“The traditional internist can no longer do that job,” said Dr. David Meltzer, chief of the University of Chicago section of hospital medicine. “They just don't have enough hospitalized patients to make it worthwhile.”
Meltzer and Dr. Gregory Ruhnke, an assistant professor with the University of Chicago section on hospital medicine, summarized their program in a Health Affairs report, but Meltzer said data on the effectiveness of the program won't be available until 2016.
“The reason why we published now is to get the idea out there,” he said. “We're still enrolling patients.”
The program's key outcome measures are self-rated health status, limitations on activities of daily living, and mortality. Its economic success will be judged by the cost of care to Medicare.
While many argue that coordinated care depends on clinical teams with nurses, nurse practitioners, physician assistants and other nonphysician professionals empowered to “practice at the top of their license,” Meltzer warns that this is not always the best way.
“I think it's an iconoclastic perspective,” Meltzer said. Team-based care, he said may add fragmentation and communication errors during patient handoffs.
Under the University of Chicago's “comprehensive-care physician model,” five doctors visit patients in the hospital in the morning, while nurses and other professionals provide noncomplex care at the physicians' clinic. One doctor is assigned afternoon rounds and weekend call. Hospitalists, meanwhile, may see patients on night rounds.
The physicians are each assigned panels of 200 patients expected to average about 10 hospital days a year. They are assisted by a clinic coordinator, registered nurse, nurse practitioner and a social worker.
Meltzer emphasized that the concept was “not in any way a repudiation of hospitalists,” but a “best of both worlds” model that combines the duties of a general internist and a hospital medicine specialist.
“Providing these physicians with a high volume of inpatients and locating their clinics in or near the hospital can allow them to offer many of the same benefits that hospitalists provide in terms of inpatient experience and physical presence and to offer the additional benefit of continuity across settings and over time,” Meltzer and Ruhnke wrote in Health Affairs.