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Success with midlevels: How does your group stack up?
Programs need more than a "more-hands-on-deck" approach
by Bonnie Darves



Published in the July 2010 issue of Today's Hospitalist

If you need proof that midlevel providers can play a vital role in hospital medicine, look no further than the Hospitalists of Northwest Michigan.

Many of the PAs in the group, which is based in Traverse City, operate as high-functioning members of the clinical team. One performs inpatient dermatology consults, while another serves as the group’s go-to fracture specialist in the ED.

But what may be even more unique about the practice’s use of midlevel providers is that several have assumed top leadership roles within the group and the four hospitals it
"It may not take two years of on-the-job training, but it may."

–David Friar, MD
Hospitalists of Northwest Michigan


serves. One of the PAs, Daniel Ladd, PA-C, is president of the group’s Munson Medical Center hospitalist program and sits on the hospital’s credentialing and peer-review committees.

"When Dan is heading up meetings or interacting with other service lines, he does so wearing his ‘president’ hat, and nobody cares what initials he has after his name," says hospitalist David Friar, MD, CEO of the 50-provider group. "He has grown into the role to become one of the best leaders we’ve ever had."

The group’s ability to incorporate midlevels into all levels of its practice is certainly a success story, but it’s one that many programs haven’t been able to replicate. That’s because across the country, hospitalist groups have struggled to make midlevels work for them.

It’s not for any lack of effort. With demand for hospitalist services continuing to outstrip supply in most markets, hospitalists everywhere are trying to use midlevels to stretch the very finite number of doctors.

But hospitalists are learning—sometimes the hard way—that success with midlevel providers takes a lot more than just throwing new bodies into an under-staffed program.

Some collaborations with midlevels falter because groups don’t spend enough time upfront figuring out how much autonomy midlevels will have in clinical care. Others hit snags in not managing their own physicians’ or medical staff’s expectations of midlevels’ scope of practice.

And almost all groups run into trouble if they stint on on-the-job training for midlevels. They learn that simply taking a "more-hands-on-deck" approach can seriously backfire.

Dealing with reluctant doctors
Mr. Ladd, who also serves on the Hospitalists of Northwest Michigan board of directors, suspects that many hospitalist groups don’t understand that midlevels respond to the same challenges as doctors: working through diagnoses and helping patients and families deal with disease.

"The professional and patient-related interactions that physicians find gratifying are also gratifying to PAs and NPs," says Mr. Ladd. "Those interactions are a lot of what makes medicine enjoyable."

But there are times when a hospitalist group—or the medical staff it works with—simply isn’t ready to have midlevels working within their midst. "One of the main reasons these programs have trouble or fail with midlevels is because the model isn’t appropriate for the environment," says Roger Heroux, PhD, MHA, a partner in the San Diego-based national consulting firm Hospitalist Management Resources. "Culture is very important, but some groups don’t take that into account."

Dr. Heroux recalls one group whose midlevel called a surgeon directly for advice on a patient. The problem was that the surgeon didn’t even know that the hospitalist program used midlevels—and was upset to learn that a nonphysician was managing his patients.

At Hospitalists of Northwest Michigan, Dr. Friar says that it may take as long as two years working with the hospitalists’ midlevels for all the consultants to come on board.

He also notes that the role of midlevels in his practice has evolved over time. Midlevels now keep admissions flowing by staffing two afternoon and evening admitting shifts in the ED—the busiest times of the day for admissions—and by doing triage. (They carry the triage pager.) But initially, Dr. Friar says, even physicians within the group resisted having PAs in those roles. They believed that those tasks were too important for a midlevel to fill.

"But the PAs proved to be more than capable," he recalls, "and they free up the physicians to round on the wards with fewer interruptions. It makes for a better work flow."

Ground rules
Even when groups are ready to take full advantage of midlevels, many don’t do enough to lay the proper groundwork to define exactly how NPs and PAs will interact with hospitalists.

"Hospitalist groups need clear guidelines on how they’ll utilize midlevels," Dr. Heroux explains. "Ideally, they’ll have written policies that define their roles." They also need to work out in advance what treatment guidelines they’ll all follow and what clinical triggers midlevels should use to call physician consults.

Baptist Physician Associates in Pensacola, Fla., a 15-doctor practice that serves two Baptist Health hospitals, is one practice that worked those issues out in advance.

The group, which hired an NP 18 months ago, spelled out a fairly defined role. "She sees only medically stable patients," explains Mark Strauss, MD, medical director of the group, "but we always see the patient first."

Hospitalists do all of the H&Ps and the consults, and most of the discharge summaries. The NP’s primary focus is ensuring that patients’ treatment plan is proceeding well, and adjusting most medications, including insulin, antihypertensives and anticoagulants.

"We follow behind her and sign off on her notes," Dr. Strauss says, adding that hospitalists may step in earlier if pain medications need to be modified. The NP has grown into the role and now helps hospitalists comanage low-acuity patients in the inpatient behavioral health unit. She also now writes some discharge summaries for low-complexity patients whose hospital course has been unremarkable.

Managing physician expectations
Many groups, however, don’t work out those ground rules in advance—and run into trouble.

Hospitalist groups struggle, for instance, trying to figure out how much autonomy to give NPs and PAs, particularly those who come from a specialty background where they may have enjoyed a great deal of clinical independence. NPs used to writing their own orders, for instance, may not understand (or appreciate) that they have to consult first with hospitalists.

Success with midlevels also depends on what hospitalists think their scope of practice should be. Some physicians are comfortable allowing NPs to write orders for low acuity patients. But others want midlevels’ role to be limited to family discussions and discharge preparation.

Alegent Health Clinic in Omaha, Neb., which operates hospitalist programs in four facilities in Nebraska and Iowa, began incorporating NPs into its hospital medicine services two years ago. The hospitalist group had grown from six to 12 hospitalists over an 18-month period and has successfully recruited 15 highly skilled NPs.

Initially, the program didn’t have a clear picture of how NPs would fit into clinical care or of how expansive their roles would become, says Randy Pritza, MD, Alegent Health Clinic’s chief medical officer.

Alegent Health also realized that it needed to be more proactive in managing physician expectations of NP roles. Going forward, Dr. Pritza adds, the hospitalist program plans to incorporate more clinical training and direct physician oversight for midlevels, particularly with new hires.

On-the-job training
And no matter how much work hospitalist groups put into creating policies and setting expectations, programs that succeed at incorporating midlevels say those expectations need to be tempered during on-the-job training.

Martin Johns, MD, a hospitalist and medical director of the hospital division at Gifford Medical Center in Randolph, Vt., knew that midlevels in the 25-bed critical- access hospital had to be able to act as the primary (with physician supervision) in caring for hospitalized patients. That’s why he had the first midlevel he hired shadow him for three months.

"We spent three months doing admits and discharges together, learning my routine and going over medications and inpatient protocols," Dr. Johns says. He then reworked order sets and reconfigured each of their clinical roles based on that training experience.

Today, the PAs at Gifford care for about 60% of all patients, with hospitalists handling the other 40%. Multidisciplinary morning rounds keep the group’s four physicians and four NPs on the same clinical page.

Balanced oversight
Dr. Johns says that giving midlevels the right amount of clinical autonomy was also a work in progress.

"You need to find a balance between managing and overseeing, and being overbearing," he explains. "We spent lot of time figuring this out."

The PAs in the group "work fairly autonomously," he adds, "and there are times when I only see a patient perfunctorily as opposed to doing the full work-up." If a case is moderately complex—a diabetic ketoacidosis patient, for example—the hospitalist does the secondary assessment and remains in the room to confirm the PA’s proposed plan. The PA then documents the encounter.

"The hospitalist’s input doesn’t require an hour," he explains. "It’s five or 10 minutes. I found that level of oversight was really all that was needed with the majority of patients because the PA originally had all that face time with the physician."

The hospitalist group at Gifford also spent considerable time coming up with a workable schedule. Three of the PAs work seven-on/14-off, which proved to be very attractive for recruiting. For two of their days on, the PAs are backed by another PA at night, ensuring adequate downtime during the week.

"The PA has two nights where there’s no call," Dr. Johns explains. Generally, the ED handles all admissions after 10 p.m., so the PA doesn’t have to come in unless the patient is unstable.

Using NPs to teach NPs
At Hospitalists of Northwest Michigan, Dr. Friar and his colleagues spend even more time getting a handle on each PA’s skill level, and how each will function within the group. That raises a key question: How long should groups plan on training midlevels?

"It may not take two years of on-the-job training, but it may," Dr. Friar says. At the very least, he expects to give PAs at least one year of on-the-job training.

According to Dr. Friar, PAs fresh out of school are like medical students, while those with practice in another field are like residents. It can take from six months to a year to train a PA coming in from an orthopedic or trauma service, he adds.

If you’re lucky enough to find a midlevel with experience working for another hospitalist group, Dr. Friar says, you can whittle that training period down to about three months. His group gives midlevels formal training with benchmarking and mentoring.

"We’ve found through years of trial and error that using NPs to teach midlevels works best for us," says Dr. Friar. "Other PAs know what practical training they need."

Bonnie Darves is a freelance health care writer based in Seattle.


Hiring midlevels? Avoid these common mistakes

MANY GROUPS APPROACH ADDING MIDLEVELS as a way to boost group revenue—and that’s a big mistake, according to David Friar, MD, CEO of the 50-provider group Hospitalists of Northwest Michigan. The practice, which is based in Traverse City, serves four community hospitals. Dr. Friar discussed his group’s decade-long (and very successful) integration with midlevel providers at this spring’s Society of Hospital Medicine meeting.

The real impact of an NP/PA program is in the growth in physician productivity, Dr. Friar pointed out. "The involvement of NPs improves the entire group’s function, so it’s not about billing." While the physicians are compensated largely on productivity, he added, the group doesn’t even measure the revenue that midlevel providers bring in.

Another big mistake, Dr. Friar said, is to assume that midlevels—if given the right amount of training or time—"can do what I do" as an MD or DO. While midlevels have very real clinical skills, they can’t function as a full-fledged hospitalist, he claimed. But they can function more effectively in many inpatient capacities than physicians.

Individual PAs in his group, for instance, are star administrators and business managers, ace recruiters, CPOE champions, and the quality leaders who enforce core-measure compliance.

"It makes much more sense to be using midlevels, who earn $64 an hour, as hospitalist representatives throughout the hospital," says Dr. Friar, "than having a physician earning $250 an hour doing big-time committee work. Who’s the cheapest guy to send?"

Dr. Friar also said that groups are headed for trouble if they don’t treat their midlevels as full citizens, or if there are power struggles with physicians that midlevels will always lose.

Midlevels shouldn’t, for instance, be given all the "dirty jobs and bad shifts," he said. They need a full vote in group issues, and they should be able to choose the cases that they want. In his group, a different NP or PA every day carries the triage pager. For admissions and consults, that midlevel has the option of treating a case him- or herself and picking a physician to work with; giving the case to another midlevel and choosing the physician to work it as well; or handing the patient directly over to a physician.

That brings up another problem that groups run into: telling individual midlevels which hospitalist they have to pair up with. "Let them pick who they want to work with," Dr. Friar said.
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