In 2017, hospitalists at Vanderbilt were struggling with the common challenge of providing consistent care for patients who were repeatedly hospitalized. “Continuity of care is fractured by the shift-based and block-based scheduling models that are required to serve 24 hours per day, seven days per week,” said ACP Member Francis Balucan, MD, MBA, during a session at SHM Converge 2022, held in Nashville April 7 to 10.
Patients would point out inconsistencies, he noted: “Hey, this doctor told me this thing last week. Why are you telling me something different?” That dynamic creates dismay for all involved, said Dr. Balucan, a hospitalist and an assistant professor of clinical medicine. “If you don't have a plan, what happens is you have frustrated patients, frustrated physicians and APPs [advanced practice providers], and you have burnout.”
He and colleagues came up with a plan to help tackle the issue: Vanderbilt Familiar Faces (VFF).
How it works
VFF is a hospital medicine service that focuses on complex, frequently admitted patients—those with several comorbidities (Charlson Comorbidity Index >3) or a high risk of readmission (LACE Readmission Index >30).
The patients who meet these criteria have diverse characteristics, according to Dr. Balucan, who serves as medical director for VFF. “Some are just medically complex. Some have social determinants of health, and some have behavioral or psychiatric comorbidity,” he said.
The caregiving side of VFF includes hospitalist physicians and APPs who have volunteered to work the service, as well as a case manager, a social worker, a pharmacist, and a psychiatric nurse practitioner. “We are a regular hospital medicine service that not only takes care of this high-need population, but also general hospital medicine,” said Dr. Balucan. The program strives to locate VFF patients together, allowing more nursing continuity, he noted.
The VFF team develops an ongoing plan for each patient's management, in collaboration with subspecialists and primary care physicians when possible. The patients are identified in the electronic health record as part of VFF. “We create an FYI flag that alerts the emergency room every time that patients present to the hospital and alerts the triage attending about this patient if they're going to be admitted,” said Dr. Balucan. “They are assigned to our team probably 80% of the time.”
Early data on the program's effects are “promising,” with the caveat that they come from a pre-post analysis, said Dr. Balucan. Among 407 participants analyzed before the pandemic, the average number of readmissions in the six months before they were treated by VFF was 3.4 versus 0.9 after. Their rate of return to the ED also decreased to the extent that 898 ED visits were potentially avoided.
When patients were readmitted, their average length of stay was reduced from 5.88 days to 4.89 days, confirming Dr. Balucan's anecdotal experience. “When I've seen this patient again and again, I know already what to do, and I know who to talk with,” he said. The team also saw some unexpected improvements in other outcomes, including the percentage of discharges before 9:30 a.m. and faculty satisfaction.
Despite the current satisfaction, an initial challenge was getting everyone involved on board, said Dr. Balucan. “You've got to change the narrative. … The first time you talk about this patient population, a lot of people react [negatively],” he said.
Even eligible patients may be displeased. “There are patients that would not like this consistency, because they like the fact that every single time it's a different provider, they can say, ‘Hey, this provider did this other thing. Why won't you do that?’ … We call them out,” Dr. Balucan said. Primary care physicians also reacted to VFF, which offers postdischarge care to some patients, possibly stepping on their toes, he noted.
Words of wisdom
To deal with these challenges and provide identifiable benefits takes time, so the beginning of a program like VFF requires patience, according to Dr. Balucan. “It took us four or five years to get a more sustainable panel of patients. It's only now that we're seeing all the outcomes.”
Given the program's effects on readmissions to Vanderbilt, a next step is to gather data on VFF patients' use of other hospitals from a state dashboard. “It will tell you if this patient is admitted anywhere, discharged anywhere, or transferred anywhere,” Dr. Balucan said. “It's real time, so we will know when the patient gets admitted. Now, the bigger question, though, when you get that information, is what are you going to do about it?”