Hospitalists

AAFP GUIDELINES FOR INTERACTION IN "HOSPITALIST" MODELS - COMMUNICATION BETWEEN THE RECEIVING INPATIENT CARE MANAGEMENT PHYSICIAN AND THE REFERRING PRIMARY CARE PHYSICIAN 

Family physicians are participating on both sides of the new models of health care delivery, which utilize a dedicated inpatient physician (or "hospitalist") to manage the inpatient care of general adult medicine patients referred by primary care physicians in the community. The American Academy of Family Physicians (AAFP) believes that family physicians are well trained and highly qualified to serve in these roles, and that participation in such arrangements should be voluntary for both the referring physician and the patient involved.

Because "continuity of care" has been a hallmark of the specialty of family medicine, the AAFP is especially concerned about safeguarding continuity in these new models through adequate communication. The following guidelines are intended to support quality care to patients and their families, and to clarify expectations for communication between physicians participating in such systems.

(1) The overarching objective for all should be the best possible care for the patient.
(2) At the request of the family physician (or other primary care physician), the inpatient care physician who may also be a family physician) should admit and coordinate the care of all patients admitted to the hospital regardless of the admitting diagnosis or type of insurance coverage.
(3) If patients present to the emergency department (ED) and the ED physician assesses them, the ED physician should then contact the patient's family physician to determine if admission is necessary or if close follow up or outpatient work up is more appropriate.
(4) If admission is necessary, the family physician should communicate information on pre-hospital treatment, work up, co-morbidities and ongoing specialty consultations, along with family and social concerns, advanced directives, etc., to the inpatient care physician who is assuming management of the patient's care.
(5) The inpatient care physician will assess the patient at admission and determine the best course of treatment. This may include treat and release, admit for general medical management or admit for medical or surgical subspecialty care, while providing general medical oversight.
(6) During the period of hospitalization, decisions regarding care, consultation, admission, transfer and discharge should be the sole responsibility of the inpatient care physician in consultation with the patient and, as appropriate, the patient's family physician and/or family members.
(7) The inpatient care physician should be readily available to discuss the patient's medical problems and hospital course with the family and should provide timely updates to the family physician designated by the patient. Communication with the family physician is extremely important at the time of any changes in the patient's status, complications or new diagnoses (e.g. cancer).
(8) The inpatient care physician should communicate the treatment plan and follow up recommendations to the patient's family physician or the covering physician on the day of discharge. This may be best accomplished by having the discharge summary dictated and faxed to the family physician.
(9) When family physicians refer their hospitalized patients to the care of an inpatient physician, the AAFP strongly encourages them to maintain ongoing communication with the patients, their families, and the inpatient care physician throughout the hospitalization.
(10) Health care systems which utilize inpatient care management models should seek to constantly monitor and improve their processes through the use of ongoing surveys for patient and physician satisfaction with the system. Data on health care outcomes is essential to the ultimate evaluation of these models.

HOSPITALIST SYSTEMS OF INPATIENT CARE MANAGEMENT - PRINCIPLES

  • As health care systems experiment with models of inpatient care management ("hospitalist" systems), the American Academy of Family Physicians supports and encourages the following principles:
  • The opportunity to participate as a "hospitalist" in such systems must be open to all interested physicians whose education, training and current competence qualify them to serve effectively in this role.
  • The decision of who should care for a family physician's hospitalized patients should be made by the patient and his or her family doctor, in the interest of what is best for patient care (i.e., participation in hospitalist models should be voluntary).
  • In the interest of preserving continuity, patient advocacy and health care decision-making which is in concert with the patient's values, the AAFP strongly encourages the use of "generalists" for inpatient general medical management. Consultation with an intensivist or medical or surgical subspecialist does not preclude the need for the continuing, comprehensive and personal care provided by a "generalist" physician.
  • In the event that family physicians elect to refer their patients for inpatient care management, the AAFP strongly encourages them to maintain open communications with those patients and their families throughout the hospitalization, as recommended in the "AAFP Guidelines for Interaction in 'Hospitalist' Models."
  • While family physicians may elect to refer their patients for inpatient care management, the AAFP cautions that they should strongly consider the mid- and long-range implications for their practices before they relinquish hospital privileges. Such implications may include (a) difficulty being credentialed and/or paid by managed care companies for services/procedures in the ambulatory setting if one does not have hospital privileges for those same services/procedures, and/or (b) the very real possibility of being unable to successfully reapply for hospital privileges at future points of career transition, without the necessity of seeking substantial additional education and retraining.
  • The AAFP will develop ways to help support members when the opportunity to provide hospital care has been removed by their health care system or managed care organization.

(2003) (2009 COD)