Notes from the Hotspotters: Where Everybody Knows Your Name

Originally posted November 18, 2014

By Eliza Hutchinson

“There was one time when I wasn’t here for seven months in a row,” “Pam” told me.
 
I sat with Pam in her third floor hospital room – the floor on which she always stays when admitted to the inpatient medicine service – as nurses, doctors, and janitors poked their heads in the door to say friendly hellos and “Nice to see you again, Pam!” A dining facility staff member entered with a tray, letting Pam know, “I brought you the usual, Pam. I missed you!” Pam smiled and joked with the parade of staff members as I pondered this oddly happy reunion. 
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Scholarship in Medical School: Skating to Where the Puck Will Be

By Rachel K. Wolfson, MD, and Vineet M. Arora, MD, MAPP

When we were in medical school, medical students could opt to participate in traditional research at some point, generally the summer between the first two years of medical school, or during the fourth year. There were no required scholarly projects, semi-annual progress reports, or specific concentrations or tracks for students to choose. Some of our classmates took an extra year to do research, but there was no year-off forum, quarterly newsletter announcing student dissemination of scholarly work, or faculty with protected time to promote student research.

Times have changed. We co-direct the University of Chicago Pritzker School of Medicine Scholarship and Discovery program, in which students can pursue scholarly work in a broad array of areas, including non-traditional research such as global health, medical education, community health, and quality and safety. We are not alone…

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Posted in Future of AMCs, Medical Education, Research | 2 Comments

A Petition for Prevention

Originally published October 21, 2014

By Natalie Wilcox

During my surgical subspecialty rotation, I spent one week on the Limb Salvage service. As a branch of plastic surgery, this area of work requires extensive training and academic dedication. Yet a portion of the practice involves a task that, from a distance, appears primitive: amputation of unsalvageable limbs. Although most of my time on this service involved smaller procedures such as debriding old wounds down to viable tissue, the most unforgettable moments of that experience were spent watching surgeons meticulously remove patients’ legs and close up the wounds.

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Posted in Commentary, Medical Education | 1 Comment

Interprofessional Education Should Include Researchers Too

By Michael J. Friedlander, PhD

The article in the most recent issue of the AAMC’s Analysis in Brief, “Interprofessional Educational Opportunities and Medical Students’ Understanding of the Collaborative Care of Patients,” by Drs. Grbic, Caulfield, and Matthew, provides an interesting and informative look at interprofessional education for medical students interacting with many health professions.

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Posted in Commentary, Medical Education, Research | 1 Comment

Notes from the #Hotspotters: Identifying Our Personal Resources

By Tricia Olaes

Originally published November 4, 2014

The 2014 Hotspotting Mini-Grant Project gives health professional students an unprecedented hands-on opportunity to practice an innovative model of care delivery called hotspotting. Hotspotters identify health care super-utilizers —  people who are admitted to the hospital multiple times a year, frequently for avoidable complications of chronic conditions, and who often have social barriers to adhering to their care plan. The hotspotters proactively bring additional attention, follow-up, resources and care to these patients in their homes and communities to help keep them out of the hospital. Student hotspotters will share their experiences here twice a month for the rest of this year in “Notes from the Hotspotters.”

I excitedly opened my new email account inbox and saw the first list of potential patients to recruit. All were just names on an automated Excel spreadsheet, and I wondered which one of these individuals, strangers to me now, would be our hotspotting team’s first recruited patient. Our teamwork had already served us well, and here we were, finally beginning.

Interprofessional teamwork seems to be all the buzz these days. As a third-year medical student, I had interacted mostly with nurses on wards and sparingly had direct contact with pharmacists, social workers, physical therapists and other non-physician providers. I knew of them but knew only a few personally. I understood we all help patients in slightly different manners, but it seemed to me like we all individually provided little bits of services as needed like several input cords that disappeared into the black box of the health care system and produced an eventual effect on the patient. Don’t get me wrong — that mostly works, and I have always been amazed with how individual parts of a system can work in concert to amount to something greater than the mere sum of its parts. But such a system seems to yield predominantly one-way (provider to patient) communication, where a patient might receive differing advice from various their health care providers. Thus, when I learned about the opportunity to participate in the hotspotting project, in which interprofessional student teams practice care coordination for super-utilizers – some of the neediest patients in our health system – I was admittedly a bit daunted but also intrigued, curious, and excited to explore this novel approach to patient care. 
 
As one of the first ten student teams in the nation to participate in the hotspotting cohort under the guidance of Dr. Jeffery Brenner – the family medicine physician who first adapted the concept of hotspotting for use in health care – of Camden Coalition; Primary Care Progress; and the Association of American Medical Colleges (AAMC); my team of four fellow students — one in social work, one in nursing, one in pharmacy and one in medical school — was excited to learn about the change we could incite and hotspotting’s approach to providing strong coordinated care not just to help but to empower particular patients. Our initial fuel was our curiosity and yearning to be a part of something wonderfully qualitative and patient centered, and we were impressed and additionally inspired by the passion Dr. Brenner and Primary Care Progress exuded. They helped inspire us and showed us we could do more than yearn; with our willingness to embark on this project, we too, as students, could be agents of real change in our community.
 
But how?  We were at point A (no patients) and wanted to be at Point B (with a patient panel). We had to recruit patients. But how? Wandering the halls of the hospital was an option, but we wanted to be more efficient and structured than that. We needed to obtain a list of patients to potentially recruit.  We tried what I now call “manual data mining,” which is about as fun as it sounds. Initially, we relied on staff from a particular practice to suggest patients, then manually looked them up via EHR, but many of the leads didn’t quite fit our criteria.
 
Each team member then contacted various faculty at their schools. Our physician mentor contacted staff from other ranks within the Virginia Commonwealth University’s Health System (VCUHS).  We found enthusiastic experienced individuals willing to serve as advisors to help us with our project. We arranged a large meeting for students and faculty to introduce themselves and their current roles in the health system. We voiced our thoughts and shared our vision to select patients who fit certain criteria: more than two inpatient admissions in the last 12 months, primary care providers from certain practices within VCUHS. We shared our efforts and challenges thus far.
 
One of the nursing school faculty involved in a home-visiting program mentioned they received daily lists of admitted patients who are potential candidates for home visits. My team wondered aloud if a similar list could be fashioned for us, too. Another faculty member suggested that VCUHS’ Office of Health Innovation might be of help.  Established in 2011 to assist in the development of health reform implementation activities and innovation strategies through research and projects, they had data and computer know-how to possibly help us. I felt a flicker of hope. A few days later, we learned it was possible, but to receive protected health information, we needed secure computers and special email accounts that only health system employees have. After a flurry of calls, emails, and inquiries to our institution’s health information team and an explanation about our project, we received secure email accounts and thus that glorious email with a list of potential patient recruits.
 
The work that went into achieving that first step demonstrated the power and utility of interprofessional teamwork. A team of diverse individuals with varying ranges of knowledge shared a goal and vision, which in itself is a rare opportunity. I believe we are fortunate to have that magic mix of motivated individuals – both students and our extended advisory team – who not only share a vision but are also excited and willing to contribute their knowledge, time, and ideas. Our hotspotting team spent countless hours trailblazing a process for our workflow. Starting wasn’t easy and certainly wasn’t a straight line from Point A to Point B, but as a student team, we are constantly in flux, actively communicating with each other, our patients, and our extended advisory team.
 
We started a few moths ago as a group of students who barely knew each other with a mere vision and idea, and now we are in the active work of hotspotting, partnering with our panel of five patients identified as super-utilizers with various social and medical needs that we are helping address. As I continue practicing hotspotting, I know there will be more issues to tackle. Though I might not have a clear-cut plan of action to immediately answer situations, I’m comfortable with the challenges that arise. Just as important as the bond we form with our patients are the bonds we form with each other as a team. Interdisciplinary teamwork is becoming an integral part of patient-centered care, and I will be fortunate to work with team members who are just as enthusiastic, genuine, and hardworking as the team members I am working with now.

Olaes TriciaTricia Olaes is a Los Angeles native and a fourth-year medical student at Virginia Commonwealth University. She looks forward to matching into a family medicine residency in Spring 2015 and working with the underserved.

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Interprofessional Teams Learn PCMH Principles, Improve Diabetes Care at LSU

Medical, nursing, pharmacy, and social work students were brought together in an innovative interprofessional training program at Louisiana State University School of Medicine to deliver diabetes care in a patient-centered medical home model. The research project benefited both patients and students. “Students rarely get longitudinal experiences, which limits their ability to develop skills, to learn about one another, and to develop relationships with patients,” says primary author Mary T. Coleman. Guided by PCMH principles including physician-directed teams, enhanced provider access outside of office visits, and coordinated, integrated care, students provided care to a high-risk population of uncontrolled diabetic patients receiving primary care at the internal medicine residency training site. This innovative initiative earned LSU honors in the AAMC’s Clinical Care Innovation Challenge. Coleman sat down with Wing of Zock editor Jennifer Salopek to explain more. A full abstract of the project can be found here.

 

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A Day in the Life of a Young Hospitalist

Originally published October 23, 2014

By Joshua Allen-Dicker, MD, MPH

I am a young hospitalist who is 16 months into my role at an urban academic medical center. Unlike many of my more senior colleagues who found their way to hospital medicine by circumstance, luck, or as a second career path, I have been planning my career in hospital medicine since the beginning of my residency training. The things that drew me to hospital medicine as a trainee—its emphasis on problem-solving, strong communication skills, teamwork and leadership—are still what excite me each day as a young hospitalist. When friends, family and patients ask me about my job, I often tell them about these passions and describe what a “day in the life” looks like for me. While no two days are ever exactly the same in hospital medicine, the following is an account of a Wednesday I had last month.

I arrive at the large office I share with 9 other hospitalists. I log in to my computer and learn about the patients who were admitted to the hospital the night before, and any important events that occurred for the patients I cared for the day prior. With the help of our electronic medical record, I organize the list of fifteen patients I will be caring for, and review important laboratory, radiology and procedural reports. Three of my colleagues have also arrived and are similarly preparing for their day, an activity we call pre-rounding. As we work, we engage in an informal discussion of challenging cases—patients who may have a mystery illness, or a known illness that has been resistant to treatment. By reviewing cases, we learn from each other and are better prepared to start our day.

8:15AM

I begin seeing patients, who are all located on the same medical unit. By co-locating the physicians and the patients they care for, something we call geographic admitting, our hospitalist group has allowed for the creation of care teams. These care teams work together to ensure safe care during and after each patient’s hospital stay. My team today consists of:

  • Several registered nurses
  • Several nurse practitioners
  • Two physicians
  • A nurse manager
  • A social worker
  • A case manager.

I go from room to room, first visiting patients who may be especially sick, and then those who may be ready to leave the hospital that day. One patient admitted for treatment of a serious skin infection called cellulitis tells me about the fevers and chills she had overnight. I examine her, we discuss laboratory results and vital signs, and then she and I agree on a treatment plan together.

Another patient recovering from pneumonia excitedly tells me that he was able to walk down the hallway without any difficulty breathing. He knows that we have already prepared his discharge prescriptions and have made an appointment for him with his primary care doctor, and asks when he can be discharged.

9AM

Hospitalists in my group spend about half of our weeks on teams with resident physicians, and the other half on teams with nurse practitioners—today I am working with a team of nurse practitioners. I meet with them to discuss important medical events and review urgent issues that should be accomplished this morning, including facilitating the antibiotic change and discharge for the two patients I saw earlier.

I return to seeing patients, stopping in between rooms to write notes, consider important diagnostic dilemmas, coordinate with other physicians, and contact key family members.

At multidisciplinary rounds, the entire care team meets to discuss each patient on our unit. We review the reason the patient is in the hospital and how our team can best navigate the unique complexities of each situation to get the patient to their ideal health state. In addition to identifying a plan for medical treatment (e.g. new medications, changes to old medications, wound care, therapy/exercise), we often work directly with families, outpatient providers and insurance companies to ensure each person’s necessary outpatient support structure can be put into place. For half of the patients on the floor we actually bring the entire multidisciplinary team to the patient’s bedside all at once (instead of seeing them each individually after rounds).

12PM

As the work of hospitalists is so integral to day-to-day operations of hospitals and medical schools, many of us are also leaders in the areas of medical education, quality improvement, hospital administration and more. My colleague helps direct the internal medicine residency program. Another is the medical director for a hospital unit. Today is the monthly meeting of our Department’s Morbidity and Mortality Committee, which I co-chair. Our goal is to mitigate morbidity and reduce mortality in the hospital. We review patient cases, identify areas for health system improvement, and initiate projects to help providers give the highest quality of care possible.

1PM

I spend the afternoon working with my hospitalized patients. I do not have clinic hours at an off-site office, nor do I stray very far from the floor I work on—attributes that appeal to patients, families and hospital administrators. One very ill patient is being evaluated by several medical and surgical teams, who each have expertise in different aspects of the patient’s illness and may approach the same problem in different ways. I spend time speaking with each group of doctors, and then with the patient, to come up with the most appropriate treatment plan.

Another patient has fever, confusion and an unknown diagnosis. I review their chart, confirm their history with family members, and consult the literature to determine the necessary testing and treatment.

A third patient being treated for a new blood clot asks me about a blood test they saw online. We discuss the patient’s clinical progress, current evidence-based guidelines, and that occasionally some testing may be more harmful than helpful. We both agree that continuing the current treatment plan makes the most sense.

I remain in regular contact with the rest of my team. One nurse practitioner tells me about a patient who has developed new shortness of breath and is getting an x-ray and electrocardiogram. Another tells me about how they fielded a call from a concerned family member. Based on new information, we update our clinical plan. Over the last 15 years, it has become generally acknowledged that the provision of safe care depends on effective team work. No single physician can safely navigate the health system for all of their patients without strong skills in communication and help from a diverse group of providers. I rely on my team each day to help me fulfill my professional mission.

For patients who are being discharged, we contact their primary care physician via secure email, telephone, or fax. If we can provide outpatient physicians with the necessary information, we can all work together to keep the patient healthy and out of the hospital.

5PM

I attend a seminar hosted by several hospitalists about a new role our group will play helping surgeons and anesthesiologists to ensure patient safety before, during and after surgery—something known as perioperative care. It is exciting to see my colleagues take on new leadership roles within the hospital. I return to my office to complete my remaining work, including making sure the overnight physician is aware of important test results that may come back during the night. I pack up and head home to relax and prepare for the next day’s challenges.

As an early-career physician, hospital medicine offers me the opportunity for daily improvement as a compassionate clinician (I love working with patients) and leader (I love working with my teams). As hospitalists are key players in many health care operations, my job also allows me to explore my academic and clinical interests in improving care and developing the infrastructure for tomorrow’s health system. It is exciting to be part of the world’s fastest growing medical specialty!

Joshua Allen-Dicker is a hospitalist at Beth Israel Deaconess Medical Center and Instructor in Medicine at Harvard Medical School, both in Boston, Massachusetts.  He wrote the above post while working as a hospitalist at Mount Sinai Hospital in New York, New York.  He received his medical degree at New York University School of Medicine and obtained his Master of Public Health from Harvard School of Public Health. He completed both his internship and residency in internal medicine at Beth Israel Deaconess Medical Center.  Josh sits on the Society of Hospital Medicine’s Physicians in Training Committee, is a compassionate health provider and quality improvement / systems enthusiast.

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Health Wonk Review: The Election Week Edition

imagesBy Jennifer J. Salopek

The frost is on the pumpkin; the Republicans have maintained control of the House and gained control of the Senate; and it’s time for another edition of Health Wonk Review. Surprisingly, few submissions this week actually dealt with the midterm elections, so we’ll lead off with the one that does. Joe Paduda deeply into his crystal ball to author his post on Managed Care Matters, “The GOP Wins the Senate: Implications for the ACA.” Paduda acknowledges the likelihood of efforts to revise or repeal the Affordable Care Act, and tees up some likely—and not-so-likely—targets. He writes:

While some will argue that a GOP Congress will push for repeal, I’m not so sure. With about 10 million more Americans covered under PPACA, that’s a lot of voters that might be upset if their coverage was yanked out from under them.  There are any number of provisions that are quite popular – covering children to 26, eliminating lifetime dollar caps on expenses, no-cost preventive care, no medical underwriting come to mind. Any move to go back to the bad old days would result in a lot of angry insureds.

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