Family Caregiver Guide
PrintPicture this: Your mother is in the hospital. People come in and go out of her room, asking questions, checking monitors, and taking notes. They introduce themselves so quickly you can’t keep track of their names or their jobs. No one seems to be in charge. Finally, someone with an air of authority comes in. “I’m Doctor Smith. I will be managing your mother’s care while she’s in the hospital.” From her bed, your mother speaks up, “Where is Doctor Jones? I want my regular doctor.”
Do you know how to respond? Here is a guide that can help you answer such questions.
Hospital care has changed a lot in the past 20 or 30 years. Patients now are admitted only for serious illnesses or injuries. They stay for shorter times and many are discharged when their condition is stable but before they are fully recovered. Discharges often happen with little advance notice. As a family caregiver you may have had this experience.
There is another change that is just as important. It’s about the doctors. In many hospitals, there are now special doctors called “hospitalists.” They manage patient care during the hospitalization. This is a job that used to be done by doctors with offices in the community. Today doctors in the community may not even know that their patients are in the hospital.
It is important for you as a family caregiver to know about hospitalists, and the services they do and do not provide. It is also important for you to know ways to ensure the best care for your family member, both in the hospital and after discharge. This guide provides information about hospitalists, along with actions you can take and good questions to ask. But remember that this guide is general – each hospital has its own way of providing patient care.
Who Are Hospitalists and Why Are They in Charge?
According to the Society for Hospital Medicine, a hospitalist is “a physician who specializes in the practice of hospital medicine.” The term was first used in 1996, when there were only a few hundred doctors in this field. Now “hospital medicine” is the fastest growing medical specialty. More than 30,000 hospitalists practice in U.S. hospitals. Chances are you will find these specialists in your local hospital.
Here are more facts about hospitalists:
- Most hospitalists are physicians who have been trained in internal medicine (internists). Others have been trained in family practice, pediatrics, or a few other specialties.
- Some hospitalists have advanced training in managing critical illnesses and are leaders in patient safety and high quality care.
- Hospitalists may play a role in the Intensive Care Unit (ICU) but another doctor (an intensivist) may be in charge.
- Surgeons are often in charge of their patients’ surgical care in the hospital. But surgeons may consult with a hospitalist about other aspects of a patient’s care, such as a chronic medical condition.
- Hospitalists may consult with palliative care specialists for pain or other symptoms.
Hospitalists are usually available 24 hours a day, with doctors rotating in shifts. That means that a hospitalist can respond quickly to a patient’s danger signs. But it also means that in a hospital stay of a week, you may meet two or more hospitalists who take turns managing your family member’s care.
Hospitalists often work in teams that may include physician assistants and nurse practitioners (nurses with advanced training). The hospitalist is in charge. There may be others including floor nurses (who work on a particular hospital unit), social workers, physical and occupational therapists, chaplains, and technicians. In a teaching hospital or academic medical center, the team may include house staff; these doctors-in-training (residents and interns) are supervised by a more experienced doctor. It can be confusing to have so many people involved in your family member’s care. Feel free to ask if you want to know a team member’s name or role.
Hospitalists develop special skills for managing acute (serious) illnesses because they are in the hospital all the time. But their knowledge of community resources and care at home may be limited. For this reason, hospitalists should communicate with the patient’s primary care doctor or other specialists.
You as the family caregiver can help by making sure that the hospitalist communicates with you and the primary care doctor about your family member’s illness, treatment, and follow-up care.
Why Are Hospitals Using Hospitalists?
Hospitalist care has grown very quickly because of changes in how health care is delivered in hospitals and the community. Hospitals have economic pressures to discharge patients earlier while maintaining safety and quality of care. Hospital care happens at a rapid pace. Care is complex and many decisions have to be made right away. It often is not practical to have a community-based doctor come to the hospital for just an hour or two each day. Instead, many hospitals look to hospitalists to safely and efficiently manage patient care.
Hospitalist care can also benefit community doctors. It used to be that primary care doctors managed a patient’s care in the office as well as in the hospital. But today, community doctors with busy practices may not have enough time to manage the fast-paced, time-consuming care of patients in the hospital.
Hospitalist care offers many benefits. But sometimes there are problems coordinating post-discharge care with hospitalists and primary care doctors. Family caregivers can help.
What You Can Do Before a Planned Hospitalization
At a routine office visit or before a planned hospital admission, ask if your family member’s primary care doctor treats patients in the hospital. Perhaps the answer will be, “A hospitalist manages most of the care, but I do try to stop by to check how things are going.” Perhaps the answer will be, “Yes, I’ve always done it and I will continue to do so.” But if the answer is “No, I don’t make hospital calls anymore,” then find out from the hospital how their hospitalist service works.
8 Ways to Work with Hospitalists
It can be difficult for you and your family member to start working with a new doctor in the hospital. This can be even harder if that doctor is not one you have chosen, there is a medical crisis, or you just spent hours waiting in the Emergency Room. Here are some ways to feel more in control:
- Ask to talk to the hospitalist if you arrive at a time when he or she is not present. Hospitalists may be assigned to more than one patient unit and not able to meet you right away.
- When you meet the hospitalist, ask how to contact him or her and best times to call.
- Explain your relationship to the patient and say that you are responsible for his or her care after discharge. The hospitalist then knows who to contact with updates and instructions.
- Give your cell phone number (or other way to reach you) to everyone involved in your family member’s care. This information should also be written in the patient’s chart and shared with the team. Doing so makes it easier to follow HIPAA privacy rules because the team can share medical information with you as the person responsible for the patient’s care (unless, of course, the patient objects). See the Next Step in Care guide HIPAA: Questions and Answers for Family Caregivers.
- Ask the hospitalist how long he or she will be on duty. When is the shift change? Who will be caring for your family member on the next shift?
- Ask the hospitalist to contact your family member’s primary care doctor and, as needed, other specialists. If the patient is under the care of one or more specialists (such as a cardiologist), request that the hospitalist check with that specialist about medications or recent tests. Make sure the hospitalist knows the name and contact information for the patient’s primary care doctor.
- Tell the primary care doctor and important specialists that your family member has been admitted to the hospital. Provide the name and phone number of the hospitalist in charge. Many hospitals do not inform community doctors when a patient is admitted. You can help by opening lines of communication between the hospitalist and your family member’s community doctors.
- Review your family member’s medications with the hospitalist. Tell the team about all the medications that your family member takes including over-the-counter medications, herbal preparations, and vitamin or nutritional supplements. Also mention if your family member has had an allergic reaction, such as a rash or difficulty breathing, to certain medications. It helps to have an updated medication list.
You can learn more at the Next Step in Care guide, Medication Management and the Medication Management Form.
Getting Ready for Discharge
Although the hospitalist’s care ends with your family member’s discharge from the hospital, he or she should help with that transition. Here is another important step where your input is important. When getting ready for discharge, make sure that the plan for going home or to a nursing home for short-term rehabilitation is well thought-out and includes all needed services and equipment. Here are some ways to help:
- Find out as early as you can when your family member might be discharged. The hospitalist is the best person to ask since he or she will sign off on the discharge.
- Explore options for care after discharge. A social worker or case manager will help you make the choice of discharge to home (with or without home care services), short-term nursing home rehabilitation program, or long-stay nursing home placement. For more information on common options for care after a hospital stay, see the Next Step in Care guide Leaving the Hospital and Going Where?.
- If your family member is eligible for home care services, make sure you have the agency information and know who to call before the first nurse visit. There may be a gap of two to three days between the first visit and start of services.
- Make sure the needed papers are signed. Medicare requires a doctor to confirm in writing that he or she has examined the patient within 30 days and that the patient needs skilled nursing care. Without this signed paper, the home care agency cannot “open the case” (begin treating your family member). The doctor signing this paper can be a hospitalist or community-based doctor who has seen your family member within the past 30 days.
- If there are home care services, make sure the home care agency knows who is in charge of your family member’s medical care after the hospital discharge. This is important because the home care nurse should know who to call with questions about medication changes.
- Let the primary care doctor know when your family member will be discharged from the hospital. This way, he or she knows to expect a discharge summary and perhaps a call from the hospitalist about pending test results or medication changes. Sometimes this communication does not happen.
- Make an appointment for your family member to have a post-discharge visit with the primary care doctor. This visit should take place as soon as possible.
Who Pays for Hospitalist Care?
Many hospitalists work directly for a hospital, a hospital corporation, or a health care system. Some belong to independent hospitalist groups that contract with hospitals to provide services. Some large primary care group practices provide hospitalist care. Hospitalists may be paid a salary or combination of salary plus productivity or quality bonuses. Each of these ways can impact your family member’s healthcare bill.
Most hospitalist services will be paid for by insurance, including Medicare. This is billed as part of the hospital services. Your family member might receive a separate bill from the hospital or the hospitalist group for services not covered by insurance. This is like the way anesthesiologists or other specialists bill separately for their services, and in the old system, a primary care doctor would bill for each hospital visit. Ask the hospital social worker to explain what costs to expect. If your family member has already been discharged, call the hospital, hospitalist group billing office, or your insurance company to learn more about the bill.
After Discharge
Make – and keep – follow-up appointments with your family member’s community doctor. At each appointment, bring an updated medication list that includes any new, changed, or stopped medications. Tell the doctor about anything important that might not be on the discharge summary. This includes how your family member responded to having tests or other procedures. The doctor needs to know whether your family member had any unusual memory lapses or other things that worried you.
For most people, it is a big change to be treated by a hospitalist. At first this change may feel unsettling and upsetting. The good news is that there are many ways you and the hospitalist team can work together to provide the best care for your family member.
© 2013 United Hospital Fund