Patient Types in Hospital Medicine: Unassigned, Comanaged, and Post-Discharge Care

02.05.202214.07.2023 by alexxlab

Where do hospitalists’ patients come from. Who do hospitalists hand patients back to. How quickly do hospitalists communicate with primary care physicians after discharge. What are the trends in patient types for hospital medicine.

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The Evolution of Patient Types in Hospital Medicine

Hospital medicine has undergone significant changes since its inception over a decade ago. Initially, primary care physicians were concerned about hospitalists not returning patients after inpatient treatment. Today, the landscape of patient types and care transitions in hospital medicine is much more complex and nuanced.

A recent survey by Today’s Hospitalist provides insights into the current state of patient types and care transitions for full-time adult hospitalists. Let’s explore the key findings and implications for hospital medicine practice.

Unassigned Patients: A Core Component of Hospitalist Care

Unassigned patients continue to be a significant portion of hospitalists’ caseloads, aligning with one of the original goals of the specialty. According to the survey:

Approximately one-third of hospitalists’ patients are unassigned
44% come from primary care doctors with hospitalist contracts
About 20% are from specialists in comanagement arrangements

The proportion of unassigned patients varies by practice setting:

23% for hospitalists in multispecialty/primary care groups
45% for hospitalists in universities and medical schools

Why do university and medical school settings have a higher percentage of unassigned patients? This could be due to several factors, including:

A higher proportion of complex cases referred from other hospitals
More patients without established primary care relationships
Greater emphasis on teaching and training roles for hospitalists

The Rise of Comanagement in Hospital Medicine

Comanagement has become an increasingly important aspect of hospitalist practice. The survey reveals several key trends in this area:

Top Specialties for Comanagement

Orthopedics (85% of hospitalists)
General Surgery (83%)
Cardiology
Neurology
GI/Hepatology

Interestingly, even specialties that were not traditionally associated with hospitalist comanagement, such as OB/GYN and psychiatry, are now being mentioned by survey respondents.

Experience and Comanagement

The survey data indicates a correlation between hospitalist experience and involvement in comanagement:

90% of hospitalists with 10+ years of experience comanage orthopedic patients
Only 71% of hospitalists with 2 years or less experience do so

What factors contribute to this trend? Possible explanations include:

More experienced hospitalists have established stronger relationships with specialists
Senior hospitalists may be preferentially assigned to complex comanagement cases
Newer hospitalists might focus on core hospital medicine skills before expanding into comanagement

Post-Discharge Communication: Bridging the Gap

Effective communication with primary care physicians after patient discharge is crucial for continuity of care. The survey provides insights into current practices:

60% of hospitalists deliver a discharge summary within 24 hours
Almost 25% provide a discharge summary to primary care physicians within 48 hours

While these numbers are encouraging, there is still room for improvement. Timely communication can help prevent readmissions, improve patient outcomes, and strengthen relationships between hospitalists and primary care providers.

Implications for Hospital Medicine Practice

The survey findings have several implications for hospitalists and hospital medicine programs:

Adaptability: Hospitalists need to be prepared to care for a diverse range of patient types, from unassigned to comanaged cases.
Skill development: Programs should focus on building comanagement skills, especially for newer hospitalists.
Communication: Improving the speed and quality of post-discharge communication should be a priority.
Collaboration: Strengthening relationships with primary care physicians and specialists is crucial for effective patient care.

Challenges and Opportunities in Patient Type Management

As the field of hospital medicine continues to evolve, several challenges and opportunities emerge in managing different patient types:

Balancing Workload

How can hospitalist programs effectively balance the workload between unassigned patients and comanagement responsibilities? Strategies may include:

Implementing flexible staffing models
Developing specialized teams for high-volume comanagement services
Using data analytics to predict patient volumes and adjust staffing accordingly

Enhancing Comanagement Skills

With the growing importance of comanagement, how can hospitalist programs ensure their physicians are prepared for these responsibilities? Consider:

Offering targeted training programs in common comanagement scenarios
Pairing junior hospitalists with experienced colleagues for mentorship
Developing clear protocols and guidelines for comanagement arrangements

The Future of Patient Types in Hospital Medicine

Looking ahead, several trends may shape the future of patient types in hospital medicine:

Increased Specialization

Will we see more hospitalists specializing in specific patient types or comanagement arrangements? This could lead to:

Dedicated orthopedic hospitalist teams
Neurology-focused hospital medicine programs
Specialized geriatric hospitalist services

Technology and Patient Type Management

How will advancements in healthcare technology impact the management of different patient types? Potential developments include:

AI-powered triage systems to optimize patient assignments
Telemedicine platforms facilitating remote comanagement consultations
Automated systems for post-discharge communication and follow-up

Optimizing Care Across Patient Types

To provide the best possible care across all patient types, hospitalists and hospital medicine programs should focus on:

Continuous Education

Staying up-to-date with the latest developments in various specialties is crucial for effective comanagement. Programs should encourage:

Regular attendance at interdisciplinary conferences
Subscription to relevant specialty journals
Participation in collaborative research projects

Streamlined Communication

Improving communication processes can enhance care for all patient types. Consider implementing:

Standardized handoff protocols for shift changes
Secure messaging systems for rapid specialist consultations
Automated alerts for critical lab results or medication interactions

Patient-Centered Care Models

Adapting care models to meet the unique needs of different patient types can improve outcomes. Explore:

Multidisciplinary rounds for complex comanagement cases
Enhanced discharge planning for unassigned patients
Culturally competent care strategies for diverse patient populations

By focusing on these areas, hospitalists can ensure they are well-equipped to provide high-quality care across the spectrum of patient types they encounter in their practice.

Measuring Success in Patient Type Management

To gauge the effectiveness of patient type management strategies, hospital medicine programs should consider tracking key performance indicators (KPIs) such as:

Patient satisfaction scores by patient type
Length of stay for comanaged vs. non-comanaged patients
Readmission rates for unassigned patients
Time to discharge summary completion
Specialist satisfaction with comanagement arrangements

Regularly reviewing these metrics can help identify areas for improvement and guide resource allocation decisions.

As hospital medicine continues to evolve, adapting to changing patient types and care models will be crucial for success. By embracing the challenges and opportunities presented by diverse patient populations, hospitalists can enhance their value to healthcare systems and, most importantly, improve patient outcomes.

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A look at patient types

Published in the December 2014 issue of Today’s Hospitalist

IN THE EARLY YEARS of hospital medicine, primary care physicians worried that hospitalists would not return their patients after treating them in the hospital. That was more than 10 years ago, and we thought it would be interesting to see exactly where hospitalists’ patients come from “and who hospitalists are handing patients back to. Here’s what we found for full-time adult hospitalists in the 2014 Today’s Hospitalist Compensation & Career Survey.

Unassigned patients
It’s probably no surprise that unassigned patients make up about one-third of hospitalists’ patients, part of the specialty’s original mission. Nearly half (44%) come from primary care doctors who have contracts with hospitalists, and about one-fifth come from specialists hospitalists work with in comanagement arrangements.

Unassigned patients appear to make up the lowest percent of patients for hospitalists working for multispecialty/primary care groups, with only 23% of hospitalists in this setting saying they treat unassigned patients. Among hospitalists working for universities and medical schools, by comparison, 45% of their patients are unassigned.

Comanagement
In terms of comanagement, orthopedics tops the list, with 85% of hospitalists saying they work with orthopedic surgeons. General surgery is close behind (83%). Other popular specialties for comanagement include cardiology, neurology and GI/hepatology. Even specialties like OB/GYN and psychiatry, which didn’t use to be commonly comanaged by hospitalists, are identified by hospitalists in our survey.

Our data also show that the more years hospitalists have been in the specialty and working at their current jobs, the more likely they are to work with other specialists. While 90% of hospitalists who’ve been in the specialty for 10 years or more comanage orthopedic patients, that’s true for only 71% of hospitalists in the specialty for two years or less.

Post-discharge communication
Finally, how quickly do hospitalists communicate with the physicians to whom they return patients post-hospitalization? Just under two-thirds (60%) say they deliver a discharge summary within 24 hours, while almost one-quarter get a discharge summary to primary care physicians within 48 hours.

By region, 66% of hospitalists in the Pacific region say they turn around discharge summaries within 24 hours. That’s true for only 50% of hospitalists in the Southwest.

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Psychological reactions of the patient to illness

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The reflection of the disease in a person’s experiences is usually defined by the concept of the internal picture of the disease (VKB). It was introduced by the domestic therapist R.A. Luria is still widely used in medical psychology. This concept, according to the definition of the scientist, combines everything “that the patient feels and experiences, the whole mass of his sensations, his general well-being, self-observation, his ideas about his illness, about its causes – all that huge world of the patient, which consists of very complex combinations of perception and sensation, emotions, affects, conflicts, mental experiences and traumas.

As a complex structured formation, the internal picture of the disease includes several levels: sensitive, emotional, intellectual, volitional, rational. VKB is determined not by a nosological unit, but by a person’s personality, it is also individual and dynamic, like the inner world of each of us. At the same time, there are a number of studies that reveal the characteristic features of the patient’s experience of his condition.

Thus, the concept of V. D. Mendelevich (“Terminological foundations of phenomenological diagnostics”) is the idea that the type of response to a particular disease is determined by two characteristics: the objective severity of the disease (determined by the criterion of mortality and the likelihood of disability) and the subjective severity of the disease (the patient’s own assessment of his condition).

The idea of the subjective severity of the disease is made up of social and constitutional characteristics, which include sex, age and profession of the individual. Each age group has its own register of the severity of the disease – a kind of distribution of diseases according to socio-psychological significance and severity.

So, in adolescence, the most severe psychological reactions can be caused not by those diseases that are objectively threatening the safety of the body from a medical point of view, but by those that change its appearance, make it unattractive. This is due to the existence in the mind of a teenager of a basic need – “satisfaction with one’s own appearance.”

Persons of mature age will react more psychologically to chronic and disabling diseases. “This is connected with the value system and reflects the aspiration of a person of mature age to satisfy such social needs as the need for well-being, well-being, independence, self-sufficiency, etc.” In this respect, the strongest experiences are associated with oncological diseases. For the elderly and the elderly, the most significant are diseases that can lead to death, loss of work and performance.

Individual psychological characteristics that influence the specifics of experiencing a disease include temperamental features (in relation to the following criteria: emotionality, pain tolerance as a sign of emotionality, and restrictions on movements and immobility), as well as features of a person’s character, his personality (ideological attitudes, level of education).

There is a typology of how a patient responds to an illness. Knowing the type of patient’s response helps to choose an adequate strategy for interacting with him and his family, to use appropriate methods of communication, motivation for treatment.

Types of psychological response to a severe somatic illness

Typology of response to illness A.E.Lichko and N.Ya. Ivanova (“Medical and psychological examination of somatic patients”) includes 13 types of psychological response to a disease, identified on the basis of an assessment of the influence of three factors: the nature of the somatic disease itself, the type of personality in which the most important component determines the type of character accentuation and attitude to this disease in the reference (significant) group for the patient.

In the first block there are those types of attitude to the disease in which there is no significant violation of adaptation: light, but without underestimating the severity of the disease. The desire to actively contribute to the success of treatment in everything. Unwillingness to burden others with the burdens of self-care. In the case of an unfavorable prognosis in the sense of disability – switching interests to those areas of life that will remain available to the patient. With an unfavorable prognosis, attention, worries, and interests are concentrated on the fate of loved ones, their business.

Ergopathic : “leaving the disease for work” is typical. Even with the severity of illness and suffering, they try to continue the work at all costs. They work hard, with even greater zeal than before the illness, they devote all their time to work, they try to be treated and undergo research in such a way that it leaves room for continuing work.

Anosognosic : active rejection of thoughts about the disease, its possible consequences, denial of the obvious in the manifestation of the disease, attributing them to random circumstances or other non-serious diseases is characteristic.

Refusal of examination and treatment, the desire to manage their own means.

The second block includes types of response to the disease, characterized by the presence of mental maladaptation:

Anxious : for this type of response, continuous anxiety and suspiciousness regarding the unfavorable course of the disease, possible complications, inefficiency and even the danger of treatment. The search for new methods of treatment, the thirst for additional information about the disease, possible complications, methods of treatment, the continuous search for “authorities”. Unlike hypochondria, more interested in objective data about the disease (test results, expert opinions) than their own feelings. Therefore, they prefer to listen more to the statements of others than to endlessly present their complaints. The mood is primarily anxious, depression – as a result of this anxiety).
Hypochondriacal : focus on subjective painful and other unpleasant sensations. The desire to constantly talk about them to others. On their basis, the exaggeration of the real and the search for non-existent diseases and suffering. Exaggeration of the side effects of drugs. A combination of desire to be treated and disbelief in success, demands for a thorough examination and fear of harm and painful procedures).
Neurasthenic : behavior of the “irritable weakness” type is characteristic. Outbursts of irritation, especially with pain, with discomfort, with treatment failures, adverse examination data. Irritation often pours out on the first person who comes across and often ends with repentance and tears. Pain intolerance. Impatience. Inability to wait for relief. Subsequently – repentance for anxiety and incontinence.
Melancholic : characterized by depression by the disease, disbelief in recovery, in a possible improvement, in the effect of treatment. Active depressive statements up to suicidal thoughts. A pessimistic view of everything around, disbelief in the success of treatment even with favorable objective data.
Euphoric : characterized by unreasonably elevated mood, often feigned. Neglect, frivolous attitude to the disease and treatment. Hope that “it will work itself out”. The desire to get everything from life, despite the disease. Ease of violation of the regime, although these violations may adversely affect the course of the disease.
Apathetic : characterized by complete indifference to one’s fate, to the outcome of the disease, to the results of treatment. Passive obedience to procedures and treatment with persistent prompting from the outside, loss of interest in everything that previously worried.
Obsessive-phobic : characterized by anxious suspiciousness primarily concerns fears of not real, but unlikely complications of the disease, treatment failures, as well as possible (but poorly justified) failures in life, work, family situation due to the disease. Imaginary dangers are more exciting than real ones. Signs and rituals become protection from anxiety.
Sensitive : characterized by excessive concern about the possible adverse impression that knowledge of one’s illness may make on others. Fear that others will avoid, consider inferior, dismissive or wary, spread gossip or unfavorable information about the cause and nature of the disease. Fear of becoming a burden for loved ones due to illness and hostility on their part in connection with this.
Egocentric : “Departure into illness” is characteristic, showing off one’s sufferings and experiences to relatives and others in order to completely capture their attention. The requirement of exceptional care – everyone should forget and drop everything and take care only of the sick. The conversations of others are quickly translated “on themselves”. In others, who also require attention and care, they see only “competitors” and treat them with hostility. Constant desire to show his special position, his exclusivity in relation to the disease.
Paranoid : characterized by the belief that the disease is the result of someone’s malicious intent. Extreme suspicion of drugs and procedures. The desire to attribute possible complications of treatment and side effects of drugs to the negligence or malice of doctors and staff. Accusations and demands for punishments in connection with this.
Dysphoric (characteristically sad and embittered mood).

Interaction with some of these patients can bring significant psychological discomfort to the physician. But knowing the psychological foundations of this type of patient behavior will help the doctor better understand his needs, expectations, fears and emotional reactions, optimally organize the process of interaction with him, and use certain tools of influence. It is important to understand that, even while demonstrating complete indifference to the outcome of treatment, the patient most of all wants to hear words of hope and needs to strengthen his faith in the best. Patients who are constantly worried about their condition need a calm, optimistic and attentive conversation with the doctor, and patients who demonstrate reactions of aggression towards others and the doctor need an authoritative confident position of the doctor, which will help to cope with the strongest fear hidden in the soul for their lives.

Thus, understanding the type of patient’s response to the disease will help to make the relationship between the doctor and the patient more effective, contributing to the psychological well-being of both participants in the treatment process.

Types of patients: what are they and how to find an approach to each? | Materials from companies

Even Hippocrates identified 4 main types of temperament (sanguine, melancholic, choleric and phlegmatic), which, despite the individuality of each person, mean a generalized model of behavior.

It is the same in case of illness – everyone behaves differently. Not only the physical, but also the mental state changes: who adequately perceives, who panics, denies or goes into experiences. Absolutely different attitude to the prescribed treatment.

The division into psychotypes has been used in our country since 1980. The classification is based on three factors: the peculiarity of the disease, the type of personality and the attitude towards this disease.

Photo: medicina360.ru

A total of 12 psychotypes were identified, which cover the entire range of possible reactions to the disease. These psychotypes, in turn, are divided into 3 blocks, the first of which distinguishes people who perceive their diagnosis calmly and do not focus on internal experiences.

These are harmonic, ergopathic and anosognostic types. Such patients adequately respond to the diagnosis, actively participate in treatment, try to comply with all prescriptions, and are determined to defeat the disease. Unlike the harmonic type, when the patient is determined to complete the treatment, the ergopathic and anosognostic types tend to abandon treatment when they improve, so they often need more control and the involvement of relatives.

The second and third blocks include psychotypes that, one way or another, but strongly enough, react to their illness.

Intrapsychic orientation:

increased anxiety when you need to calm and encourage;
constant feeling of being unwell (hypochondriac type) – patience is required here;
irritability, when it is better for the attending physician to agree with the patient in order to then give the necessary recommendations;
apathy, lack of desire to be treated — treatment control and family support are needed.

Interpsychic orientation:

sensitive type of patient, vulnerable and concerned about the opinions of others, needs approval and active involvement in treatment;
the egocentric type, on the other hand, exposes the disease for increased attention – here formality and firmness are required;
paranoid – does not believe in drugs and believes that he was jinxed or spoiled;
dysphoric type — with manifestation of hatred and anger towards healthy people; in treatment, a special approach is needed, based on the strict fulfillment of professional duty and tolerance.

For more information on psychotypes and methods of behavior with patients, you can find in the article https://medicina360.ru/article/raznye-tipy-paczientov-kak-vesti-sebya-s-kazhdym-iz-nix

And we should not forget that not only successful treatment depends on the right approach to the patient, but also the emotional state of the doctor himself, so it is desirable to identify the psychotype already at the initial stages of interaction.