arch Intern Med. vol. 170. 2010. pp. 2004-2010.
Salerno, SM. “Modified ten commandments for effective consultations”. Arch Intern Med. vol. 167. 2007. pp. 271-275.
Rohatgi, N, Loftus, P, Grujic, O, Cullen, M, Hopkins, J, Ahuja, N. “Surgical co-management by hospitalists improves patient outcomes: A propensity score analysis”. Ann Surg. 2016.
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