Hospitalists Outside the Hospital: Preparing for New Settings of Care Delivery-Slides

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This document reports on a session led by Dr. Timothy J. Judson and colleagues, addressing the evolving role of hospitalists delivering care outside traditional hospital settings. Increasing pressures such as hospital capacity constraints, acute care costs, patient expectations, and advances in technology have catalyzed new models: Hospital at Home, virtual discharge clinics, and in-person post-discharge clinics. These models allow hospitalists to provide acute and transitional care in patients’ homes or through virtual platforms.<br /><br />Hospital at Home programs enable select patients requiring acute care to be treated safely at home, reducing readmissions, ED visits, infections, delirium, and improving mobility, comfort, and patient satisfaction while lowering healthcare costs. Mayo Clinic’s Advanced Care at Home program exemplifies this with its command center, supply chain, technology, and geographically distributed operations.<br /><br />Virtual Transitions of Care (VToC) clinics, exemplified by UC San Diego’s program, provide multidisciplinary, virtual post-discharge follow-up that accelerates specialty access, medication management, and patient engagement, with demonstrated reductions in 30-day readmissions and substantial bed days saved. Hospitalists report positive impacts on discharge practices and value seeing patients in their home environment.<br /><br />In-person post-discharge clinics, like John Muir Medical Group’s program, focus on intensive management of recently discharged patients within a week post-discharge. They address medication reconciliation, pending tests, specialty follow-ups, home health arrangements, and education. Though challenges include scheduling, patient engagement, and PCP collaboration, these clinics aim to reduce readmissions and hospital length of stay.<br /><br />Hospitalists’ expanding scope beyond inpatient care leverages their expertise in acute care, complex navigation, and leadership to improve transitions, utilizing virtual assessments, remote monitoring, and ambulatory testing. The session emphasized the need for hospitalists to develop new skills to succeed in these innovative care models.<br /><br />Overall, these home-based and virtual care models represent a shift toward decentralized, patient-centered acute and transitional care, aiming to improve outcomes, optimize resources, and enhance patient experience post-hospitalization.

Keywords

Hospitalists

Hospital at Home

Virtual Transitions of Care

Post-discharge Clinics

Acute Care

Transitional Care

Patient-centered Care

Remote Monitoring

Readmission Reduction

Healthcare Innovation