UNC Health Talk

Inside Job

by Zach Read – zachary.read@unchealth.unc.edu

For Charlotte-area native Allen Liles, MD, associate professor of internal medicine and pediatrics at the UNC School of Medicine, North Carolina has always been home. Liles received his undergraduate and medical degrees from UNC and served as chief resident of internal medicine at UNC Hospitals.

“My mom still lives in the same house as when I was two years old,” says Liles. “Other than two years of school at the University of Virginia, Raleigh was as far as I made it from UNC.”

After completing residency, he spent three years practicing primary care at WakeMed Hospitals. He loved the experience because the clinic’s AHEC status allowed him to continue teaching residents. In 2003, however, the opportunity to spend even more time working with residents brought him back to UNC Hospitals as residency program director of the combined internal medicine and pediatrics program.

“I like to say that Roy Williams followed me home that year,” Liles says, laughing.

All joking aside, the position was Liles’ dream job. He was able spend a large portion of his time caring for patients, attending in the newborn nursery and on the pediatric wards, as well as in the pediatric ED and internal medicine wards, and focusing, once again, on medical education on an everyday basis. In 2008, after five years as residency program director of the combined internal medicine and pediatrics program, a position opened at UNC Hospitals that drew his attention: director of the UNC Hospital Medicine Program.

“It seemed like a huge platform from which to affect care,” says Liles. “I could improve how care is delivered on a broader scale.”

It seemed like a huge platform from which to affect care. I could improve how care is delivered on a broader scale.”

Last month, Liles, as lead hospitalist at UNC Hospitals, was one of ten physicians nationwide to be named American College of Physicians Top Hospitalists (ACP) for 2014 by ACP Hospitalists. Based on achievements in quality improvement, patient safety and satisfaction, high-value care, and medical education, receiving the award requires nomination letters from supportive colleagues. The ACP Hospitalists editorial board then decides on the winners.

Liles smiles when asked to describe what exactly a hospitalist does.

“When I explain it to my family and friends, I begin by telling them it’s a made-up word,” he says. “It’s just an inpatient physician.”

The word’s early usage, Liles says, can be traced to the New England Journal of Medicine in the mid-1990s, though the idea that someone would focus solely on the inpatient side of care originated much earlier.

“The days of my uncle, a family doctor in Albemarle County who delivered babies, saw families, rounded in the hospital, managed a busy clinic, left clinic if there was an emergency, are no longer possible today,” says Liles. “Patients’ medical needs have become more complex and have increased in number. As health care has grown, it has become too difficult for a physician to manage a clinic and an inpatient census. It’s just impractical and can’t happen today.”

Hospitalists, Liles says, play a critical role in delivering care to admitted patients more efficiently. The patient’s care becomes more focused – better – if an inpatient physician partners with the patient’s outpatient physician after admission. Patients are able to communicate about their needs more readily with the inpatient physician and the inpatient physician can react more seamlessly to any acute care needs. Inevitably, the patient moves more through the hospital more quickly and more safely.

In addition to working closely with the patient’s outpatient physician, the hospitalist navigates units and specialties within the hospital to manage the care of the patient, creating a division of labor that clearly identifies roles for care providers. One example of this in action is a joint Hospital Medicine, Orthopedic Surgery, Emergency Medicine project involving treatment of elderly patients with hip fractures at UNC Hospitals. Prior to the implementation of the project, pre- and post-operative care was the responsibility of the orthopedists. Liles worked with orthopedic surgery on a solution to co-manage pre- and post-operative care between hospitalists and orthopedists.

“Immediately, the emergency medicine physicians were relieved that internal medicine physicians were one call away if hospitalization was needed,” he says. “It took a lot of flexibility from everyone – nurses and physicians – to get more comfortable with the surgical post-op management, but people across disciplines worked together to form care plans and keep care focused on these often frail elderly patients. It broke down a lot of barriers. We said, ‘You take care of the surgical fix. We’ll manage the care pre-operatively and post-operatively, and we will ensure safe and high-quality care throughout hospitalization.”

Hospital Medicine has also implemented a procedure service that frees up specialty teams to continue giving care to their patients, and in the near future, the program will provide services to neurosurgery patients to relieve neurosurgeons of post-operative care and allow surgeons to enhance their availability.

“If you start the morning and you have 15 patients you have to see, but that fourth patient needs a lumbar puncture, in the past you’d have a decision to make,” says Liles. “You could stop and do it and make the rest of your patients wait or you could finish seeing all the patients and make the patient who needs a lumbar puncture wait. Through the procedure service, today you can give us a call and we’ll supervise your resident doing it or we’ll do it for you. It’s a huge timesaver and more efficient care for the patient. Physicians are able get more done in a more time-efficient manner, which means better care.”

“We want to deliver excellent, efficient care – what you would want for your mom if she were admitted.”

Liles is currently investigating another area for improvement: care of high-need patients. During readmission prevention, he was struck by the number of serial readmissions that occur among a small group of patients. Hospitalists, Liles says, have become, essentially, primary care physicians for these high-needs patients at UNC Hospitals.

“To me, the fragmentation of their care is a marker that things are not going well in their lives or in their care outside the hospital,” says Liles. “By focusing on those most vulnerable, we realized this represented about 55 patients. This is a small enough number that we can find ways to make a difference in their care. It may take a year or two but we should be able to touch each of their lives and refine their care such that it can improve. I think that the hospitalists are centrally located to coordinate multiple subspecialists and primary care doctors and get us all on the same page.”

In 2008, when Liles first started as director of the UNC Hospital Medicine Program, he was among a handful of doctors in the program. Today, more than 30 physicians make up the program. He credits hospital leadership for understanding the important role hospitalists can play in streamlining care, improving quality, and saving costs.

“We’re thrilled that people see the benefit of the work we do,” says Liles. “We all want the same thing. We want to deliver excellent, efficient care – what you would want for your mom if she were admitted.”