Patients' primary doctor no longer oversees their in-hospital care

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

Most people who are hospitalized are quick to ask, "When can I go home?" The answer to that question is quite a bit different today than 20 years ago or 10 years ago.

For help understanding what is changing about hospitalizations, I'm speaking with Dr. Timothy Creamer. He's an assistant professor of medicine at Upstate, and he started the hospitalist program at the Community campus in 2001.

Welcome to "The Informed Patient," Dr. Creamer.

Timothy Creamer, MD: Thanks for having me.

Host Amber Smith: Hospital stays are different today than a couple decades ago, so I'm looking forward to you walking us through some of the changes and the reasons for those changes.

One thing people may notice is, if they have a primary care doctor and they're hospitalized, their primary care doctor is not the one who takes care of them. It's a hospitalist like yourself, right?

Timothy Creamer, MD: That's correct. Medicine has expanded greatly over the past 30 years, and especially with regard to the availability of different types of medications and care, and what's happened is that because of that, being a primary care physician focuses your time. I was a primary care physician in Fabius for 25 years, and so I understand that dynamic of taking care of people and then driving in and seeing people in the evening.

The other problem was that as a primary care physician, your focus was in the office, and you weren't always available to the patient for questions and needs and out-of-town family and things of that sort. Out of that, the hospitalist developed, and the term was coined in 1994 and then really got started in the late '90s. And in 2001, we started the program over at the Community campus. It's expanded since, and what's happened is that now, in the hospital, you have a specialist taking care of you who specializes in the care of hospitalized patients.

Your primary care physician is still involved because we use their data and their medications and their interface to get background on the patient, and also the primary care physician helps to say, "Oh yes, the hospitalist will take care of you in the hospital," and kind of helps that interface.

One of the more difficult things that a hospitalist has to do is to establish a relationship with a patient and family at the time when the patient is in some level of crisis, either low level or more high level, so what happens is the primary care physician helps us with that interface to make sure the relationship is smooth.

Host Amber Smith: Do most of the doctors who specialize in hospital medicine have a background like you do, in primary care?

Timothy Creamer, MD: In the early days, yes, they all were primary care physicians. I was the only hospitalist for 14 months at Community General (now called Upstate Community Hospital) until we expanded the program. Program now has eight physicians and eight APPs, advanced practice providers, either PAs (physician assistants) or nurse practitioners assisting them.

So, having that background helped. I also worked with family practitioners at the LaFayette Health Center, and so I had familiarity with family practice and how they were trained and was able to interface well with them.

Host Amber Smith: Do hospitalists specialize? Are they subspecializing in particular types of illnesses?

Timothy Creamer, MD: Not necessarily. Now, there is a board certification for hospital medicine, and so it is considered a specialty. We focus on the care of patients in the hospital, whereas a gastroenterologist takes care of things associated with the digestive system, and cardiologists take care of the heart, the hospitalist takes care of the hospitalized patient. And with the availability of all the different techniques, it continues to expand as a specialty and really needs separation from the primary care, separation as well as integration with the primary care. Because as an outpatient, you have different responsibilities now, so it's a specialty that continues to expand.

Host Amber Smith: Do we know yet whether hospitalists have measurably improved overall care in the hospital?

Timothy Creamer, MD: Definitely. There's definite data, especially out of Johns Hopkins (University), that shows that the hospitalist availability in and of itself as far as the interface with patient and families, we can address the needs of a patient within minutes, whereas if I was in Fabius, it might take hours for me to get into the hospital. And really a lot of that was handled previously by nursing. Now it can be handled by physician.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with Upstate's Dr. Timothy Creamer about the hospitalist program and what a hospital stay is like these days from the patient's point of view. Technology is improving health care in many ways. Can you tell us some of the things a hospitalized patient might notice today?

Timothy Creamer, MD: There's a number of things that are really changing.

One of them is the length of stay. We used to send people home from the hospital when they were well. We then sent people home from the hospital when they were better. And now we're really looking at getting people home when they are treated.

As you led in with, people always want to get home as soon as possible. First question a lot of people ask is, "When can I go home?"

And so what happens is the services in the community are expanding and continue to expand to the point where we really feel safer going home and being at home and comfortable at home, yet still providing the services necessary for them to get well.

The other thing people may notice is a lot more bedside technology. Used to be, we had a stethoscope and our ears to do diagnostics at the bedside. Now, with technology, point-of-care ultrasound is now being used actively, and actually there's a program that's being recognized nationally at Upstate to allow physicians at the bedside to have a sonography at the bedside. In other words, a sound wave test, the tests that used to have to schedule and go down to a special unit. These tests are now being done at the bedside and much more rapid diagnostics.

Well, the last thing I'll say is that the involvement of the previously mentioned APPs, the advanced practice providers, which includes physician assistants and nurse practitioners, are much more involved.

When I started at Community, we had three to four doctors and one PA. We now have eight physicians and eight APPs, and these are professionals that have been involved with health care since they started their training. And so, you'll see more of them at the bedside, assisting the physicians in their care.

And actually, they're as specialized in bedside care as many of the physicians are.

Host Amber Smith: You mentioned length of stay. How short are lengths of stay now compared to the time that you began practicing as a hospitalist?

Timothy Creamer, MD: When I started my first day in hospital medicine, our length of stay was 7.1 days. That number is now down to 4.5 days on average.

And even at an institution, a Level 1 trauma center like Upstate downtown, it's still in the four- to five-day range, so it's decreased significantly from where it was before, but again, the services available as outpatient, especially in our local region, have expanded to where that's safe.

We want to be sure that patients have a safe discharge, and they are evolved to a safe environment at home.

Host Amber Smith: Is the goal to save money, or has it been proven that patients can heal better at home?

Timothy Creamer, MD: There are studies that show that people do better at home, especially mentally. The hospital, especially, has demonstrated, with the COVID pandemic, they really can be treated at home and do better at home.

During the pandemic, we sent people home who we previously would've admitted to the hospital, and actually the outcomes were as good, if not better, because I think mentally they felt they could get better at home.

And again, with the support services available, especially the use of telemedicine, there was still an interface with their provider that they could access if they were getting uncomfortable.

Host Amber Smith: And so this whole program, the Hospital at Home program, can you describe how that works, and is that something that Medicare is supportive of?

Timothy Creamer, MD: Medicare, yes. The Hospital at Home program actually was begun prior to the pandemic, in 2017, and it was recently approved for another two years. It was continued through the pandemic and then approved for another two years. Hospital at home is a great tool to get people back to a setting they're comfortable with, when they're stable medically.

The two types of patients we really look at are people who need long-term antibiotics but are stable medically, but need, say 10, 14 or 21 days of antibiotics in order to complete their treatment course. Those people, basically, in the hospital, just are waiting for, daily or twice daily, for their intravenous, when now they can be at home getting their antibiotics in a comfortable setting with family support around them, and also, in addition, the support of our home care group, the Nascentia (home care agency) group, which has nurses go in at least twice a day, and are available 24/7, as they would be in the hospital to care for them.

The other type of patient that it helps out is, hospice services in Central New York are a little bit overwhelmed with the population. And what happens is sometimes the delay to get into hospice is upwards of three to five to seven days. And what we can do is, especially in a circumstance where a patient wants to be home, if they have a terminal illness, we're able to get them home, keep them comfortable, still have nursing intervention, and yet have a seamless transition to hospice when hospice has the availability to properly care for them.

Host Amber Smith: So how does that work, in terms of nursing intervention? If a patient's at home, does a nurse come to their house? Or how do they check in with the doctor if they have questions or concerns?

Timothy Creamer, MD: There's, three ways that health interventions occur.

The nurses go in at least twice a day, and then they do what they call a tuck-in call in the evening. They're also on call through telephone or telemedicine. We have an iPad set up to where you can get a visual of the patient as well as the visual of the provider or the nurse.

The other interface is the previously mentioned APPs at the hospital. There's one assigned each day to interface with the patient so that any orders that need to be updated or any immediate interventions that they have, the availability of contacting a professional provider to adjust their medications and their therapies.

And then the third thing is that I specifically have been doing house calls on admission and discharge and at least every three days in between to, assist in the interface and to let the patients know that their physician is still involved with them. I can also do a telemedicine interface if necessary.

And so this three-way, this troika, if you will, of communication between three of the providers afford the patient a safe environment to get the therapies they need and also to address their more urgent needs, should they arise.

Host Amber Smith: So, as the doctor overseeing care of these patients in the hospital, if you have a patient who really would like to go home, in addition to the medical issues, do you also have to look at social concerns, such as the safety of the home environment or what type of home environment they have to return to?

Timothy Creamer, MD: Yes, absolutely. What happens is Nascentia Home Care has experience in the homes and recognizes when it's safe and making sure that the environment is set up in a way. I know that we bring in medical equipment into the, home, but what happens is when the nurses go in initially, they can basically see where the patient needs to be and adjust, say, where the hospital bed can go, where the IV pole can go, whether there's appropriate bathroom facilities on the floor, and also the availability of family and family support. We are usually able to get a pretty good engagement with the family to describe to them what type of setting we need. And people are so excited, I guess is the word, to get their family member home that they really do adjust the environment so that the patient can be moved safely to the home.

And, we can also intervene in between times to make it even better.

Host Amber Smith: What options does a person have if they live alone?

Timothy Creamer, MD: That's very difficult. It's a difficult circumstance because anytime a person who is chronically ill or terminally ill lives alone, it's very difficult to send them back to that isolated setting.

Chronic illness is difficult to deal with on your own, but to be alone with it is a tricky circumstance. We usually do everything we can to find family members that are available, specifically, even shirttail relatives, to come in and stay with the patient so that we're able to get them home.

But that is a difficult barrier in any setting. Sometimes these people are more supported in a more social situation that a facility might provide. And in general, with people who we are unable to do anything with them living alone, we usually recommend that they go to a facility.

It also all depends on the illness. We have had people who have just needed intravenous antibiotics and have actually handled it on their own. And in that particular circumstance, we do everything we can to get them home and get them the care they need and get them the physical support they need, possibly more phone calls during the day, but that's a situation that is tricky, that we work very hard to get the person home to as safe a setting as possible.

Host Amber Smith: So at some point, the patient will be ready for discharge. And similar to how you would look at someone in the hospital to determine whether they're ready to be discharged to go home, how do you look at a patient who's home to decide whether they're ready to not have that connection with the hospital?

Timothy Creamer, MD: Well, with Hospital at Home, we have the interface of three of us, at least three of us, if not more, being able to kind of see the person physically, see the person daily through tele-interface. And between the three, of us, we are able to determine whether the patient really can be discharged from the, intense service and go back to their life, just like they would if they were in the hospital. We also have the ability to do physical therapy in the home to make sure they're moving, make sure they're up and about. We can also instruct family members, on how to keep them active, and progress them to general good health.

We really haven't, at this stage, knock on wood, had the circumstance of someone deteriorating at home, because I think the attentiveness has been such that we've been able to support them to the point where they got healthy again.

Host Amber Smith: Once someone is discharged, I assume they go back to their primary care provider.

Do they ever see their hospitalist again?

Timothy Creamer, MD: Well, like all hospitalized patients, we hope that they never come back again, and they're able to be managed as an outpatient. They may not see their hospitalist again. We try to communicate our names, and through business cards and things of that sort, who we are and what we do.

But what we try to do is look at the hospitalists as all being equally trained and have a collegial atmosphere, where we all do things in the best interest of the patient. And with our focused training, instead of focusing in on "My hospitalist being Dr. Creamer," or "My hospitalist being Dr. Hegazy," that "I was taken care of by the hospitalist group."

I think that's another thing that's happened in medicine, is that between Tuesday and Wednesday, which is our switchover day, you could have three separate providers taking care of you, the daytime hospitalist on Tuesday, the nocturnist on Tuesday evening and the new hospitalist coming on on Wednesday.

So that's the other thing that we look at in hospital medicine. We make sure that we have this collegial atmosphere to be able to take care of people. And you come into the hospital, you don't get the opinion of a single doctor, you might get the opinion of two or three different professional providers.

Host Amber Smith: Well, Dr. Creamer, thank you so much for making time to tell us about this.

Timothy Creamer, MD: Well, I appreciate you having me and hope that we've helped people understand a very complex health system, especially as we move out of the pandemic with a lot of these new things happening.

Host Amber Smith: My guest has been hospitalist Dr. Timothy Creamer. He's an assistant professor of medicine at Upstate.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed.

This is your host, Amber Smith, thanking you for listening.