SHM Converge Scientific Abstract ePoster Gallery-Service Redesign to Prioritize Continuity for Patients With Prolonged Hospitalizations

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The document describes a hospital service redesign aimed at improving continuity of care for patients with prolonged hospitalizations who are medically ready for discharge but remain in the hospital because of complex medical, social, or psychiatric barriers.<br /><br />To address problems caused by frequent provider turnover, the team created two “Enhanced Continuity” physician teams. Each team had two dedicated hospital medicine physicians assigned for two-month blocks, worked nine-hour shifts with a focus on weekday continuity, and maintained a higher patient census than traditional teams. Physicians provided full formal visits twice weekly, plus additional visits as needed for new issues and social support. Weekend coverage for both teams was handled by one physician. The hours saved from shorter shifts and reduced weekend coverage were used to create a noon-to-8 p.m. shift for admission coverage and cross-coverage.<br /><br />The effort was well received by physicians, who reported several benefits: better work-life balance, stronger relationships with patients and families, improved collaboration with the care team, reduced stress, and greater confidence that important aspects of the care plan were not being missed. The authors also note positive reception from patients, families, and other care team members.<br /><br />The project was guided by a clear aim: implement a staffing model that improves continuity for prolonged hospitalization patients. Key opportunities included recognition of the need for improvement, stable staffing, institutional alignment, strong consultant support, and leadership backing. Main barriers were the need to remain budget neutral, the fact that these patients were not already grouped together, and concern about added workload for general medical teams. Strategies included early physician engagement, piloting the change with back-out plans, consolidating patients onto two nursing units, preserving flexibility, adding an admitting service, and collaborating closely with nursing, care management, and specialists.

Asset Subtitle

Elizabeth L. Herrle

Meta Tag

Author List Daniel A. Meyer, Elizabeth L. Herrle, Matthew S. Buttarazzi

Category Innovations

Concept Continuity of Care

Concept Enhanced Continuity Team Model

Concept Physician Staffing

Concept Service Redesign

Concept Prolonged Hospitalization

Distinguished Non-Finalist

Presenter Organization MaineHealth

Presenting Author Elizabeth L. Herrle

Track Geriatrics

Keywords

hospital service redesign

continuity of care

prolonged hospitalization

enhanced continuity teams

physician staffing model

medically ready for discharge

work-life balance

patient-family relationships

care team collaboration

budget neutral

Continuity of Care

Enhanced Continuity Team Model

Physician Staffing

Service Redesign

Prolonged Hospitalization