The Extensivist Model

By one estimate, incorporating extensivists fully into the primary care system could save 6% of U.S. spending on healthcare.

This article first appeared in the September 2016 issue of HealthLeaders magazine.

With primary care physicians already stretched to the limit but still facing demands to pay more attention to the patients requiring the most time and resources, some healthcare organizations are embracing an extensivist model that uses specially trained physicians and advanced practice registered nurses to provide comprehensive and coordinated care to patients with multiple complex medical issues.

Extensivists typically take their scope of practice beyond the hospital and into the home or other settings, with a focus on keeping patients healthier and reducing readmissions.

Some organizations incorporate extensivists into their primary care lineup, while others operate separate full-service clinics with extensivists, usually with small patient panels to allow a more intense focus on each patient. The impact of extensivists can be significant, with the global management consulting company Oliver Wyman estimating that incorporating them fully into the primary care system could save 6% of U.S. spending on medical care.

A Payer and a Partner Make the Case for Extensivists

An extensivist model can address one of the biggest threats to patient safety and optimal outcomes—the patient handoff, says Arnold Milstein, MD, MPH, director of the Clinical Excellence Research Center at Stanford (California) University and medical director with the Pacific Business Group on Health, a not-for-profit business coalition based in San Francisco.

Milstein first came across the extensivist approach in the CareMore Model, developed by the CareMore health plan focusing on senior care. The model focuses on reducing the risks from handoffs and improving care after discharge. CareMore is an HMO/HMO SNP plan with a Medicare contract, based in Cerritos, California.

"Primary care doctors generally are not set up to respond to urgent occurrences, waiting for the patient to call them and feeling responsive if they can schedule the patient within a week of discharge," Milstein says. "With older patients, and especially with the shorter inpatient stays that are common now, they have a lot of needs after discharge and they can get in serious trouble fast."

Key to success No. 1: Look beyond discharge
The CareMore Model adopted the extensivist idea by dedicating an APRN or physician to care for the patient while admitted and well into the postdischarge period, providing in-home care nurses to support the physician's care plan. Milstein studied CareMore's experience and found that its extensivist model is effective for older and sicker patients, but not as much for patients under 65, with intact cognitive abilities, who are well educated, or with capable spouses able to help at home. An extensivist would be overkill for those patients, a waste of an expensive resource, he says.

"But with patients who are elderly, fragile, and without a good support system at home, if your intended processes don't go through as planned then things can go very bad, very fast," Milstein says. "With those patients the extensivist can make a real difference. No matter how well written your discharge note, with this set of patients the likelihood is high that a patient who was stabilized at very high cost in the hospital will suffer setbacks when you put them in their homes."

Data from the January 5, 2016, study "Delivery Models for High-Risk Older Patients: Back to the Future?" in The Journal of the American Medical Association, authored by Milstein; Brian W. Powers, AB; and Sachin H. Jain, MD, MBA, show that extensivists reduce both hospital lengths of stay (from 5.3 days to 3.7 days) and 30-day hospital readmissions (from 18.4% to 14.7%).

Milstein expects the extensivist model to be adopted more widely as Medicare and private payers continue pressuring physicians and hospitals to do more with less, particularly with the Merit-based Incentive Payment System kicking off in 2017.

Key to success No. 2: Forget productivity goals
The extensivist model is making a difference at Austin (Texas) Regional Clinic (ARC), which has 21 locations, with 18 providing primary care, says Anas Daghestani, MD, chief of internal medicine and medical director of population health and clinical quality. ARC developed an extensivist program that is located at two of its primary care clinics, in which a primary care physician works closely with a nurse practitioner and two RN case managers. A behavioral health counselor also is available to work with the extensivist team.

The model improves patient satisfaction and perception of health, says Daghestani. Unpublished research at ARC has suggested that emergency department visits and hospital admissions are lower for patients treated by extensivists, he says.

The extensivist clinic is not run on a productivity model, Daghestani says. New patients are scheduled for one-hour appointments, established patients for a half hour, and hour appointments are available for established patients as needed. That limits the patient volume to about half of the roughly 100 patient visits per week that are typical for a primary care physician, according to a 2014 productivity survey by Medical Economics.

High-risk populations have 24/7 access to a small team of RN case managers who get to know the patients well, he says. Those patients avoid the normal triage and clinician contact system, instead going directly to one of the case managers when they have questions or concerns. The extensivist team meets every morning for a huddle to discuss patient updates and schedules for the day and week, he says.

The geographical spread of the ARC system was a challenge for patients who originated in one of the other clinics, as well as the sense of abandonment that some patients feel when their care is transferred from their primary care physician to the extensivist team, Daghestani says.

"We had to tweak our message to convey that this is a consulting arrangement, a short-term arrangement even though it may last up to two years," he says. "We explained that this is an opportunity for the patient to benefit from extended resources."

Key to success No. 3: Anticipate financial challenges
Most patients end up appreciating the additional access and resources from the extensivist program, Daghestani says. The economics of the program can be challenging, however.

The concept does not work well in a fee-for-service environment because the resources offered increase while the patient volume is cut in half, he says. The model works well in a truly capitated system but will be challenging in many practices, he says.

ARC also plans to enhance the branding for the extensivist program to highlight the clinics as "transition of care" resources for physicians who have patients being discharged from the hospital, Daghestani says. That strategy is intended to address some of the financial challenges inherent in the extensivist model.

"When you are transitioning from fee-for-service to value and eventually risk-based reimbursement, eventually the model stresses out financially because you continue to add costs to the clinic and you're not pushing the volume up because that is not the concept," Daghestani says.

If the model can be sustained under the coming reimbursement changes, Daghestani expects the extensivist clinics to become ARC's "senior clinics," making the extensivist approach more of a natural evolution in care for the system's patients rather than a special and separate service. The senior clinics would be an extension of the primary care practice where more resources and support are available, he says.

Key to success No. 4: Consider a hospitalist/extensivist model
In some cases the extensivist takes the form of a hospitalist who is assigned to an admitted patient and then provides care after discharge before handing the patient over to the primary care physician, says David Meltzer, MD, PhD, chief of the Section of Hospital Medicine at the University of Chicago Medicine.

A primary benefit of the extensivist model is stabilizing the patient before the handoff to the primary care physician, he says. With the hospitalist/extensivist model, benefits can be realized without adding the expense of another healthcare professional.

"Every time you add more people, you have more costs and more coordination problems," he says. "If the hospitalist hands off to a care coordinator, and the care coordinator hands off to the primary care doctor, then you still have problems of coordination, costs, and good handoffs. The extensivist model gives you extended care coordination."

The University of Chicago Medicine had tried to improve the continuum of care by having the same doctor provide care in both the hospital and ambulatory care settings, Meltzer says, but there weren't enough patients at risk of hospitalization to justify the doctor's presence on a daily basis. With the emphasis on avoiding hospital admissions, a primary care doctor can be busy with patients in the clinic all day but have few patients in the hospital, which is typical in primary care, he notes.

"When you do have someone in the hospital, it's difficult to leave your busy clinic to go see them," he says. "It would be great for primary care physicians to go see their patients in the hospital every day like they used to, but if that's not possible, extensivists help fill that gap by providing some continuity of care from the hospital experience and back to the primary care physician."

Key to success No. 5: Adjust physician volume
Working from that premise, Meltzer and his colleagues pioneered the Comprehensive Care Physician (CCP) model—a model that shares similarities with extensivist programs, according to the January 2016 JAMA study—in which physicians provide both inpatient and outpatient care for patients at increased risk of hospitalization, leveraging the power of the doctor-patient relationship to improve outcomes and control costs. This model utilizes a subset of physicians who only see patients at high risk of hospitalization, making their panels small enough that they can provide all the patients' primary care in the afternoon and always have enough patients in the hospital to justify morning rounds every day.

Whereas a typical primary care physician may see 2,000 or more patients annually and have few ever admitted to a hospital, a physician in the CCP model may have only 200, Meltzer says. But because those 200 patients are quite sick, they are often in the hospital.

"We're making it possible for them to do what primary care doctors used to do, seeing their patients in the clinic and the hospital," Meltzer says. "And by doing that, we're improving that continuity of care so that there are fewer handoffs and we hope better outcomes."

Meltzer and his colleagues have been studying the results with 1,950 patients involved in a trial of the CCP model and expect to have results soon. Several hospitals have expressed interest in adopting the model, and some are taking the first steps in that direction, he says. Scale and efficiency are important in making the CCP model work, Meltzer says. The program has to be large enough to provide the patient volume necessary for the physicians to be successful, but it also must not grow too quickly.

"The trick in this model is identifying the patients at high risk of hospitalization and helping the doctors build up a practice that focuses on them," Meltzer says. "You don't want to overhire so that you have physicians sitting on their hands waiting for patients, but you can't under hire or the physicians will be overwhelmed and burn out. That would destroy the continuity in the relationship, which is the secret sauce that makes the whole thing work."