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Am Fam Physician. 1999;60(2):402-404

to the editor: We are writing to present our approach to structuring a hospitalist system with the hope that it may benefit other family physicians who see these changes on the horizon.

Although the hospitalist movement is still small, it has been heavily publicized in medical journals and keenly watched by an increasing number of health care providers. Hospital administrators, who have an eye on cost-effectiveness of care, length of hospital stay, patient satisfaction and competition for contracts, are very interested in the concept. Payors, particularly health maintenance organizations, see the hospitalist movement as an opportunity to increase efficiency, assure accessibility of physicians and address issues of timeliness.

At the same time, family physicians are seeing increased demands with more complex inpatient care and packed outpatient schedules. Physicians want to ensure that their patients receive good continuity and quality of care; however, many physicians are reluctant to give up the long-established relationships with their patients and the expertise of inpatient medicine by “abandoning” the care of these patients to other health care providers.

Physicians who work in the outpatient clinic of our hospital have wrestled with some of these issues. In response, we developed a set of goals that includes continuity and cost-effectiveness of both inpatient and outpatient care; availability and timeliness of care; coordination of care; relative manpower resources; and quality issues (communication, competency, patient satisfaction and documentation). We also included any physicians who were interested in using the system and, as long as the issue of quality was adequately satisfied, did not require participation.

Our system combines the manpower of several smaller clinics with physicians who rotate through an inpatient service. Admissions are accepted throughout the day, while admissions at night continue to be handled by the patient's primary care clinic. Because we emphasize primary care, the whole spectrum of inpatient admissions is covered, from nursery to hospice care. Thus far, our inpatient service has been well accepted by the physicians, patients and hospital staff, and we are now developing a system to ensure continuous monitoring.

Early observations indicate that length of stay has decreased, care is timely and physicians are more accessible. Such benefits have elicited many positive responses from patients and their families. Our family physicians and the receiving inpatient service colleagues stress that they work as a team, and at discharge, patients are sent directly back to “their” primary care physician. This system appears to be working; some physicians suggest that it is more important for the inpatients to have continuity of care than to have the more piecemeal cross-coverage that often exists with call groups.

Communication between the inpatient physician and the patient's primary care physician is the most significant concern. This communication occurs routinely at the times of admission and discharge; however, more effort is needed to convey significant or unanticipated changes in the patient's status or challenges in communicating with the patient's family.

We believe that the hospitalist movement is an extension of the general crisis in health care in the United States. And, like all crises, it promotes discussion that hopefully will lead to new opportunities for improving patient care.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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