Matthew Berger, MD
William Southern, MD
John Loehner, MD
Traditionally, Montefiore depended heavily on its housestaff for the majority of inpatient care. Geographically scattered clinical units, rapid growth, unpredictable shifts in patient volume, a lack of flexibility to assign patients to either the attending or housestaff services, and need to comply with a myriad of changing housestaff regulations are some of the challenges that Montefiore Medical Center's Medicine service has faced in recent years.
The current regulatory, financial and patient volume climate necessitated a multi-component inpatient Medicine service that seamlessly combined the strengths of attendings, housestaff and other providers, and fulfilled a variety of organizational needs while providing the best medical care for patients.
The strategy was to redesign the teaching attending service to include clear accountability and structure, improved staffing with electronic scheduling, increased full-time physicians and fewer moonlighters, continuity in scheduling, more education and training, an electronic evaluation system, regular quality reviews, an electronic sign-out system, and supervised sign-out rounds.
In addition, the Department of Medicine expanded the use of hospitalists and recently established a formal Section of Hospital Medicine. In the hospitalist model, newly admitted patients are "handed off" from their primary care physician to internal medicine physicians who manage their care for the duration of their stay, then transitioned back to their primary care providers after discharge. From admission to discharge, hospitalists supervise the care of inpatients, simplifying the process, improving communication and reducing the chance of medical error. The new Section builds on hospitalists' current roles—either direct care (clinician) or teaching (clinician educator)—to include a third track (clinician investigator), promoting involvement in performance improvement and generate new knowledge through research.
More than 30 hospitalist faculty members on both the east and west campuses form the core of the Section of Hospital Medicine, with a mission to provide high-quality inpatient care and medical education to residents and students, participate in continuous quality improvement, maintain patient safety on the inpatient medical service, and generate new knowledge through clinical and health services research. The hospitalist component includes quality improvement in the areas of clinical oversight, education, efficiency, and enjoys the confidence of private physicians in admitting their patients to this service.
The Section of Hospital Medicine will continue to produce and implement rigorous scholarly work such as the research conducted by its chief, Dr. William (Will) Southern (General Internal Medicine). His work explores the consequences of hospitalist strategies to reduce length of stay. Dr. Southern found that patients of teaching hospitalists have shorter lengths of stay (with no difference in mortality) than non-hospitalist teams, particularly for those hospitalized with acute cerebro-vascular accidents, sepsis, chronic heart failure, asthma, and urinary tract infections. He is currently examining the relationship between physicians' years in training and their patients' length of stay, as well as the connection between length of stay and patient outcomes.
In addition to daily inpatient care, Einstein-Montefiore hospitalist faculty provide 24/7 oversight for the physician assistants (PAs) on Montefiore’s Attending Service in both the Moses and Weiler Divisions, dedicating each morning to advise PAs on newly admitted patients, assisting in chart reviews, and answering questions.
The infusion of this oversight, which connects young, energetic, dedicated PAs with seasoned specialists who have devoted their careers to inpatient care has significantly improved the quality and organization of the private attending service. The hospitalist initiative has improved quality in a number of areas, including shorter length of stay, lower readmission rates, fewer long-stay cases, maintained continuity of care and better communication with the Montefiore Medical Group, a network of over twenty ambulatory care sites staffed by faculty and non-faculty physicians
A recent effort in which inpatient hospitalist teams used the call center to schedule follow-up appointments during the discharge planning process resulted in a significant drop in no-shows to post-discharge appointments, now less than half of the Montefiore Medical Group baseline.