Hospitalists as Extensivists

I had heard something about this, but couldn’t find it. A colleague here finally tracked it down. The story is about Caremore, a California based organization. Hospitalists generally are internal medicine doctors based in the hospital; but here they care for frail elderly members at high risk of hospital admission or readmission in skilled nursing facilities and in outpatient settings both before and after a hospital stay. Here’s an article on the AHRQ Innovations Exchange website.

An excerpt:

A 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.

The results:

The program reduced readmission rates and has led to low LOS (lengths of stay) and to below-average inpatient utilization in a high-acuity population.

Is this worth considering more broadly? What are the conditions for success? I welcome your thoughts.

Paul Levy is the President and CEO of Beth Israel Deconess Medical Center in Boston. Paul recently became the focus of much media attention when he decided to publish infection rates at his hospital, despite the fact that under Massachusetts law he is not yet required to do so. For the past three years he has blogged about his experiences in an online journal, Running a Hospital, one of the few blogs we know of maintained by a senior hospital executive.

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Stephen J. Motew, MDCheap BimatoprostLaceyNatePaul Tarini Recent comment authors
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Stephen J. Motew, MD
Stephen J. Motew, MD

Now that the ‘outside’ primary care docs have been alleviated of their inpatient duties by the development of hospitalist programs (which I fully support), they want someone to do the transition care as well? Why don’t we just create an entirely new specialty of SNFists? I have no doubt that care for this patient segment would improve. What we are now seeing is the Achille’s heel of segmented care, lack of continuity. In ‘the old days’ the primary care doc was the best advocate for their patient guiding both their inpatient and outpatient care thus continuity issues were such not… Read more »

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I think this approach makes a lot of sense for elderly patients with multiple co-morbidities, especially for those who are also in a long term care facility. Nursing homes are often quick to send patients to the hospital as the path of least resistance. To the extent that this use of “extensivists” can mitigate that, it’s a good thing.
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I’m thrilled to hear that you post your infection rates, and it sounds like this transitional care program is another way that we can bring the US health care system in line with the rest of the world. International hospitals post their infection rates and offer apartment styled suites for transitional care and the result is that patients get the care they need and the quality they crave, plus the below-average utilization rate is great for the hospital. I think it should be considered more broadly, and certainly not just for Medicare as Medicare continues to cut reimbursement rates. This… Read more »


should these be employees of the hospital or of the healthplan/risk taker? It get scomplicated trying to devise a reimbursement scheme to pay someone to take money out of their own pocket. If we want to treat people outpatient so they don’t go back tot he hospital then they should be paid to do that.
This, while sounding like a great idea, looks very similar to the slippery slope HMOs feel down.
If they had a medical home would this be redundent to that care?

Paul Tarini
Paul Tarini

I wonder how this compares to the Transitional Care Model developed at UPenn: http://www.transitionalcare.info/ ?