SummaryA Medicare Advantage plan expanded the role of its employed physician hospitalists, using them to care for frail elderly members at high risk of hospital admission or readmission in the skilled nursing facility and the outpatient setting both before and after a hospital stay. Known as "extensivists" and supported by sophisticated information technology systems, these physicians generally split their time between the hospital, where they round on a small group of members each day, and an outpatient clinic, where they see recently discharged and other members at high risk of admission. Once or twice a week, these physicians also see members in skilled nursing facilities. The program reduced readmission rates and has led to lower length of stay and below-average inpatient utilization in a high-acuity population.Moderate: The evidence consists of comparisons of key metrics (average LOS, readmission rates, and inpatient days per 1,000 members) to state or national benchmarks, along with trends in readmission rates over the last 18 months.
Date First Implemented1995
CareMore began using employed physician hospitalists in the mid-1990s, after which their role expanded to include the treatment of patients outside the hospital.
Patient PopulationThe program serves high-acuity members of a Medicare Advantage plan, many of whom are frail elders suffering from diabetes (which affects 34 percent of members) and/or heart, lung, and kidney disease, including end-stage renal disease.
Problem AddressedThe traditional hospitalist role focuses on controlling inpatient costs by having dedicated physicians manage the hospital stay. Although such programs have often been successful in reducing hospital length of stay (LOS), they do little to address the uncoordinated and fragmented nature of care that typically exists after discharge to the home or a skilled nursing facility (SNF). As a result, recently discharged patients—particularly frail elders—often end up being readmitted to the hospital.
- Limited focus of traditional hospitalist programs: Traditional hospitalist programs focus on managing the inpatient stay, with little or no effort made to ensure that patients receive needed care and services after discharge. Most hospitalists have large caseloads, forcing them to round on at least 20 and sometimes 40 or more patients per day, leaving little or no time to talk with frail, elderly patients and their family members to understand (let alone coordinate) postdischarge needs.
- Leading to frequent readmissions: Medicare beneficiaries often end up being readmitted to the hospital, with roughly one in five (19.6 percent) of those enrolled in the traditional fee-for-service Medicare program being readmitted within 30 days of their initial discharge, and more than one in three (34 percent) being readmitted within 90 days.1 These readmissions often occur because of inadequate self-management support and lack of ongoing monitoring and followup after discharge.2
Description of the Innovative ActivityA Medicare Advantage plan expanded the role of its employed hospitalists, using them to continue following and caring for recently discharged members until their condition stabilizes, as well as other members at high risk of a hospital admission. Known as "extensivists" and supported by sophisticated information technology (IT) systems, these physicians generally split their time between the hospital, where they round on a small group of members each day, and an outpatient clinic, where they see recently discharged members and other members at high risk of an admission. Once or twice a week, these physicians also see members in SNFs. Key elements of the program are described below:
- Daily inpatient rounds on small caseload: A group of 35 CareMore-employed physicians across California, Nevada, and Arizona conduct rounds on hospitalized members on most days, with each typically seeing 6 to 8 patients over a half-day period. This small caseload allows the physician to spend time talking with patients and family members to develop an understanding of their needs and the issues and challenges they will face after discharge. These physicians also spend time coordinating care with specialists and keeping primary care physicians updated regarding their patient's situation. Based on this interaction, the extensivist works with a case manager by telephone to arrange for any of a variety of other CareMore resources and support to assist the patient/family after discharge, including (but not limited to) the following:
- A social service "SWAT" team: CareMore has an intervention team consisting of physicians, social workers, case managers, and behavioral health professionals who support the patient/family in accessing needed social services (e.g., financial assistance, Medicaid coverage for board and care) and in dealing with any challenges they may face. For example, the team may call in Adult Protective Services to deal with children who may pose a threat to the member.
- Home team: As needed, a team that includes a physician and nurse practitioner visits members in their homes after discharge. This team can provide medical care for homebound patients, assess the home environment (e.g., available caregiver support, risk of falling), and arrange for any needed environmental changes (e.g., installing grab bars in showers, removing tripping hazards) and support services.
- Nurse practitioner–led clinics: CareMore operates disease-specific clinics in its 20 care centers where cross-trained nurse practitioners provide self-management support and ongoing care management for diabetes, wounds, hypertension, congestive heart failure, pulmonary disease, coronary artery disease, and end-stage renal disease. (This program is described elsewhere in the Health Care Innovations Exchange; a link to this writeup can be found in the Associated Profiles section.)
- Periodic SNF rounds: Each extensivist spends a portion of 1 or 2 days each week visiting members who have left the hospital to go to a SNF. These SNF rounds operate much the same as the inpatient rounds, with the extensivist focused on understanding the patient/family situation and arranging for access to other CareMore programs that can help support the patient and family after discharge.
- Clinic for recently discharged members: Twice a week, each extensivist spends roughly half the day in an outpatient care center seeing the same set of members he/she had been following in the hospital or SNF. The frequency and duration of these visits will vary by individual, with some members being seen several times a week on an ongoing basis, while others are seen only once or twice before they are deemed to be stable enough to return to the care of their primary care physician (PCP). For a small minority (roughly 2 percent) of very sick members, the extensivist will take over from the PCP on a permanent basis, essentially becoming the member's regular physician.
- Clinic for those at risk of hospitalization: Although the vast majority of members seen by the extensivists in the care centers have recently been in a hospital or SNF, some patients may be referred to the clinic-based extensivists through other CareMore providers (e.g., PCP, nurse practitioner); typically these members are very frail and face a high risk of an acute episode. For example, members who have recently experienced a fall may be referred to the extensivist for an evaluation and recommendations on interventions to prevent future falls. Members who are candidates for surgery may be referred to the extensivist for a preoperative evaluation to confirm the individual's ability to handle the surgery and determine his or her likely needs after discharge.
- Support from sophisticated IT systems: CareMore maintains an electronic medical record (EMR) that provides the extensivists and other providers (e.g., nurse practitioners, home team) with secure, Internet-based access to a member's longitudinal medical record in any setting, including the hospital, SNF, and outpatient centers. Various applications allow the extensivist to easily understand all the conditions the member faces and to track and coordinate his or her care, including laboratory values, specialists seen, and medications/medication compliance. The system also provides point-of-care decision support and assigns a green, yellow, or red status to each discharged member based on his or her risk of readmission. This system helps the extensivist to determine the frequency of needed follow up visits and support.
- Regular communication with PCP: With the support of case managers, extensivists keep members' PCPs abreast of what is happening with their patients. In urgent cases (e.g., if a patient requires immediate care), the extensivist will typically call the PCP to alert him/her of the situation. For more routine matters, each PCP receives updates via his or her preferred mode of contact, such as by telephone or fax. Case managers typically take responsibility for faxing relevant reports to PCPs through CareMore's EMR, and for sending a copy of the hospital discharge report.
Context of the InnovationCareMore operates network-model Medicare Advantage plans and special needs plans for seniors in Southern California (High Desert, Los Angeles, and Orange County), Northern California (Modesto), Arizona (Tucson), and Nevada (Las Vegas). CareMore has 44,000 members, with membership increasing by 30 percent over the past year. CareMore began as a single staff-model medical group, which later expanded to include a variety of medical groups, individual physician practices, independent practice associations, and physician pods that contract with the CareMore health plans. To participate in CareMore plans, network physicians must agree to collaborate with CareMore on its many programs designed to serve frail elders, including 20 CareMore outpatient centers. The extensivist program began in the mid-1990s after CareMore leaders found that the traditional hospitalist program did little to ensure that discharged patients receive needed support and coordinated care after leaving the hospital or SNF. After using several different types of contract physicians as hospitalists (including pulmonologists, cardiologists, and internists), CareMore leaders decided to bring the program in-house using employed physicians and to expand the traditional hospitalist role by having these physicians follow the same patients after discharge.
ResultsThe program reduced readmission rates and has led to low LOS and to below-average inpatient utilization in a high-acuity population.
Moderate: The evidence consists of comparisons of key metrics (average LOS, readmission rates, and inpatient days per 1,000 members) to state or national benchmarks, along with trends in readmission rates over the last 18 months.
- Low LOS: CareMore's average LOS is 3.2 days, well below the roughly 5.6-day average in Medicare fee for service3 and the 4.5-day average achieved by traditional hospitalist programs in California.
- Low readmission rate: Information provided in December 2011, indicates that for the year of 2011, CareMore's 30-day readmission rate (excluding end-stage renal disease patients, who often require frequent hospitalizations) averaged 13.8 percent, well below the nearly 19.6 percent average in Medicare fee for service.1
- Below-average inpatient utilization in a high-acuity population: Information provided in December 2011 indicates that for the year of 2011, CareMore averaged 1,053 inpatient days per 1,000 Medicare Advantage members. This includes all members, such as end-stage renal disease members who often require frequent hospitalizations. CareMore's member population tends to be sicker than that served by the typical Medicare Advantage plan, with an average acuity of 1.3. (The average Medicare beneficiary has an acuity of 1.0.)
Planning and Development ProcessKey steps in the planning and development process included the following:
- Launching program with core group: CareMore launched the program with a small, core group of physicians who knew how to do the work involved in being an extensivist.
- Expanding program through training of new extensivists: New extensivists undergo an approximately 6-month process to learn how to perform the role. During this time, the physicians go on rounds with the nurse practitioners, SWAT team, and home visit team to learn about these CareMore programs to support recently discharged patients. The physicians also receive training on the IT support systems and shadow case managers and experienced extensivists in the hospital and SNFs. Over time, new extensivists begin conducting their own rounds and seeing patients in the outpatient center, with an experienced extensivist overseeing them until they become completely acculturated to and comfortable with the role.
Resources Used and Skills Needed
- Staffing: CareMore employs 35 medical extensivists who typically see 7 to 8 patients in the hospital each morning and then see an additional 7 to 8 patients in the outpatient center on most afternoons. As noted, once or twice a week each extensivist visits members in SNFs rather than seeing members in the care center. Extensivists need not have special training in geriatric medicine; rather, the key is that the physician feel comfortable with the notion of following patients across settings.
- Costs: Program costs consist primarily of compensation for the extensivists, who earn a base salary of $200,000 per year, plus a bonus that ranges between 5 and 65 percent of salary depending on seniority and performance on various metrics, including (but not limited to) 30-day readmission rates, productivity in the outpatient clinic, and compliance with discharge summary dictations. Although hard data are not available, these costs are likely more than offset by the savings generated through reductions in LOS and readmissions.
The program is funded internally by CareMore.
Tools and Other ResourcesA description of CareMore's nurse practitioner-led outpatient clinics can be found in the associated Innovations Exchange profile, which can be accessed through a link in the Related profiles section.
Getting Started with This Innovation
- Determine appropriate population to be served: Given limited resources, extensivists should be deployed to serve those patients where they can make the biggest difference. While CareMore uses extensivists with all hospitalized members (because its membership consists primarily of frail elders with above-average acuity), other health plans and organizations may want to limit their use to patients sick enough to benefit from extensivist services. The definition of the eligible population is also important to the financial viability of the program, as higher acuity members bring in more funding from Medicare.
- Consider splitting into two teams: An organization using extensivists with both Medicare and commercial populations may want to create two separate extensivist teams—one to serve frail elders and a second to serve commercial enrollees, as the needs of these populations can be quite different.
- Invest in training: Some physicians find it difficult to transition from a traditional hospitalist role to that of an extensivist, as seeing patients outside of the hospital and considering postdischarge issues remain unfamiliar to them. Significant training may be necessary to ensure a successful transition.
Sustaining This Innovation
- Keep caseloads low: Extensivists may burn out and will not be able to perform their jobs well if they have to see too many patients on a daily basis.
- Keep PCPs informed (and monitor performance in doing so): PCPs may rebel against the program if they do not receive regular, timely updates on their patients from the extensivist and/or support staff. To avoid this problem, regularly monitor whether PCPs receive updates as they have requested, including copies of preliminary notes and discharge summaries, periodic phone updates, and the like.
- Monitor, report on, and create incentives for extensivist performance: Measure individual extensivist performance with respect to LOS and readmissions for members in their caseload. Periodically provide such information to extensivists, along with comparisons of their performance with that of peers, and consider creating financial incentives to reward extensivists for strong performance on key indicators.
Contact the InnovatorHenry Do, MD
Senior Medical Officer
12900 Park Plaza Drive, Suite 150
Cerritos, CA 90703
Innovator DisclosuresDr. Do has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.
Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-28. [PubMed]
2 Transforming care at the bedside how-to guide: creating an ideal transition home for patients with heart failure. The Institute for Healthcare Improvement and the Robert Wood Johnson Foundation; October 2007.
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Original publication: October 13, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: December 18, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: November 15, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.