SHM Converge Scientific Abstract ePoster Gallery-Designing a Primary Hospital Provider Team to Improve Continuity in an Academic Medical Center

Pdf Summary

This project describes the creation of a Primary Hospital Provider (PHP) Team at an academic medical center to improve continuity of care for high-need, high-complexity (HNHC) patients, who often have frequent hospitalizations and fragmented inpatient care. To address this, the hospital medicine division reorganized one team into a small, dedicated PHP team designed to care for the same patients across repeated admissions whenever possible.<br /><br />The PHP team includes seven physicians and two advanced practice providers (APPs), with physicians self-selecting into the model and both APPs newly recruited. Staffing was structured to support continuity and coverage: one physician works seven-day blocks, while APPs rotate in three- to five-day blocks. The team partnered closely with clinical operations leadership to make the schedule work.<br /><br />To identify eligible patients, the team worked with informatics staff to create a Best Practice Alert that flags patients appropriate for the PHP model. When these patients are readmitted, they are preferentially assigned back to the PHP team when census allows. A dedicated registered nurse case manager was also added to help coordinate transitions between inpatient and outpatient care. In addition, the team holds weekly virtual meetings to discuss active patients, follow-up needs, complex social issues, and goals of care.<br /><br />The project aims to improve patient outcomes, workforce experience, and operational efficiency. Future work will evaluate the model’s impact on readmissions, patient experience, and staff outcomes, and the team is considering broader collaboration with primary care clinicians and potential expansion to other hospitals.

Asset Subtitle

Sara Westergaard

Meta Tag

Author List Alyssa Hummel, Andrea Wipperfurth, Claire Strangstalien, Eduard E. Vasilevskis, James Ircink, Jessica Beier, Kaia Moe, Katherine E. Mooney, Luisa Barrueto, Matthew Lakosky, Paula Cynkar, Samantha Murray-Bainer, Sara Westergaard

Category Innovations

Concept Primary Hospital Provider Team

Concept Inpatient Continuity

Concept High-Need Patients

Concept High-Complexity Patients

Concept RN Case Manager

Distinguished Non-Finalist

Presenter Organization University of Wisconsin School of Medicine and Public Health

Presenting Author Sara Westergaard

Track Transitions of Care

Keywords

Primary Hospital Provider

continuity of care

high-need high-complexity patients

hospital medicine

readmissions

inpatient care coordination

advanced practice providers

best practice alert

case management

academic medical center

Primary Hospital Provider Team

Inpatient Continuity

High-Need Patients

High-Complexity Patients

RN Case Manager