How an Orthopedic Hospitalist Program Can Provide Value to Your Hospital
By now, you are likely familiar with the term "hospitalist"—a physician that is dedicated to a hospital-based practice. Chances are you even have a hospitalist program at your facility. While the concept itself is not new, this model has only relatively recently expanded into the specialty of orthopedics—with numerous benefits realized by all constituents.
The Birth of the Orthopedic Hospitalist
Providing call coverage for a hospital emergency department has long been considered a part of the fabric of the specialty physician’s life. In the last few decades, however, this aspect of the orthopedist’s job has come under fire. For a variety of reasons, busy local orthopedists often no longer have the time, desire, or expertise to provide quality, timely emergent care for their hospital’s emergency department. Hospital leaders have responded to this lack of coverage in a variety of ways, including adding stipends, using locum tenens, designing formal agreements for call coverage with community physicians, and even employing physicians. One of the more recent solutions to this challenge has been gaining traction over the last 15 years—the orthopedic hospitalist.
First coming into prominence in the early 2000s, the orthopedic hospitalist model arose in a similar manner to the traditional internal medicine hospitalist. The increasing complexity of inpatient medicine in the mid-1990s led to a small group of internists becoming inpatient medicine specialists. The term “hospitalist” was first coined in 1996 by Drs. Lee Goldman and Robert Wachter, and since then, the hospitalist model for internal medicine has grown rapidly. It is estimated that today there are more than 50,000 practicing hospitalists, making this new field substantially larger than any subspecialty of internal medicine. Approximately 75 percent of U.S. hospitals, including all highly ranked academic medical centers, now have some form of a hospitalist program.1
Similar to the traditional hospitalist, the orthopedic hospitalist movement started as local orthopedists found they did not have the time or expertise to provide regular emergency coverage to their hospitals. Additionally, many hospitals found either a shortage of orthopedists on staff or that those who had taken call were aging out of their call panels. The net effect was hospitals trying to find physicians willing to cover their musculoskeletal emergencies. Since approximately 30 percent of emergency visits are orthopedic in nature, having this coverage is essential to a well-functioning emergency department. Hospitals began using independently contracted physicians to provide this coverage in the early 2000s. Firms that were initially formed to provide obstetric hospitalist services were soon creating orthopedic hospitalist programs at the request of their hospital clients. As call coverage has continued to become a significant issue for specialists, a handful of companies—including Surgical Colleagues—emerged to provide the orthopedic hospitalist model to hospitals.
The Neurosurgical Hospitalist Model
Surgical Colleagues is a company committed solely to providing solutions in specialty surgical services. They are the first practice in the country to apply this model to neurosurgery, covering emergency department visits as well as admitted patients. The group recruits and manages a full complement of permanent, full-time neurosurgeons who serve as a dedicated hospital-based practice, providing 24/7/365 coverage along with a follow-up clinic. This broadened scope of care supports an elective component that augments specialty coverage for hospitals that want/need to improve patient access, and the integration of emergent and elective cases has demonstrated tighter physician alignment, new revenues, lower costs and recruiting advantages.
In this model, Surgical Colleagues takes the burden off the hospital and the physician group for all aspects of the management of the practice—recruiting and human resources, assumption of malpractice risk, scheduling and ensuring call coverage, provision of clinical best practices, utilization management, and billing and collections. Surgical Colleagues neurosurgeons are expected to practice team medicine, become active members of the medical staff and community and to participate in performance improvement activities.
What Does an Orthopedic Hospitalist Do?
Initially, the orthopedic hospitalist began simply as a qualified body to cover empty call days. The role has evolved similarly to the medical hospitalist to become a subspecialty of orthopedic surgery. The modern orthopedic hospitalist is an inpatient orthopedic specialist, devoting his or her time and knowledge to the fractures, injuries, and other issues that present to emergency departments as well as among the inpatient floors.
An orthopedic hospitalist can address all acute care orthopedic needs. Some of the most commonly treated injuries include:
Hip fractures in the elderly
Wrist fractures from typical falls
Pediatric forearm fractures from sports or playground accidents
Diabetic infections of the extremities
Depending on the capability of the hospital, the orthopedic hospitalist may also be a full-fledged traumatologist, taking care of the multiply injured in concert with the trauma team. In most places, however, orthopedic hospitalists can be considered Community Orthopedic Traumatologists.2
Not only do these physicians choose to specialize in community trauma and urgent care orthopedics, but they also become well-versed in the issues that affect the hospital, both financially and clinically. As bundled payments have become more prevalent in the payment world, orthopedic hospitalists have become their institution’s experts on cost-effective orthopedic care. The current emphasis on the patient’s perception of care has also led orthopedic hospitalists to push for patient satisfaction and quality innovations. From best practices, as simple as how to most effectively interview and comfort an injured patient, to the complex structuring of geriatric fracture programs, orthopedic hospitalists have become the go-to experts for hospital administrations in the best care models for the musculoskeletal patient.
The Orthopedic Hospitalist Provides Value to All Constituents
The primary challenge for the hospital is often the lack of call coverage for the orthopedic service line. Not only does the hospitalist model provide this basic level of service, but in fact, it goes above and beyond. Quality metrics are not only followed, but they are valued as a sign of excellence. Working with administration to improve the urgent care of orthopedics in the facility is a necessary part of the job. The hospital will gain a partner whose very livelihood depends on the satisfaction of the hospital, so motivation is assured. The orthopedic hospitalist will support medical staff committees and will participate in important performance improvement initiatives of the hospital. The orthopedic hospitalist service also has flexibility—they are available much more readily than there moved private orthopedist (who is stuck with 50 patients in the office), they can fill in gaps in the4 The Future of Specialty Hospital Medicine OR schedule to prevent 2nd and 3rd shift OR cases and costs, and they improve response times, resulting in reduced length of stay and enhanced patient satisfaction. In addition to the orthopedic hospitalist model, oftentimes when hospital communities are challenged to provide enough orthopedic coverage due to physician shortages, etc., Surgical Colleagues implements an outpatient elective model. The beauty of this comprehensive model is the inpatient/outpatient collaboration that occurs among providers and the reduction in outmigration by retaining patients in the community. The outpatient elective physician focuses on clinic-based care, while benefiting from the orthopedic hospitalist managing the care of the patient in the hospital. Finally, hospitals that offer an orthopedic hospitalist program among their services enjoy increased credibility in the community, enhancing their reputation and ultimately increasing market share.
The Private Orthopedist on Staff
Many primarily elective orthopedic surgeons are uncomfortable with trauma. They focus their educational efforts on their specialty, not on the latest implants, techniques, and clinical pathways for hip fractures. This discomfort can often impact outcomes and satisfaction, not just of the patient, but for the staff and the physician. Additionally, taking away the burden of call and the aftershocks seen with clinic follow-up leaves more room in the orthopedist’s schedule for the patients he or she desires to take care of. This increase in elective revenue more than compensates for the loss of emergency department revenue. In fact, this “lost” revenue from the emergency department is frequently found to be inconsequential compared to the significant increase in elective revenue from opening up the schedule.
The Medical and Nursing Staff
Those who interact with the on-call orthopedists the most—the emergency department and hospital medicine program—are often the most welcoming of the orthopedic hospitalist program. Emergency providers welcome a trauma specialist who can respond quickly to their patients. The hospitalist service enjoys the protocol-driven, consistent, less-variable care provided by a cohesive orthopedic hospitalist team. The nursing staff also better understands the pre- and post-op care patterns due to established protocols and consistency among the team.
Patients and their families benefit greatly from the orthopedic hospitalist model, enjoying real-time personal attention to their orthopedic needs, from the emergency department visit through post-op and follow-up care in a dedicated orthopedic clinic. Patient compliance and satisfaction are enhanced by the personal attention they receive, and repeat emergency department visits for follow-up care are reduced in this model.
The Orthopedic Hospitalist
These orthopedists have chosen to subspecialize in acute care orthopedics. By linking the hospital administration and the private medical staff, they provide a key service in the care of the orthopedic population for their hospitals. Additionally, they often have more control over their schedule and can take time off more frequently and consistently than a private practice orthopedist, so they can pursue other interests. And finally, they can focus their “on” time by caring for patients rather than the hassles of running a business, as the back-office functions like marketing, human resources, and finance are taken care of for them.
What Types of Hospitals Benefit Most from an Orthopedic Hospitalist Model?
As outlined above, the orthopedic hospitalist model provides a unique and adaptable resource for a variety of hospital settings. The program can be tailored to fit each institution’s unique needs, be it augmentation of an existing service line or establishment of a new program.
1 Robert M. Wachter, M.D., and Lee Goldman, M.D., M.P.H., N Engl J Med 2016; 375:1009-1011September 15, 2016.
2 Bray TJ. The Community Orthopaedic Traumatologist. Journal of Orthopaedic Trauma 2011Jan; 25(1):1–4.