Design and implementation of an inpatient disease management program.

OBJECTIVE: To describe the development and implementation of an inpatient disease management program. STUDY DESIGN: Prospective observational study. PATIENTS AND METHODS: On the basis of opportunities for improving quality or efficiency of inpatient and emergency department care, 4 diagnoses, including congestive heart failure (CHF), gastrointestinal hemorrhage, community-acquired pneumonia and sickle-cell crisis were selected for implementation of a disease management program. For each diagnosis, a task force assembled a disease management team led by a "physician champion" and nurse care manager and identified opportunities for improvement through medical literature review and interviews with caregivers. A limited number of disease-specific guidelines and corresponding interventions were selected with consensus of the team and disseminated to caregivers. Physician and nurse team leaders were actively involved in patient care to facilitate adherence to guidelines. RESULTS: For quarter 2 to 4 of 1997, there were improvements in angiotensin-converting enzyme inhibitor use, daily weight compliance, assessment of left ventricular function, hospital costs, and length of stay for care-managed patients with CHF. Differences in utilization-related outcomes persisted even after adjustment for severity of illness. For the other 3 diagnoses, the observational period was shorter (quarter 4 only), and hence preliminary data showed similar hospital costs and length of stay for care-managed and noncare-managed patients. CONCLUSIONS: An interdisciplinary approach to inpatient disease management resulted in substantial improvements in both quality and efficiency of care for patients with CHF. Additional data are needed to determine the program's impact on outcomes of other targeted diagnoses.

How to design a hospitalist service. An academic health system case study.

Medical centers throughout the country are employing hospitalists--dedicated inpatient specialists--to care for patients during hospitalization in place of their primary care provider. There has been expansive growth of hospitalist programs as the number of practicing hospitalists has doubled in two years from approximately 1,500 to over 3,000. In July 1997, the department of medicine at University Hospitals of Cleveland, the primary teaching affiliate of Case Western Reserve University, created a hospitalist service. This paper will discuss the design of a hospitalist service at a major academic medical center, the factors that were considered during the design stage and financial feasibility.

An integrated inpatient management model.

The academic health center has emerged as the cornerstone of the American health care system. To assess the vulnerability of the academic medical center to the new competitive forces that exist today, a prototype project has been developed that attempts to address the issue of competition in clinical activity, while at the same time enhancing the academic health center's education and research roles.

The integrated inpatient management model. A new approach to clinical practice.

The delivery and financing of health care have undergone a metamorphosis over the past 10 years. These changes have been particularly dramatic for hospital care. The new health care environment, with more prospective-payment and managed-care systems and less fee-for-service payment for both physicians and hospitals, has made physicians and hospitals mutually dependent. A hospital's long-term financial viability is now dependent largely on the practice style of its physicians. The Department of Internal Medicine at The University of Michigan has developed a new clinical management system called the Integrated Inpatient Management Model (IIMM). This new system includes a major revision of the hospital organization structure, new administrative information systems, and new clinical information systems. Physicians in the Department of Internal Medicine have assumed for the first time formal organizational responsibility for many aspects of the operations of the inpatient medical service. The IIMM represents a prototype of a system that we believe offers considerable promise for involving physicians to a much greater extent in the management of the nation's hospitals. We hope that describing the system in detail will facilitate the development of other systems for the management of the inpatient practice of internal medicine.