Trustee talking points
- A growing number of small and rural hospitals, unable to recruit or afford physician hospitalists, are staffing their hospital medicine programs with nurse practitioners.
- Hospitals that use this approach must comply with state and federal regulations regarding scope of practice, billing and other factors.
- In many states, NPs can manage patients independently with access to a collaborating physician who does not have to be on-site.
- Hospital medicine is frequently not part of NP training programs, so hospitals must assess NPs' capabilities carefully and use an onboarding process that corresponds to their level of preparation.
Hospitalist programs, ubiquitous in medium-size and large hospitals for more than a decade, are now emerging in the nation’s smallest hospitals. Some of these facilities are pioneering new staffing models that may point the way to the future of hospital medicine.
In Ladysmith, Wis., nurse practitioners run the hospitalist program at Rusk County Memorial Hospital with oversight from an off-site collaborating physician. The NP-only model, which was pioneered at two other Wisconsin critical access hospitals, was the linchpin of a turnaround when the hospital’s future was threatened.
“We had to make a change to a different model that better reflects how people want to be served today and who wants to serve them,” says Gordon Dukerschein, chairman of Rusk’s board of trustees. “It really was our salvation.”
In several small hospitals in Indiana and Ohio, Hospital Care Group uses NP hospitalists to supplement the care provided by physician hospitalists.
“Our primary model is to have a physician there during the daytime and a nurse practitioner covering that hospital either on-site or off-site during the night, usually from 5 p.m. until 7 a.m.,” says Mark Drapala, the hospitalist company’s CEO.
By contrast, the NP hospitalist at Pinckneyville Community Hospital in Illinois works weekdays, allowing him to round with primary care physicians as they check on their patients and provide continuity of care throughout the day. “He is constantly in and out of the rooms, checking on each patient, regardless of their acuity level,” says CEO Randall Dauby. “The perceived care is better, the customer service is better, and the results are showing up on our Press Ganey scores.”
Pinckneyville’s NP hospitalist sits on the hospital’s quality council and works on process improvement initiatives that community physicians don’t always have time for.
“Our physicians are happy because they get to their office quicker,” Dauby says. “And the improvement in 30-day readmissions has been great because the nurse practitioner is involved in the discharge case management process. Overall, it’s been wonderful.”
Nearly 65 percent of all adult hospital medicine programs and 33 percent of pediatric programs use either NPs or physician assistants in some capacity, according to the 2016 State of Hospital Medicine Report, based on a biennial survey conducted by the Society of Hospital Medicine. That’s about the same as reported in 2014 but up significantly from 2012, says Leslie Flores, a partner in Nelson Flores Hospital Medicine Consultants and a member of the society’s practice analysis committee.
In previous surveys, respondents reported that the work of NPs or physician assistants was sometimes not billed to a payer, or their work was billed as “shared services” using the physician’s provider number. “More recently, we’re finding that a much higher proportion of practices are using their NPs and PAs in ways that allow them to bill independently under their own provider numbers,” Flores says.
She attributes that to the ongoing shortage of hospital physicians, noting that hospitalists now care for the vast majority of inpatients across the country. In addition, physician hospitalists are becoming more familiar with and confident in the capabilities and clinical scope of their NP and PA colleagues.
That shortage is perhaps best documented by the continuing rise in compensation for physician hospitalists. In 2015, median compensation for adult hospitalists was $278,472, up almost 10 percent from 2013, according to the Medical Group Management Association, which licenses its hospitalist compensation and production data to SHM for the State of Hospital Medicine Report. Since 2010, the median compensation for adult hospitalists has risen 26 percent.
That trend tells Tracy Cardin, an acute care nurse practitioner and a SHM board member, that hospitalist medicine programs are heading toward significant change. As hospital revenues decline in the emerging era of value-based reimbursement, hospitals will be unable to afford a hospitalist staff that is entirely or primarily composed of physicians.
“All hospital medicine practices rely on hospital funds transfer to survive,” says Cardin, an NP hospitalist at the University of Chicago Medical Center. “With hospitalist physician salaries going up in an era of shrinking reimbursement, that is not a sustainable business model.”
Traditionally, hospital medicine programs have used NPs and PAs in support roles that do not take full advantage of what they have to offer, Flores says. She sees that changing as the hospital medicine field matures.
In some hospitals, NP and PA hospitalists are responsible for admitting patients during evening or night shifts. In others, they are co-managing a specific patient population, in conjunction with a physician hospitalist.
“Or, they might be running the observation unit for the hospital, working pretty independently,” Flores says. “We are starting to see people becoming much more thoughtful about how they are using NPs and PAs so they can function more independently and really make use of their advanced practice license and skills.”
Compared with larger community hospitals and tertiary/quaternary care centers, critical access hospitals have been slow to adopt hospitalist programs, primarily because of the cost. But as small-town physicians get older, they want to cut back on their inpatient responsibilities, and younger physicians are reluctant to take jobs that require call duty.
“As time goes on, a lot of small hospitals are falling into the dilemma of how they are going to take care of inpatients at their hospitals,” Drapala says.
When Rusk, a CAH that maintains an average daily census of six to eight patients, faced that dilemma, its trustees knew they needed to act quickly. Physicians were referring patients to other hospitals, and market share dropped dramatically.
“We have a lot of pride in our community, and the hospital is a really important part of the vibrancy of our region,” Dukerschein says. “Without the hospital, local businesses’ ability to recruit professionals and workers to the area would be very challenging.”
The board decided to invest in starting Rusk’s own physician clinic and launching a hospitalist program so physicians did not have to take call duty, thereby making it more likely that physicians would stay in the community.
“We didn't have a lot of choice,” Dukerschein says. “This was, as I could see, our only path forward.”
And it’s working. Even though the hospitalist program is a major new expense for Rusk, the increase in patient census that it yields makes the investment worthwhile, he says.
“That’s where nurse practitioners really come in” Drapala says. “The bottom line is they are half of the cost of a physician in terms of total compensation costs.” The median compensation for NP and PA hospitalists was $106,246 in 2015, a 3 percent increase from 2013, Flores says.
In Pinckneyville, three primary care physicians still round on their inpatients and take call duty every third weekend, but the hospital finds that paying for an NP hospitalist is money well-spent, Dauby says. The NP hospitalist works closely with each physician and uses the electronic health record system to do the history, physical and discharge summary and order ancillary tests. Although the physicians are still rounding with the patients, the NP hospitalist allows them to spend less time in the hospital, freeing them up to see more outpatients.
“We have better customer service for our physicians,” Dauby says.
For Rusk, advanced practice nurse hospitalists have also improved customer service for patients, Rusk CEO Charisse Oland says. They “really enjoy engaging with patients and their families,” she says. “They are available whenever the family needs them, rather than just morning or evenings, and spend more time compared with the old model. Our climbing patient satisfaction scores are indicative of these improvements.”
Challenges at hand
Hiring NPs and PAs as hospitalists requires careful attention to a myriad of laws and regulations at the federal, state and institutional levels. Laws regarding the scope of practice for NPs and PAs — that is, how independently they can work — vary greatly state by state. But that is just the beginning of the state issues to consider.
“Often, the focus of attention is on the issue of independent practice, but there needs to be more focus on other statutes and regulations that can have a significant impact on the utilization of advanced practice clinicians,” says Matthew Stanford, general counsel for the Wisconsin Hospital Association.
Indeed, when the Wisconsin Hospital Association hosted a three-part webinar series last year on the use of NPs and PAs in hospitalist programs, nearly 400 individuals from 78 hospitals tuned in. That shows the breadth of interest in using midlevel practitioners as hospitalists — and the lack of clarity about what those clinicians can and cannot do.
Because so many laws and regulations were written when only physicians managed patient care, some may unintentionally limit other clinicians from handling certain tasks permitted by the clinician’s licensure, Stanford says. For example, does a state statute allow an advanced practice clinician to admit a patient to a nursing home or activate a power of attorney? The WHA is advancing legislation to begin to address such issues on the books in its state.
Meanwhile, the Centers for Medicare & Medicaid Services’ billing rules for physicians differ from those for midlevel providers. And Medicare requires a physician’s signature for inpatient admissions and discharges.
Beyond that, medical staff bylaws may need to be adjusted as NPs and PAs assume responsibilities previously handled by physicians. For example, Rusk’s bylaws previously stated that physicians could vote on hospital practices only if they were admitting a certain number of patients to the hospital each year. When the NP hospitalist model was adopted, most physicians would have lost their voting privileges because they no longer met that criterion.
“We rewrote our bylaws to allow physicians who are actively participating in committees — quality, infection prevention, peer review and so forth — to continue to have an active status and to be able to vote on our medical staff,” Oland says.
Physicians believed strongly that an NP hospitalist should not be a medical officer or director of a hospital department, and that was codified in the medical staff bylaws.
Sorting out roles, responsibilities and working relationships is another challenge that hospitals face as NPs and PAs take on hospitalist duties. In addition to scope-of-practice limits in some state statutes, medical staff bylaws sometime require a physician to sign off on a midlevel hospitalist’s work.
In some cases, physician hospitalists are reluctant to trust NPs or PAs — which is particularly problematic if the physician is required to approve their work.
“We have to be respectful of the physicians’ concerns, and their main concern is always, ‘I’m going to get sued,’ ” Cardin says. “What I find is that once they work with NPs and PAs, they love them, and the working relationship increases physician satisfaction.” T
Lola Butcher is a contributing writer to Trustee.
One challenge of nurse-led hospitalist programs is finding the right nurse practitioners to fill the positions. For one thing, nurse practitioners are in high demand, so recruiting them to small, rural hospitals can be difficult, says Gordon Dukerschein, who chairs the board of Rusk County Memorial Hospital in Ladysmith, Wis. Beyond that, Rusk experienced quite a bit of turnover among its nurse practitioner hospitalists in the first two years of its program, possibly because the schedule — on duty round-the-clock for seven days, then off for two weeks — is not easy for everyone to adapt to.
“It was such a new model, and I think the nurse practitioners had to settle into what this type of job means,” Dukerschein say. “We’re happy with the people we have now. But the situation is not perfect simply because there are just not enough people to choose from in most medical jobs, and that certainly includes nurse practitioners with inpatient care experience.”
Other things to think about when establishing a nurse-led hospitalist program:
- Do not assume that an NP’s training program provided all the education needed to succeed as a hospitalist. “I always say, when you hatch doctors from their doctor box, they are pretty much ready to doctor the day that they hatch,” says Tracy Cardin, a nurse practitioner in the University of Chicago Section of Hospital Medicine. “NPs are not like that — there’s a wide range in the rigor and vigor of graduate-level education.”
Cardin, a member of the Society of Hospital Medicine, points out that many NPs have special training in, for example, family medicine or emergency medicine. There currently are a limited number of acute-care training programs for NPs.
- Look for inpatient experience. “People who have been NPs for 20 years but have been working in a clinic setting are less likely to be a good candidate,” says Charisse Oland, Rusk CEO.
On the other hand, an NP who worked as an intensive care unit or med/surg nurse before pursuing NP training may adapt easily to the hospitalist role.
- Use an extensive onboarding process, if possible.
At Rusk, which has an average daily census of six to eight patients, all new hospitalists go to a weeklong “hospitalist boot camp” and/or shadow another NP hospitalist at another critical access hospital for a week, complete a competency assessment, and have mentoring time with the collaborating physician.
Hospital Care Group, which provides hospitalists through contracts with 10 hospitals in Ohio and Indiana, typically places NPs in night and weekend shifts while physicians fill the weekday shifts. NPs typically spend up to two months in orientation before they begin practicing, says CEO Mark Drapala.
“They will round with our nurse practitioners at night for usually four to six weeks, and then they will do usually two weeks of rounding with the physician at that hospital during the day, just to get comfortable with how the physician practices,” he says. “That is because most NP programs provide very limited inpatient training.”
Cardin, who practices in a busy tertiary care setting, says administrators should expect an even longer period for inexperienced NP hospitalists to become fully acclimated.
“If you look at the most successful programs, they have a very vigorous onboarding structure to get people up to speed,” she says. “They have mechanisms for ensuring that people are adequately prepared — it’s a nine-month onboarding, not two weeks.”