Hospitalist programs, common in medium-sized and large hospitals for years, have been too costly for many smaller and rural hospitals to adopt. But a new model using nurse practitioners opens the door for small and critical access hospitals, in some cases with dramatic results for patient outcomes and patient satisfaction, as well as for physician retention rates. They could even be a key to the survival of some of America’s most challenged hospitals.
Nurse practitioners run the hospitalist program at Rusk County Memorial Hospital in Ladysmith, Wis., overseen by an off-site collaborating physician. “Without the creation of our hospital medicine program, it is unlikely our hospital could have survived,” says Charisse Oland (pictured right), CEO of Rusk, a 25-bed bed hospital with a service area of about 18,000 people.
A few years ago, an independent medical group that had been providing much of the area’s primary care started having a difficult time attracting new physicians to replace those who left. On top of that, the physicians who remained increasingly referred patients to another hospital 45 minutes away.
Rusk took several steps to address the problem, including starting its own primary care clinic. But it was the adoption of a nurse practitioner hospitalist model pioneered at two other Wisconsin critical access hospitals — Eagle River Memorial Hospital and Aspirus Medford Hospital — that sparked an impressive turnaround.
The accompanying case study digs deeper into the Rusk success story, including the three scenarios hospital leaders considered in choosing and designing the hospitalist program, how the program works and the lessons learned along the way.
Other hospitals are discovering the value of the nurse hospitalist, as well. Several small hospitals in Indiana and Ohio contract with Hospital Care Group, which uses NP hospitalists to supplement care provided by physician hospitalists. Hospital Care Group employs 25 physicians and 15 NPs who provide round-the-clock hospitalist coverage at 10 hospitals. The mix of physician and NP staffing varies from one hospital to the next, depending on each one’s medical staff needs and what it can afford.
“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 company’s CEO.
By contrast, the NP hospitalist at Pinckneyville (Ill.) Community Hospital 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 (pictured left). “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 offices 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,” he says, “it’s been wonderful.”
What’s happening at small hospitals
Compared with larger community hospitals and tertiary and 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. “That’s where nurse practitioners really come in — the bottom line is that they are half of the cost of a physician in terms of total compensation costs.”
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 take the patient’s history and physical, record the discharge summary and order ancillary tests.
Although the physicians are still rounding with patients, the NP hospitalist enables 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.
Rusk employs advanced practice nurse prescribers as hospitalists, and Oland also reports improved customer service for patients. The APN hospitalists “really enjoy engaging with patients and their families,” she says. “They’re available whenever the family needs them, rather than just morning or evenings, and spend more time than under the old model. Our climbing patient satisfaction scores are indicative of these improvements.”
NPs, PAs in hospital medicine
The use of NPs in hospitalist programs has been growing for nearly a decade, says Tracy Cardin, an acute care nurse practitioner and a hospitalist at the University of Chicago Medical Center. 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.
Traditionally, many hospital medicine programs have used advanced practice nurses 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.
For example, the UChicago Medical Center has seven hospitalist teams. Of those, five comprise APNs and physicians; one has only physicians; and one has only APNs.
“I work at the maximum scope of practice and rely on my physicians when I need higher-level medical decision-making,” Cardin says.
In some hospitals, nurse 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.”
Cardin, who last year became the first NP elected to the SHM board of directors, believes that hospital medicine programs are heading toward significant change, and that NPs and PAs increasingly will become important. 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,” she says. “With hospitalist physician salaries going up in an era of shrinking reimbursement, that is not a sustainable business model.”
That said, few observers expect nurse-led hospitalist programs to become standard in the foreseeable future because most hospitals want physicians to be involved in inpatient care, Drapala says. “Even if regulations allowed nurse practitioners to function independently, we would still provide that physician backup coverage because we just feel that’s the right quality of care to provide patients,” he says.
Challenges at hand
Hiring NPs and PAs as hospitalists requires careful attention to myriad laws and regulations at the federal, state and institutional levels.
Laws regarding the scope of practice of advanced practice nurses — that is, how independently they can work — vary greatly 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. While there is broad interest in having NPs and PAs take on the hospitalist role, there’s also a lack of clarity about what exactly they can and cannot do. A three-part webinar series hosted by the WHA to address these issues last year drew an audience of nearly 400 individuals from 78 hospitals.
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. So, it may be difficult to determine whether a state statute allows an advanced practice clinician to admit a patient to a nursing home or activate a power of attorney, for example. The WHA is supporting legislation to begin to address such ambiguities in Wisconsin.
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 APNs assume responsibilities previously handled by physicians. In some hospitals, bylaws require a physician to co-sign notes written by APNs, Flores says. At Rusk, medical staff bylaws used to say 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.
Meanwhile, physicians felt 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 oles, 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 sometimes require a physician to sign off on a midlevel hospitalist’s work. Hospitals with successful programs stress the importance of a sound onboarding program to make sure NPs and PAs are fully trained for the new roles they’ll be taking on.
In some cases, physician hospitalists are initially reluctant to trust NPs or PAs, which is particularly problematic if the physician is required to approve their work; but Cardin finds that, in time, physicians grow to appreciate the program.
“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.”
Executive Corner: How to Choose A Nurse Practitioner Hospitalist
Here are some tips from those with experience in choosing a nurse practitioner for a hospitalist program.
- Do not assume that an NP’s training program provided all the education needed to succeed as a hospitalist. “I always say that when you hatch doctors from their doctor box, they are pretty much ready to doctor the day that they hatch,” says Tracy Cardin, an acute care nurse practitioner at the University of Chicago Medical Center's 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 are a limited number of acute care training programs for NPs currently.
- 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 good candidates,” says Charisse Oland, CEO of Rusk County Memorial Hospital in Ladysmith, Wis. On the other hand, an NP who worked as an intensive care unit or medical-surgical 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. Nurse practitioners usually 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 usually will do 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.”