“Their group has over 25 years of experience specializing in the complexity of treating geriatric and chronically ill patients, and has demonstrated an ability to make significant differences in the quality and continuity of care for patients in these settings."
R. Scott Koelliker, RN, MSA, FABC
Heartland Clinic Administrator
Home // Our Staffing Models // “Post-Hospitalist” Medical Services

“Post-Hospitalist” Medical Services

Post-hospitalist medicine is a recognized, specialized approach to the practice of medicine in the post-acute and long-term care setting, where patient acuity is increasing dramatically and where physicians need to have a medical practice that fits into a true interdisciplinary environment and is specialized in the care of patients in post-acute facilities.

Post-Hospitalist Program Services: Specialized medical services performed exclusively on-site as the medical director, attending physician and/or PCP for patients residing in post-acute facilities.  Post-hospitalist program services focus on addressing the needs of high-risk, medically complex patients. These services include but are not limited to:

  • Regularly scheduled daily on-site hours in facilities
  • Oversight/follow-up through a multidisciplinary team of physicians, certified nurse practitioners and clinical nurse specialists
  • Consistent providers for continuity of care
  • Comprehensive assessments
  • Daily intervention
  • Individual patients are visited based on their needs and medical necessity
  • Medication reconciliation
  • Pre and/or postoperative care and rehabilitation
  • Monitoring of services to ensure compliance with all regulations and standards
  • 24/7 coverage is provided as needed
  • Communication with other providers and care givers, ancillary service requests and family are provided timely.
  • Discharges to home or to a lower level of care (usually custodial) are timely and SNFists coordinate the discharge and transition plan with the patient and/or their community-based caregiver or primary care physician (PCP).

Post-Hospitalist Programs are similar to Hospitalist Programs

As hospitalists provide specialized care to hospitalized patients, “post hospitalists” provide specialized services exclusively as on-site attending physicians, medical directors and advanced nurse practitioners in a wide variety of post-acute settings:

  • Sub-acute centers
  • Long-term acute care hospitals
  • Rehabilitation centers
  • Skilled, intermediate and long-term care nursing facilities

Post-hospitalist programs generally are provided by a collaborative group practice of physicians, certified nurse practitioners and clinical nurse specialists that focus their services on-site in post-acute facilities to address the needs of high-risk, medically complex patients with the following diagnoses and needs:

  • Asthma                                                                     *Major Depressive Disorder
  • Chronic Obstructive Pulmonary Disease (COPD)            *Osteoporosis
  • Congestive Heart Failure (CHF)                                     *End Stage Renal Disease
  • Dehydration                                                                    *Hepatitis C
  • Pneumonia                                                                      *Hypertension
  • Urinary Tract Infections (UTI)                                        *Rheumatoid Arthritis
  • Diabetes Mellitus                                                           *Pre and/or Postoperative Care and Rehabilitation
  • Coronary Artery Disease                                                 *Medication Reconciliation

Our Typical “Post-Hospitalist” Program Caseload

  • Ranges between 150 and 200 patients depending on case mix considerations, oversight requirements and service volume differences between the number of acute care, versus chronic (custodial) care patients being followed.
  • General caseload will include 20% acute care and 80% chronic care patients.
  • Patients are initially visited and care plans developed within 24 hours of hospital discharge.
  • Unstable patients are visited 3-5 times weekly or daily if clinical condition requires daily oversight.
  • Stable patients are visited up to two times per month based on clinical need.
  • Discharges to home or to a lower level of care (usually custodial) are timely.
  • “Post-hospitalists” coordinate the discharge and transition plan with the patient and/or their community based caregiver and payers.

Our “Post-Hospitalist” Program Goals

Enhance and coordinate care of older adults and chronically ill patients in all post-acute settings by utilizing the most cost effective means.

  • Specific Goals
    • Reduce hospital lengths of stay.
    • Reduce the frequency of potentially avoidable hospital (PAH) admissions and readmissions.
    • Reduce unnecessary ER utilization.
    • Improve patient health outcomes.
    • Improve the process of transitioning between inpatient hospitals, post-acute facilities and home settings.
    • Reduce overall health care spending.
  • 45% of hospitalizations among post-acute patients (primarily frail, elderly or disabled) are potentially avoidable.  
    • These hospitalizations are expensive, disruptive, disorienting and often dangerous for this population of patients.
    • These populations of patients are especially vulnerable to the risks that accompany hospitalizations and transitions of care, including transfer trauma, medication errors, hospital-acquired infections and decubitus ulcers.
    • Hospital episodes are even more difficult for individuals with dementia.
    • Six medical conditions are responsible for nearly 80% of the potentially avoidable hospitalizations  (PAH).
      • Pneumonia
      • Congestive Heart Failure
      • Urinary Tract Infections
      • Dehydration
      • Chronic Obstructive Pulmonary Disease
      • Asthma
    • Four behavioral health diagnoses require care coordination and further stratification.
      • 67% of post-acute patients who have a behavioral health (BH) diagnosis are transferred to the ER at least three times per year.  50% of these patients are subsequently admitted to the hospital for further treatment.  The vast majority of these admissions prove to be PAH.
      • There are four behavioral diagnoses that often accompany or may exist separately from the primary medical diagnoses. These diagnoses require stratification in patient care to avoid PAH. These are dementia, delirium, schizophrenia and manic depression.
      • Increased observation, oversight, examination and treatment are required to avoid unnecessary ER transfers and hospitalizations.

Traditional (not Post-Hospitalist/SNFist Programs) Models of Care in Post-Acute Environments

  • Typical community PCPs and most other NP/PA/extender models often do not have the time or ability to effectively monitor patient care when the patient is in a post-acute facility including skilled, intermediate and long-term care nursing and assisted living facilities, resulting in increased ER utilization, hospitalizations and readmissions.
  • When a patient becomes ill with an urgent or non-emergent problem, these other models typically direct the patient to the ER, utilizing the ER as an outpatient clinic, rather than going to the facility the next day and examining and treating the patient on-site.  This results in increased ER utilization, hospitalizations and readmissions.

Post-Hospitalist/SNFist Program Services

Certain state health plans around the country utilize the term “SNFist program services” when they define specialized physician services that are required for their individual health plans.  The term “SNFists” is a less recognized name used to describe the exact same functions we perform under our post-hospitalist medical services section.