The Holston Medical Group Extensivist Clinic: Delivering Hospital-Level Care in an Ambulatory Setting

By the Playbook staff

Dr. Chris Neglia is a hospitalist physician and co-founder of the Holston Medical Group’s Extensivist Clinic in Kingsport, Tennessee. The Holston Medical Group is an independent multi-specialty physician group with more than 150 primary care physicians, specialists and mid-level providers, serving Johnson City, Kingsport, and Bristol, Tennessee as well as surrounding communities in Northern Tennessee and Southern Virginia. Rob Mechanic, Executive Director of the Institute for Accountable Care and Senior Fellow at Brandeis University, recently spoke to Dr. Neglia for the Playbook.

Q:  Tell us about your Extensivist Clinic and why the clinic is different from urgent care?

A:  Thank you for having me. The Extensivist Clinic is staffed with hospitalists who traditionally manage patients inside the hospital. Rather than seeing patients in an inpatient setting, our physicians they work in a freestanding outpatient clinic. The clinic also employs experienced registered nurses (RNs) who have worked in emergency departments and hospital intensive care units. We employ RNs because our nurses need to administer IV medications. They are more comfortable treating more severely ill patients than a regular office nurse might be. Our goal is to deliver as much medical care as possible that we would traditionally provide in a hospital, outside the hospital setting.

Our patients are much sicker and require much more time to treat. The Extensivist Clinic is more like an emergency department or an observation unit where we’re watching patients for hours to make sure there is improvement and not decline. The illnesses are much more severe and complex.

Q:  What inspired you to start the Extensivist Clinic?

A:  The inspiration was Dr. Harlan Krumholtz’s article in the New England Journal of Medicine where he coined the term “post-hospital syndrome” which is a weakness or vulnerability people develop beyond their illness, just by the fact that they’re in an American hospital. In the hospital, patients become physically deconditioned by lying in a bed all day. They frequently suffer from malnourishment because of the fasting required for lab testing and the rigid meal schedules. They suffer from sleep deprivation. And patients have what I call cognitive overload that is particularly stressful for elderly patients with dementia or cognitive decline. These frail patients may be completely functional in their home environment but get confused and agitated when they’re in the hospital.          

Everything Dr. Krumholtz said just clicked with our hospitalist team. What he was saying wasn’t necessarily new to us, but we finally had it down on paper that people coming to hospitals run into problems.

I’m proud to say that that article came out in January of 2013, and we had our Extensivist Clinic up and running by May of 2013. Our goal was to manage as many hospital-eligible illnesses as possible without the hospital. We were trying to deliver the same care we would deliver in the hospital but in a condensed timeframe, thereby allowing the patients to go home and sleep in their own bed. That’s how it got started.

Q:  Walk me through what happens to a typical patient who comes to your clinic. What’s it like for them?

A:  We’re not a hospital and so we’re not ready for somebody with a gunshot wound or a heart attack. We’re also not a walk-in clinic. Patients are referred to us by nurses or doctors who are part of the Holston Medical Group. We discuss the patient’s symptoms with them by phone before we accept a referral because we don’t want patients who are beyond our capability to care for safely. We also don’t want patients with simple problems who could be treated in an urgent care center.

We have a triage system designed to make sure the patient’s condition is appropriate for the clinic. If it is, the referring clinician gives the patient the option of the clinic or the ER. Most patients opt for the clinic. When they get here, we do a work-up similar to what I would do in the hospital. If they have pneumonia, they get X-rays, blood work, antibiotics, and IV fluids. And we monitor the patients closely for up to several hours.

After the treatment, we re-evaluate the patients. If we feel they don’t need further intervention and can go home safely, then they are discharged home with a return appointment for the next day. So a patient who might otherwise have a three-day hospitalization for pneumonia or heart failure would usually be seen in our clinic over three days. They receive the same treatments and diagnostics that they would get in the hospital. The only big difference is they go home at night.

Q:  Do they need a family member to stay with them at home?

A:  Well, not everyone gets to go home. We don’t send home elderly patients without a family member or other responsible party to stay with them. And if we feel a patient is unstable or getting worse, we strongly encourage the patient and their family to let us admit them directly to a hospital, bypassing the ER. It’s akin to a hospital-to-hospital transfer

Q:  You mentioned pneumonia, but what the other conditions do you commonly treat in the clinic?

A:  We treat lots of patients with congestive heart failure or volume overload. The patients often need supplemental oxygen because their heart and lungs are full of fluid and they can’t breathe. We treat them just the same as we would in the hospital, with IV diuretics, and we arrange for supplemental oxygen to be delivered when they go home that night.

We treat infections that have outstripped the capacity of oral antibiotics. Infections of the skin (cellulitis), urinary infections, conditions like polynephritis, that need IV fluids, IV antibiotics, and further evaluation. Diverticulitis or colitis in patients who can’t keep fluids or oral antibiotics down.

We get patients with atrial fibrillation that’s has a rapid ventricular response, which is a common hospital admission. We slow it down with IV medications. We have the same medications as the hospital in our clinic and telemetry monitors where we monitor the heart rates until they slow down.

Q:  How many patients would you see in a typical day and over the course of a year?

A:  Usually eight to 12 patients is a typical day because you’re spending hours with these patients. Hospitalists would typically manage about 15 patients a day in the hospital. We have about 2,500 encounters but fewer unique patients because many of them are in the clinic for multiple days.

Q:  You’re providing intensive oversight of patients but in an ambulatory setting. How do you make the finances work?

A:  It’s tough. We figured out that with one hospitalist physician and two RNs our break-even point under fee-for-service is about 10.5 patients a day. We bill for professional services and don’t receive a facility fee. We do bill for infusion codes and several other things but you’re doing the work of a hospital in a clinic so there is a fair amount of expense. The goal is to break even on fee-for-service patients. I believe we deliver better patient care, but the way we justified it financially is that there is a lot of opportunity generate margin under value-based contracts. We have some contracts where we accept full financial risk. When we treat a patient with congestive heart failure for three or four days, we would generally be paid less than $1,000 dollars by a private managed care plan. If we treat the patient in the clinic and save a hospitalization, we save a lot of money.

Q:  Has the Holston Medical Group been able to get good value-based contracts?

A:  It’s been a struggle. I’m not involved in the financial end, but I know that a lot of the insurers, up until this point haven’t been willing to engage in risk-based contracting. Holston Medical Group has been pushing the payers to give us value-based contracts and some are coming along. We have been successful in the Medicare Shared Savings Program. But the extra reimbursement comes back 18 months later. One of the difficult things with the Extensivist Clinic is quantifying what we’re saving our group by avoiding these hospitalizations? It’s not as clear-cut as measuring what you generate in fee-for-service.

Q:  Does the hospital view the clinic as a threat?

A:  I don't think so, mostly because the patients we’re seeing are not their big money generators. I’m not taking away orthopedic surgeries or cardiac catheterizations. I know of some hospitals that have started their own Extensivist Clinics to help them discharge patients faster to cut their length of stay.

Q:  What challenges have you run into?

A:  There are two big challenges that I see. Number one, you touched on already. To be successful financially you need value-based contracts. The other challenge is creating a culture that utilizes the Extensivist model. It’s just easier for a lot of doctors to send the really sick patients to the ER. For me, the greatest challenge is creating a culture of keeping patients out of the hospital if we can do it safely.

Q:  Do you have plans to expand the model?

A:  Up to this point, our Extensivist Clinic has been a reactive model. We are treating sick patients because that’s what we’ve been doing all along as hospitalists. We want to start building a proactive model similar to CareMore or David Meltzer’s Comprehensive Care Physician Model, where we focus on the sickest of sick patients, managing their illness on an ongoing basis so their condition doesn’t decompensate, so they don’t need a hospital or the Extensivist Clinic.

Q:  That’s exciting. I know you’ve had a lot of interest in this model from other groups, and particularly from ACOs. If a group comes to you and wants to set up this type of a clinic, what advice would you give them?

A:  The most important thing is building that culture within your group to utilize this model because it’s outside of some providers’ comfort zones. The actual infrastructure is straightforward. We have regular office rooms with reclining chairs, a half-dozen IV antibiotic choices, and several heart rate controlling medications. So, the startup costs aren’t high.

You still need to find hospitalists who are willing to step out of their comfort zone and work in an office. But good internists and ER docs could also do well in this model. Getting the right nurses is really important. Extensivist nurses need some case managerial skills, because they’re setting up services like home oxygen that are normally managed in the hospital by case managers. The nurses need to have some pharmacy experience. We don’t have a pharmacist, so our nurses mix some of the medicines. But the most important things are the value-based contracts and creating a culture of hospital avoidance.