Published in the September 2017 issue of Today’s Hospitalist
AS A PA who’s worked as a hospitalist for the last five years, Emilie Thornhill, PA-C, has both struggled and thrived in different positions at various groups. Her conclusion? There are better and worse roles for PAs and NPs in hospitalist programs.
In her opinion, one common model—where NPs and PAs function as jacks-of-all-trade assistants to any and all doctors—often results in a less effective and satisfying experience for both the physicians and the advanced practice providers (APPs). Instead, Ms. Thornhill believes, everyone’s better off when NPs and PAs occupy more focused roles and work directly with one physician, rather than multiple ones. She bases that opinion on both her own personal experience and on anecdotes she’s collected as chair of the Society of Hospital Medicine’s NP/PA section.
“Not every physician works well with APPs.”
Ms. Thornhill touts her current job at Oschner Medical Center in New Orleans as a great example. The group’s 10 NPs and PAs collaborate with only a subset of doctors. Each NP/PA is paired with a specific physician partner, forming a team that always works together. That dyad carries a load of 25 patients, compared to an MD hospitalist working alone who is expected to cover 15 patients during a 12-hour shift.
“Not every physician works well with APPs,” points out Ms. Thornhill, who is Oschner’s APP system lead. “We limit the number of physicians to those who can meet the unique needs of managing an APP team.”
Although a majority of hospital medicine groups now employ PAs and NPs, many struggle with how to use them efficiently and effectively. Even at Oschner, Ms. Thornhill says, her “role and scope are constantly evolving.”
Moreover, her group, like most across the country, continuously questions whether it’s deploying these clinicians in the right way. Groups that successfully incorporate NPs and PAs say that it’s very much a work in progress, with roles changing as APPs gain experience—and as physicians become more comfortable with them as colleagues.
John Nelson, MD, is a big advocate of integrating NPs and PAs into hospital medicine. “I think any number of roles can be right, but ‘can’ is the key word,” says Dr. Nelson. “It’s about organization and management.” Dr. Nelson is medical director for the clinically integrated network and physician advisor for case management at Overlake Medical Center in Bellevue, Wash., and a partner in the national hospital medicine consulting firm Nelson Flores.
As a consultant, Dr. Nelson hears some common complaints: NPs and PAs feel underused, micromanaged by physician colleagues or shackled by hospital bylaws that limit them from working at the top of their licenses. Or they are expected to perform beyond their comfort level, with inadequate supervision from unsupportive physicians.
He also hears physicians and administrators complain that they don’t understand why employing NPs and PAs hasn’t helped their bottom line.
“It’s really common to hear that a group’s productivity didn’t go up by adding an NP or PA, but that’s about management, not a criticism of NPs and PAs,” says Dr. Nelson. “The doctor who repeats everything NPs and PAs do is not going to suddenly get 50% more productive when having access to an NP or PA. A concerning number of groups execute on a good idea poorly.”
Sushama S. Brimmer, MD, medical director of the Christus Good Shepherd Medical Center’s hospitalist group in Longview, Texas, describes her group’s experience figuring out how to best deploy NPs as a 10-year “journey.”
“I think any number of roles can be right, but ‘can’ is the key word.”
Over the years, NP/PA roles in her group have continually changed. Sometimes, NPs have worked as patient volume “surge” pop-off valves, traveling between two hospitals as needed. Sometimes, they have taken on primary respon sibility for LTAC and nursing home coverage. One NP she hired two years ago covers the night shift, while the most recent hire came on board expect ing to cover a new observation unit. That didn’t pan out due to circumstances beyond hospitalists’ control, so she is now one of two regular NP daytime rounders and admitters. The group currently includes 20 physicians and four NPs.
“We have learned from our mistakes,” Dr. Brimmer said, “and what we have now may not be what we will have in a year or two.”
Dr. Brimmer has learned, for instance, to not have NPs and MDs compete for volume and RVUs, which built resentment on the NP side, and that she can’t assign just any NP to work as a nocturnist. The one in that position now, she says, is a perfect fit: an ex-ICU charge nurse who has “done it all in this hospital and is comfortable consulting all the physicians at night who need to be consulted.”
At the same time, she says that her hands are tied in how she can deploy NPs—not because of state laws but because of hospital by-laws. NPs in Texas can function as independent providers, Dr. Brimmer points out, and “we would love to have the NP admit at night,” particularly at the smaller of the two hospitals the hospitalist group staffs. “But our bylaws do not allow an NP to be the sole provider.”
Alissa M. Clough, MD, president of Inpatient Physician Associates in Lincoln, Neb., says her group has likewise learned through trial and error that NPs and PAs come to the table “with variable skills.” That means they need several months of onboarding before starting in earnest. (See “Onboarding NPs and PAs.“)
“If we can, we do 100% shared visits,” she says, where physicians follow up the NPs’/PAs’ work with short patient visits. (Medicare pays 15% less for solo NP/PA care.) But “we are always re-evaluating our workflow processes,” including “how we can best use NPs and PAs and what, if any, is the standard approach. Networking with other groups is key.” Considerations include an unshared service with the group’s orthopedic or acute rehab patients.
“We expect our NPs and PAs to be at least 90% independent.”
Dr. Clough’s group, a private practice that provides hospitalist services at Bryan Medical Center’s two campuses, currently has a staff of 27 physicians and 16 NPs/PAs. In general, the NPs/PAs focus on discharges and admissions during the day and admissions at night. (They also take all night-time cross-cover calls.) The NPs/PAs work with all the physicians, not in a dyad model like Oschner’s, which is “just not possible with our staffing numbers and current rounding schedule.”
As a result, Dr. Clough points out, it’s important when hiring NPs and PAs to find people who can fit the culture and core values of the group and can handle different personalities. “You have to be able to not take offense if Dr. Clough wants X, Y and Z, but Dr. Tom likes it this other way,” she says. “They have to figure out the quirks of all of us.” Fortunately, she adds, “we have a very experienced group of practitioners who, with time and trust, have made this work.”
Nurse practitioner Laura Coryat, RN, MS, NPC, is used to working more independently at the 60-bed Northern Dutchess Hospital in Rhinebeck, N.Y.
Ms. Coryat is the first of the hospitalist team in every morning. She sees any patients who came in overnight and takes the first admissions that come in. She also makes the day’s rounding assignments for herself and the physicians who arrive later. (She shares that role with the practice’s other NP.) Her physician colleagues follow up on those admissions.
Ms. Coryat rounds during the rest of the day while physicians take admissions, but then she and her NP colleague switch back to admissions when the physicians are off call at 5 p.m. (Doctors continue to take beeper call during the evenings and nights.)
Her predecessor was an NP who worked very differently: “She did most of the medical consults, saw patients on follow-up and followed the rehab patients, so the doctors were used to that,” Ms. Coryat says. “But after I worked with the hospitalist group for a couple of months, they learned I had experience and they came to trust me. Now, they accept me and my counterpart—who has a ton of experience and her doctorate—as just one of the group. We are treated like everyone else.”
Finding the right balance
Ms. Coryat notes that she’s worked as an NP hospitalist for more than five years. Before that, she was as an ICU nurse and an NP with a nephrology group. Given that level of experience, it’s no wonder she’s taken on broad admitting and rounding roles.
But many groups say that finding experienced NPs/PAs is a challenge—and that even when they can find them, their budget often precludes them from hiring them.
“We find newbies more than experienced people,” notes Louis J. O’Boyle, DO, president and medical director of Advanced Inpatient Medicine, a private hospitalist group in northeastern Pennsylvania. The group staffs four hospitals, two long-term acute care facilities and several nursing homes.
“We happen to be in an area where there are multiple college campuses with NP and PA training programs, so there is an abundance of students.” The group’s 20 APPs occupy many different positions in the practice, from nocturnist to full-time nursing-home rounder to site leader at one hospital.
The challenge is to strike the right balance: “You don’t want the NPs/PAs working below their job description, doing scut work or basically acting like scribes for the physicians,” he says. Each day, the admitting physician of the day assigns patients to providers working that shift. Generally, Dr. O’Boyle notes, the goal is to “give the NPs/PAs patients who are appropriate for their level of competency so they can function independently, if they need to.”
NP/PA skill sets
In Ms. Thornhill’s large group at Ochsner, NPs and PAs now own several specific tasks, mostly related to caring for “lower acuity, higher-turnover, observation-type patients,” including those on a cardiology and an epilepsy service.
“When the NPs and PAs took over these observation patients, the length of stay dropped drastically and the quality of care was equivalent, if not better,” Ms. Thornhill says. By contrast, when physicians were assigned to those teams, “those patients were the lowest priority” for doctors who needed to see their sickest patients first.
Her group has also discovered that when NPs and PAs assume the role of admitter, they bring an added benefit of making sure that protocols, order sets and clinical pathways are initiated on all appropriate patients from the start of the hospital stay.
“APPs come out of training with a different skill set than physicians,” she says. That includes being comfortable operating under clinical care pathways and using electronic medical records. “Our APPs have been and continue to be the early adopters for EMR updates.”
At Advanced Inpatient Medicine in Pennsylvania, NPs and PAs make up 50% of the private hospitalist group.
According to Dr. O’Boyle, his group’s NP/PA hospitalists who work day shifts have their own panels of about 12 patients (compared to about 16 for physicians). Each physician working that same shift has the added duty of seeing and co-signing the NP/PA notes—but only when the census permits it.
“We don’t want our docs to ever have to do more than 20 encounters in a day, and that includes supervisory encounters,” says Dr. O’Boyle. “We expect our NPs and PAs to be at least 90% independent. We want to minimize the amount of interaction that the docs have to have with the NPs’ patients.”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.
Onboarding NPs and PAs
ASK LOUIS J. O’BOYLE, DO, president and medical director for Advanced Inpatient Medicine in northeastern Pennsylvania, about the mismatch that can occur between NPs/PAs and the role they are shouldering, and he chalks most of that up to how well those clinicians have (or have not) been prepared to fill that job.
“The key is onboarding,” says Dr. O’Boyle. All his group’s new PA and NP hires go through a week-long internal medicine boot camp (sometimes completed online, sometimes at an offsite conference), a full-day orientation covering the group’s culture and computer training, and a month or more of side-by-side work with another PA or NP, with gradually increasing responsibility and decreasing supervision.
“When you are a small group, it’s hard to pay someone for two months to have zero productivity,” he notes. “But we learned the hard way. We ended up relying on our doctors to do more supervision than they should have to do and doing duplicate work.” Instead, it “absolutely pays off” to invest in onboarding.
Brenda Sebek, RN, group administrator for Inpatient Physician Associates in Lincoln, Neb., agrees. It used to be that new NPs or PAs might shadow colleagues informally for a bit. But basically, they’d be thrown right into a schedule.
But with seven new hires this year and retention and productivity on everyone’s mind, the group decided the old way no longer worked. Their senior advanced practice providers (APPs) “emphasized that we need to have structured onboarding,” Ms. Sebek says.
Experts say that putting new and inexperienced providers into practice without adequate training can hurt them. “It has become very clear to us that you cannot expect an NP or PA to come straight out of training and slide right into a hospitalist role and be good at it,” says Leslie Flores, a La Quinta, Calif.-based hospital medicine consultant. “There is a very significant orientation, mentoring and training period that has to occur if you want NPs and PAs to be successful.”
In Ms. Sebek’s group, for example, each new NP/PA is now paired with an experienced APP for two months, a period when they’re not considered or counted as staff. Then, for three additional months, “they will be doing their own work, but they are never alone,” says Ms. Sebek. They will always work on a shift with another APP, and their preceptor will remain as their official mentor, keeping an eye on them their entire first year.
New NP/PA hires are also encouraged to attend onsite monthly case review sessions run by a local family practice residency program. (Attendance may become mandatory.) And Ms. Sebek is now in the process of developing an internal “case of the day” review session for APPs.
She points out that MDs also have their own learning curve. Her group has started working with its MD hospitalists to help them learn how to give NPs and PAs effective feedback.
“The APPs want to continuously improve, so they don’t just want to hear, ‘You’re doing great!’ ” Ms. Sebek says. “They want to hear something more objective, immediate and meaningful”—which some doctors need coaching to be able to provide.
When NPs and PAs see patients independently, they can bill only 85% of what physicians charge per visit. To capture that additional 15% of revenue, many groups opt for shared visits and billing.
But Emilie Thornhill, PA-C, the system lead for advance practice providers at Oschner Medical Center in New Orleans, doesn’t think that makes sense financially—as long as groups have experienced NPs/PAs who can function independently.
“The difference in reimbursement between a PA and a physician is 15%,” Ms. Thornhill says. “But in terms of salary, a physician probably makes two or three times more.” So a PA managing 10 patients is more cost-effective than a physician managing those same patients.
And even when APPs bill at 85%, “it comes down to dollars,” she adds. “Having a physician see every single patient the APP sees to get that extra 15% is a waste of resources.” Instead, if the APP sees 10 and the physician sees 15, “you now have 25 patients you are billing for vs. maybe 15 or 20 shared between them. The most expensive way to manage a patient is to pay two people to see the same patient.”