Change at the bedside

SARANAC LAKE – The days of your family doctor tending to you at your bedside at Adirondack Medical Center in Saranac Lake may be numbered.

Joining a growing number of hospitals across the country, Adirondack Health has assembled its own team of specialized hospital-based doctors, referred to as hospitalists, to provide round-the-clock care for patients during their hospital stay. The change means local private-practice doctors will spend less time in the hospital and on call, and potentially more time seeing patients in their offices.

“The idea is that you have a dedicated physician or physicians in the hospital now 24 hours a day, seven days a week to deal with the hospitalized patients,” said Dr. William Viscardo, one of AMC’s hospitalists. “This is part of the whole revolution in health care.”


Hospitalist programs have been growing across the country over the past 15 years. In the mid 1990s, there were about 7,000 hospitalists in the United States. As of 2012, there were nearly 35,000, according to the Society of Hospital Medicine.

The change has been brought on by a combination of factors, including a transition toward medical specialties and the fact that many new doctors would prefer the shift work allowed under hospitalist programs as opposed to be being constantly on call.

“No physician wants to work 24-7 anymore, so it starts to get pieced out into shift work,” Viscardo said. “So where one doctor used to carry that thread, him or herself, all the time, you’re now breaking that up and you’ve got specialists, of which the hospitalist is a specialist.”

New federal guidelines and mandates, some of which are tied to President Obama’s Affordable Care Act, are also contributing to the growth in hospitalists.

“The hospital has 50 additional quality measures it didn’t have three years ago,” Viscardo said. “Trying to train 100 physicians to meet all those measures is almost impossible. Trying to train four of us or six of us to meet those measures might be possible.”

Financial incentives are also a big driver of the change, including enhanced reimbursements for hospitals that reduce their rates of patient readmission, which studies have shown hospitalist programs can do.

The program

In a press release about the program, AMC officials define a hospitalist as “an acute-care physician, physician assistant or nurse practitioner who cares for a hospital patient from admission to discharge while working with their primary care physician.”

“A hospitalist doesn’t replace a patient’s primary care physician, but does provide care for those patients without a primary care physician,” the release states. “Hospitalists do not provide care to a patient once they are discharged from the hospital.”

AMC’s hospitalist program was launched on a part-time basis by Dr. Frank Nocilla in 2009. It recently went full-time with a team of four physicians and one physician assistant. In addition to Nocilla and Viscardo, who previously was Adirondack Health’s chief medical officer, the program includes Dr. Mandeep Saluja, who joined AMC as a hospitalist in 2011, and Dr. Anthony Lombardi, who just started last week. Alexa Pighini has been a PA in the hospitalist program since August. The program serves patients ages 16 and up.

Although it’s a full-time program now, not all of the private-practice doctors in the community have signed on to the service. Viscardo said Adirondack Internal Medicine and Pediatrics still covers its own hospital patients during the daytime, as does Medical Associates of Saranac Lake.

“They’re using the hospitalist service primarily at night and occasionally in the daytime, whereas Dr. (Barry) Kilbourne and his group (North Country Family Physicians) has basically turned all their patients over to us,” Viscardo said. “The surgeons are kind of in the middle.”


AMC officials say the hospitalist program improves patient care through early intervention and rapid response, like if a patient takes a turn for the worse.

“When a nurse notices a changing condition in the patient’s vital signs, they can call what’s called a rapid response and then everyone comes and does an evaluation,” Viscardo said. “The sooner that anyone responds to a change in condition, the better it’s always going to be for the patient.”

Viscardo said he’s seen a big difference since the hospitalist program has been implemented.

“You have fewer patients crashing,” he said. “It’s real time, it gets noticed and you have a trained eye to evaluate them. It’s not someone getting up at 3 o’clock in the morning, getting in their car and driving in here when it’s 17 below to check on this person.”

“It’s huge for nursing and huge for patient care,” said Linda McClarigan, a registered nurse and the patient care coordinator for AMC’s medical unit. “Getting immediate orders and immediate changes in patient medications, their diet, their activity or their pain – anything that can be handled quickly versus waiting for the doctor to come from their office, or they wait till the end of they day or they do telephone orders. Here, the hospitalists get to actually go and see the patient, put their eyes on them and talk with the nurses.”

McClarigan, who worked in a hospitalist program at Alice Hyde Medical Center in Malone before joining AMC last fall, said studies have shown hospitalists decrease the patient’s length of stay, because the doctor is in the building and able to order additional tests, treatments and perform procedures more quickly.


Both Viscardo and McClarigan said one of the biggest hurdles the program has faced so far is getting people used to the fact that they’re not going to see their own doctor during their hospital stay.

“Everyone’s patients, unfortunately, are going to have to give up this concept of ‘I have one doctor who takes care of me from the day I’m born to the day I die and knows everything about me,'” Viscardo said. “We’re losing a little bit of that.”

Communication will be the key to alleviating people’s concerns, McClarigan said.

“Their primary care doctor is informed of their admission, and communicated with during their stay, and then the primary care doctor also gets a discharge summary when the patient is discharged,” she explained.

Viscardo admits that creating those communication systems is “a little bit of a work in progress.

“Now you’ve got, like in any shift work, handoffs, signoffs and turnovers every 12 hours, whereas in the old days it was one doctor who had all the information in his own brain,” Viscardo said. “You have to build all these systems to protect us, all these automated things like linking of computer systems and getting information to flow.”

Cost, revenue

While large hospitals have had their own hospitalist programs for years, smaller community hospitals like AMC haven’t jumped into the game until recently, Viscardo said. Part of the reason for that is the expense of it.

“The hospitals never had to worry about paying the physicians in the past,” he said. “Now the physicians are all becoming hospital employees. So now that cost is being added, but so is the revenue.”

Where does that revenue come from? From the same patients the private practice doctors used to see at the hospital.

“They can all bill for their admissions, discharges or daily visits to their patients, so we’re making revenue from the hospitalists by them seeing our patients and billing our patients,” McClarigan said.

Private practice physicians will have to see more patients in their office to make up for their lost hospital revenue, but Viscardo says that’s a good thing “because that increases access for people who need to get in when you’ve got a sore throat, a runny nose or you twisted your knee. In theory, yes, they should want to and typically do see more patients in the office, which improves access for all patients.”

“There is a financial incentive (to the hospitalist program), but it also makes sense for the patient,” said Adirondack Health spokesman Joe Riccio. “We’re doing it for the right reasons. It’s for the sake of the patient.”

Doc’s take

One local private-practice doctor says the hospitalist program will have some “bumps in the road,” but he thinks it will become an asset over time.

“Bumps in the road will occur when someone comes into town who doesn’t know any of the systems that are in place,” said Dr. George Cook of North Country Family Physicians. “There are so many different referral patterns we’ve all generated over time. So you can imagine sending some new people into the breech that there would be difficulties in communication.”

Another concern, Cook said is that the hospitalist generally only deals with acute care, when a patient could have other significant issues that need attention.

New doctors interested in primary care may be more inclined to join a hospitalist program, given its more regular hours, which Cook said is good for AMC but could lead to to less physicians joining or starting up their own private practices.

Cook said he’s been doing a “mix and match” where he takes advantage of AMC’s hospitalist program but also still sees some of his patients when they’re at the hospital.

“There are definitely advantages to having the system, especially if one is able to remember that these folks are our patients and we should keep up with all their problems,” Cook said. “It certainly is easier on me in terms of my schedule. It may take 10 or 15 years before it’s running smoothly, and it’s going to have its ups and downs, and then it will finally become a great addition to the system.”

What’s next?

Viscardo and McClarigan said they’ll continue to try and iron out issues with the hospitalist program, such as streamlining and improving communications, as it evolves.

“We’re getting stable now,” McClarigan said. “We’ve got some stable hospitalists now and that will truly help the continuity of care and the development of a relationship between the docs that work in the community and the hospitalist docs, so that they’re more one, caring for their patients.”

Contact Chris Knight at 891-2600 ext. 24 or