When the independent primary care group that served Rusk County Memorial Hospital started referring patients to a competing facility in another community, the critical access hospital in Ladysmith, Wis., faced a crisis. The hospital’s market share fell from 43 to 21 percent between 2011 and 2013, and patient satisfaction scores plummeted.
Rusk’s turnaround strategy included a novel solution: a hospitalist program staffed by nurse practitioners.
In the three years since the hospitalist program started, primary care access in Ladysmith has stabilized, the hospital’s admissions and patient satisfaction scores have rebounded, and Rusk’s future is no longer in jeopardy.
“It saved our hospital,” Charisse Oland, CEO, says.
Ladysmith and the surrounding community — Rusk’s service area is about 18,000 people — traditionally had good primary care access provided by 10 to 12 physicians in an independent medical group. A few years ago, the group began struggling to recruit physicians to Ladysmith.
“Their administration was unable to recruit physicians due to what they perceived as primarily the burden of being on call. They felt that a hospital medicine program would alleviate this,’” Oland says.
The impact on the hospital was profound. By 2013, six physicians had left the medical group’s clinic in the previous two years, forcing Rusk to suspend its obstetrical services. The remaining physicians increasingly referred patients to a hospital 45 miles away. Rusk’s acute care inpatient days fell to roughly half the volume it had in 2010.
To address the crisis, Rusk started its own primary care clinic. But Oland knew that she would face the same recruitment and retention challenges as the independent group. More and more, primary care physicians do not want to take call duty at the hospital, and many are no longer willing to round on their patients at the hospital.
“The launch of the hospital medicine program was one of the fundamental keys to keeping our hospital open,” she says. “By offering a greater work-life balance, it has allowed us to recruit a number of physicians who are interested in rural medicine.”
The vast majority of American hospitals have launched hospital medicine programs in the past decade for just that reason. But Rusk and other small, rural hospitals have been slower to add hospitalists, mostly because of the cost.
Hospitals frequently have to subsidize physician pay for hospitalist programs when reimbursement doesn’t completely cover the physician’s salary. The smaller the caseload, the larger the subsidy — which makes it difficult for small hospitals to afford to staff a hospitalist program entirely with physicians.
Inspired by two other small Wisconsin hospitals that used nurse practitioners to staff their hospitalist programs, Rusk chose to launch its own nurse-led hospitalist program in 2014.
In designing its program, Rusk considered three options:
- A combination of advanced practice nurses and telemedicine support.
- Using nurse practitioners for night and weekend coverage, with a physician hospitalist working the weekday shift.
- Hiring three nurse practitioners to provide 24/7 coverage through a 7-7-7 model. That means each hospitalist works round-the-clock for seven days, sleeping at the hospital during their week on duty, and then taking two weeks off.
Although the telemedicine approach has worked well for another Wisconsin hospital, that idea was rejected because at that time Rusk would have had to have obtained a Medicare waiver to introduce telemedicine, and that was too time-consuming in light of the hospital’s market share decline.
The use of both physicians and NPs is a popular staffing model at hospitals in less remote communities, but Rusk likely would have had recruiting challenges. For one thing, the average compensation for physician hospitalists exceeds $250,000 a year, which would have been unsustainable for Rusk.
“With 12-hour shifts [for nurse hospitalists], you have to hire more people, and they have to move to your community,” Oland says.
So Rusk chose to use three NPs working in the 7-7-7 model. This staffing model allows hospitalists to live in another community on their off weeks, which facilitates recruitment because the nurse practitioners do not need to relocate to Ladysmith.
How it works
In Wisconsin, nurse practitioners can practice independently, meaning they can take full responsibility for a patient’s care as long as a “collaborating physician” is available by phone. Rusk contracts with the collaborating physician for the following services:
- Signing all discharges to attest that the medical care was appropriate. A physician’s signature is required by the Centers for Medicare & Medicaid Services.
- Conducting quality reviews of at least 10 patient charts each month.
- Receiving the hospitalist's summary notes each day.
- Collaborating with the hospitalist on decisions about transferring patients to other facilities.
- Being available by phone in case the hospitalist needs backup support.
Rusk employs its emergency physicians, and their responsibilities include signing the authorization for patient admissions. The working relationship between hospitalists and emergency physicians works out well for all parties, Oland says.
The emergency department physicians no longer have to “tuck in” patients admitted at night, being ostensibly responsible for them until their personal physicians make rounds the next day. The hospitalist can count on the ED physicians for support if a patient codes. And the hospital benefits because the ED physicians transfer fewer patients to tertiary care facilities; in 2016, Rusk gained 57 admissions from its ED over the previous year.
“Now we always have two providers in the hospital, which had not been the case previously,” Oland says. “Overall, I feel that we have much stronger inpatient care and better support because we have hospitalists in house who are readily available to care for patients.”
Outcomes to date
In the first year of the program, two primary care physicians moved into the community, which was key to Rusk’s turnaround. Eliminating inpatient rounds and call duty from the job description has made it easier for Rusk to attract physicians, and two others have since joined the practice. In 2016, the hospital had 417 admissions, a 23 percent increase from 2014.
“We believe admissions will grow even more because we just added another primary care physician in December,” Oland says.
Another sign of success: Patient satisfaction survey results are climbing steadily and now exceed national averages. Last year, 85 percent of Rusk’s patients said they would definitely be willing to recommend Rusk, up from just 61 percent before the hospitalist program started.
Meanwhile, transfers from Rusk’s ED to another hospital fell 13 percent between 2015 and 2016 as ED physicians gained confidence that their hospitalist colleagues could care for those patients.
“And we are seeing an upward trend in the acuity level of the patients,” Oland says.
Of course, the hospitalist program is a major new expense. During 2014, Rusk spent $410,000 on salary and benefits for three hospitalists and incurred $20,000 in recruitment costs. That expense was offset by $290,000 in revenue from hospitalist billings for services; thus, the total cost of the program to Rusk was $140,000.
However, the hospital’s increase in patient volume translated into nearly $3,500 a day, Oland says, making the program a financial win. More fundamentally, Oland says, Rusk could not have survived without the hospitalist program because it would not be able to keep physicians in the community.
“We just have to accept that most physicians coming out of medical school are not going to do inpatient work,” she says. “This is simply an expense that will have to be considered as part of the cost of doing business.”
It takes time for physicians to embrace a hospital medicine program.
At Rusk, most PCPs liked the idea of not coming to the hospital for patient rounds, but were unhappy when they realized that meant a loss of income. Meanwhile, some physicians wanted to continue hospital rounds, which Rusk allows.
“But, if you choose to follow your patients, you need to follow your patients,” she says. “It can’t be that sometimes you will come in and sometimes you won’t. We have found that most physicians — even those who say ‘I will never use a hospitalist’ — do so happily after a while.”
If she had the chance to do it over, Oland would phase in the hospitalist program over a period of time. She admires the example set by another hospital that launched its own hospital medicine program with a single nurse practitioner working one week at a time. Community physicians continued to be responsible for patient rounds and call duty the following two weeks.
“For them it was like a gift — a week off of call duty,” she says. “After they had comfort with the first hospitalist, they brought on their second and when the physicians started really liking it, they were pretty fast to bring on the third hospitalist. That pacing was really valuable.”
That facilitated primary care physician buy-in, which Oland calls an essential success factor for hospitalist programs.
Other lessons learned
- The specialists who serve as Rusk’s consulting physicians all work in larger cities than Ladysmith. Initially, when a Rusk hospitalist sought a phone consultation, many of the specialists were quick to request that the patient be transferred to his or her own hospital, regardless of whether that was necessary. “We have coached our hospitalists to ask the consulting physician, ‘What are you going to do differently from what we can do here? Is it a particular test? Monitoring? A different drug? I can do those things here and, if the situation changes, I will contact you,’” Oland says.
- It can be hard for nurse hospitalists to establish and maintain boundaries. For example, Oland found one hospitalist taking on nurse manager duties by going to the lab to track down why a report was delayed. In another case, floor nurses took advantage of their easy access to the hospitalist. Rather than gathering several nonurgent questions to ask at one time, as they would do when calling a physician, they felt free to interrupt the hospitalist at any time. “So the hospitalist is not getting any rest because the nurses are constantly asking questions,” Oland says. “Looking back, we really burned out a couple of hospitalists because the lines got way too blurry.”
- Turnover among nurse practitioners has been rather high while Rusk has gained experience with selecting the best candidates. Success factors include the ability to form a good relationship with the collaborating physician, the ability to work independently and the willingness to make Rusk a priority. “Some have burned themselves out because, not only did they work hard here, but they picked up other jobs during their two weeks off and then came to work tired,” Oland says. “We are looking for people who are really committed to the mission and success of the hospital, not just coming in to make money and get out.”
Rusk will conduct a telemedicine pilot this year based on the belief that its hospitalists can manage sicker patients if they have specialty support via two-way video connection. It is partnering with a tertiary care center in a nearby city.
“Our next exploration is: Can telemedicine take the NP hospitalist model to the next level?” Oland says.
Also new this year: Rusk’s chief patient care officer is now supervising the hospitalist staff, as well as nurses and other clinical staff. Previously, the nurse practitioners reported directly to Oland with dotted-line supervision from the chief medical officer, who works part-time. Oland believes the new arrangement will result in well-defined roles and responsibilities for the hospitalists and clear boundaries.
“In pilot projects, by the time you get to Year 3, you’re getting pretty good,” she says. “We’re expecting this year to be a banner year.”