Planning is key to successful comanagement

Working out details in advance helps avoid conflicts down the road.


Comanagement has become a mainstay of hospital medicine, and a well-executed program can be beneficial for patients, physicians, and hospitals. But success hinges on mapping out a defined strategy and maintaining open lines of communication with specialists in other disciplines, hospitalist leaders say.

“Problems with comanagement can be lumped into 3 buckets: lack of communication, mismatched expectations, and lack of clarity about roles and responsibilities,” said Arun Mohan, MD, MBA, chief medical officer for hospital medicine at physician services provider ApolloMD and an adjunct assistant professor an d hospitalist at Emory Healthcare, both in Atlanta. “You need to hammer out exactly what the relationship will look like, put it in writing, and have everyone agree to it.”

Photo by Thinkstock
Photo by Thinkstock

A formal comanagement agreement sets down important details of the relationship between the physicians caring for a patient—such as the hospitalist's role in admission and discharge—that can become areas of conflict if not spelled out in advance.

“Our goal is for no decision making to be needed when a patient shows up at our door,” said Allen Liles Jr., MD, director of the hospital medicine program at UNC Hospitals in Chapel Hill, N.C., which has ongoing comanagement agreements with orthopedic surgery and oncology, 2 of the most common areas for comanagement. “We want to make care as seamless as possible and minimize any debate about who should take care of the patient.”

Establishing a program

Setting up a comanagement program often requires several meetings among hospitalists, specialists, and others on the care team, said Sylvia McKean, MD, FACP, associate professor of medicine at Harvard Medical School and senior hospitalist at Brigham and Women's Hospital in Boston.

“Initially, the leaders of the hospitalist and specialist services get together to chat about roles and, if there is a meeting of the minds, the next step is to include nurses and other stakeholders,” she said. “Subsequent meetings should clarify details, such as who gets called on nights and weekends and who should be called when specific issues arise.”

For example, both sides must be clear about who will make decisions regarding anticoagulation after surgery and thromboembolic risk, she said. And surgeons must be very explicit about any preferred regimen for anticoagulation.

“What you want to avoid is the person who is implementing a decision feeling uncomfortable with the decision-making process,” said Dr. McKean.

At UNC Hospitals, a formal, written agreement outlines a clear division of responsibilities between hospital medicine and orthopedic surgery. The arrangement primarily involves caring for hip fracture patients, said Dr. Liles.

The orthopedic surgeons schedule operating room time, order perioperative antibiotics, and determine weight-bearing status, he said. In addition to medical management, hospitalists are responsible for admission documentation, initial orders, preoperative evaluation, and postoperative care, including venous thromboembolism prophylaxis.

A separate agreement with the oncology service specifies that hospitalists will handle all medical management, except writing orders for chemotherapy, necessary fluids, and associated therapy.

At Emory University Hospital, an agreement with orthopedic surgery specifies that problems directly related to surgery, such as pain, complications, or the need for further intervention, are in the surgeon's domain, said Dr. Mohan. Hospitalists handle medical management issues such as perioperative risk stratification, electrolyte disorders, and discharge planning.

The initial agreement should also include a venue for broaching any issues or disagreements that may arise, and his team stays in close communication with orthopedic surgeons and oncologists, added Dr. Liles. Cancer patient comanagement often requires an even higher level of communication, he said, due to the severity of patients' illness and complexity of chemotherapy regimens.

Handling conflicts

Hospitalists are under constant pressure to balance quality of care with length of stay, but specialists tend to work under different incentive structures. That often sets up a conflict around the timing of discharge, hospitalists said.

“We try to have ongoing conversations with specialists and administrators about comanaged cases,” said Dr. Mohan. “Facilitating an efficient discharge is part of the value that hospitalists bring to the relationship, and we have to discuss those issues very carefully with our specialist colleagues.”

For example, if a cancer patient is admitted to the medical ward for sepsis or infection, the hematologist-oncologist might recommend a complete workup or a prolonged course of chemotherapy, whereas the hospitalist might begin discharge planning after the patient is stable, said Efren Manjarrez, MD, ACP Member, interim chief of hospital medicine at the University of Miami Health System in Florida.

“Hospitalists' major metric is length of stay and cost per case, but hematologists-oncologists are often under less pressure to get a patient out, because they bill on a daily basis,” said Dr. Manjarrez. “We have to have a continuing dialogue about setting goals and expectations.”

Oncology comanagement can present particular challenges due to the nature of patients' relationship with their oncologists and the severity of their illness, which often causes psychological and economic distress, according to Dr. McKean. “The patient relies so much on their oncologist that it may seem to diminish the role of the hospitalist,” she said.

In such cases, it's best for the oncologist to take the lead in delivering news about the patient's condition, she said, and for the hospitalist to play a supportive role during interactions with patients and families.

“Patients often feel abandoned if the oncologist doesn't see them after a serious diagnosis,” said Dr. McKean. “The best thing for the hospitalist to do is reassure them that she is in constant communication with the oncologist and that no decisions will be made without the specialist's input—bidirectional attending communication also promotes better decision making.”

When conflicts arise, have an escalation plan in place in case things can't be resolved between attending physicians, recommended Dr. Liles.

“We encourage attending-to-attending communication as a first step, but if they can't work it out, it is elevated to physician service leaders,” he said. “If they can't solve it, then I meet with the specialty department or division chief to evaluate what happened and provide feedback to the physicians involved.”

Communication

Often, conflicts can be avoided simply by the way the hospitalist approaches conversations with the specialist, said Dr. McKean. It's important to establish a collegial rather than a confrontational tone.

“Approach the specialist in a nonthreatening manner and a spirit of open, honest communication,” she said. Good questions might include, “How can I provide better care?,” “What do you think is in the best interests of the patient?” or “Can you clarify the patient's prognosis?”

Asking open-ended questions, such as “What can I tell the patient about the effects of chemotherapy, in terms of side effects, likelihood of quality of life, and steps to prolong life?,” helps the hospitalist clarify the goals of care, said Dr. McKean. It also ensures that both physicians are communicating a consistent message to the patient.

Communicating via chart notes rather than face to face is a guaranteed path to failure, noted Dr. Liles.

“One physician might want something done a certain way, while a different physician will countermand that in the chart,” he said. “They end up giving conflicting orders to nursing and, worse, potentially communicating conflicting opinions and goals of care to the patient.”

Dr. Liles avoids that scenario by clearly communicating upfront who will take the lead on specific types of clinical decisions and who will relay orders and opinions to staff and patients. Similarly, there should be no uncertainty about which team is responsible for each step in the care process.

“You should never assume the other group is doing something. It has to be spelled out in the agreement and discussed,” he said. “With hip fracture patients, for example, we know certain things are critical, such as the timing of surgery, appropriate prophylaxis, and timing of the Foley catheter removal. We are very specific about which team is responsible for each of those steps.”

At ApolloMD, Dr. Mohan encourages hospitalists to establish early how the 2 teams will communicate over the course of a day. Typically, there is a structured meeting in the morning supplemented by more informal conversations throughout the day to ensure everyone keeps abreast of new developments.

“Patients want to know that we are all playing on the same team and that we all talk to each other,” said Dr. Mohan. “If a patient is uncertain about whether something they've communicated to one physician has been shared with everyone else, it leads to a general distrust of the system.”