Published in the January 2017 issue of Today’s Hospitalist
AS RURAL COMMUNITIES struggle with an acute primary care shortage, many critical access hospitals are adopting a relatively new strategy: developing hospitalist programs staffed by nurse practitioners, not doctors.
Rusk County Memorial Hospital, a critical access hospital in Ladysmith, Wis., is taking that approach to make sure its doors stay open. Between 2010 and 2013, the community it serves lost six primary care physicians—more than half its primary care workforce. With so many fewer outpatient doctors making referrals, the hospital’s market share fell from 43% to 21%.
In response, Rusk launched its NP hospitalist program in 2014. It has since seen its patient satisfaction scores rise, and the exodus of primary care physicians stop. Now, 11 primary care providers are working at one of two clinics in Rusk’s service area.
“The program saved our hospital,” says Rusk CEO Charisse Oland, MHA.
While hospitalist programs are now standard throughout the country, many rural hospitals have been left behind. Small hospitals—Rusk has an average daily census of between six and eight patients—cannot afford to hire physicians for round-the-clock coverage. And increasingly, outpatient doctors refuse to take call, making it hard for small communities to provide inpatient coverage.
“The program saved our hospital.”
That’s why the NP hospitalist model is gathering steam, Ms. Oland says. Last summer, Rusk hosted a summit in which several rural hospitals shared their experiences staffing nonphysician hospitalist programs. Rusk subsequently helped one hospital start an NP hospitalist program and is advising another. Because it is a new model—and because scope-of practice standards for NPs vary by location—best practices are not yet settled, and rural hospitals are learning as they go.
“We do not have a perfect model,” Ms. Oland says. “But we have a model that is working, and we are trying to make it even better.”
7-7-7 staffing model
Rusk uses three NPs to provide 24/7 coverage. Each works a 24-hour shift for seven days straight, then has two weeks off.
While such a schedule sounds like a tall order, Ms. Oland points out that it has made recruiting easier because the NPs do not have to move to Ladysmith. Instead, some stay at the hospital during their on-duty weeks while others have rented an apartment nearby. According to Ms. Oland, they must respond to calls within 15 minutes.
But “different models will work, depending on the needs of your physician community and how much support they give the hospital,” she says. Some rural facilities combine onsite advanced practice nurses with telehealth support—but at the time it launched the hospitalist program, Rusk would have needed a Medicare waiver to introduce telemedicine. That was too time-consuming, says Ms. Oland, when Rusk was losing market share so quickly.
Other health systems use NPs for night and weekend coverage, with physician hospitalists covering days. But that makes staffing more difficult, she says.
“If you have 12-hour NP shifts, you have to hire twice as many people and they have to move to your community,” she explains.
While the seven-on/14-off model attracts candidates, finding the right fit can be a challenge. In Rusk’s experience, the most successful hires have held a doctorate in nursing practice and had experience in hospitalist programs, emergency departments, intensive care units or other acute care settings.
Ms. Oland has also learned not to assume that all NPs have the same skill set. “NP training programs vary, so you really have to screen people for individual competencies,” she says. Rusk also sends all newly hired NPs to the Adult Hospital Medicine Boot Camp for advanced practitioners sponsored by the Society of Hospital Medicine and the American Academy of Physician Assistants.
Then there are NP scope-of-practice laws, which vary by state. In Wisconsin, NPs can practice independently with one caveat: A “collaborator”—a physician who oversees the NP—must be available by phone.
And because the Centers for Medicare and Medicaid Services requires a physician signature to approve inpatient care plans, Rusk’s collaborating physician must sign all discharges. That collaborator also receives the hospitalist’s summary notes every day and reviews at least 10 charts a month. She also collaborates with the NP hospitalists on transfer decisions.
The collaborator does not need to stay within 30 minutes of the hospital, which is the typical requirement for doctors on call. While that physician is available by phone, says Ms. Oland, the NP hospitalists rarely need phone support.
Not requiring outpatient physicians to take call has made it easier to recruit doctors to the region. Some older doctors, however, initially did not want to hand off hospitalized patients to the NPs.
“But if physicians choose to follow their patients, they need to follow them throughout their entire stay,” Ms. Oland points out. “It can’t be that sometimes physicians come in and sometimes they don’t.” Very quickly, she explains, “even those doctors who originally did not wish to turn over their inpatient practice to NP hospitalists realized the merits of the program.”
As for consultants, many of whom are based in other communities, specialists initially asked that NPs transfer their patients to them if the NPs asked for a consult.
“We really had to coach our NP hospitalists on how to work with consulting doctors who didn’t know their capabilities,” Ms. Oland says. “We now have those hospitalists say, ‘What is it that you’d do differently? Is it a particular test or monitoring? We’re able to do that and get back to you if the patient’s condition changes.’ ”
Having the NP hospitalists onsite has also put an end to outpatient doctors asking Rusk’s emergency physician on duty to write “tuck-in” orders. And having two providers—the ED physician and an NP hospitalist—in the hospital at all times has provided much better support for code situations.
Ms. Oland also credits the new program with improving patient satisfaction. In the second quarter of 2016, 81% of patients responding to HCAHPS surveys said they would definitely recommend Rusk vs. only 61% the quarter before the program began.
And the hospitalist program has enabled Rusk to boost its annual case mix index. To accommodate that increased acuity, Rusk needed to provide telemetry for more patients, upgrade its ventilator and respiratory equipment, and launch a formal respiratory therapy program. The hospital also needed to train nurses to assess higher-acuity patients and to work with chest-tube patients, bringing in a tertiary care nurse educator for two-day sessions.
“Our investments were worth it,” says Ms. Oland. “They allow us to provide a better service to our local community.” Transferring patients out “is taxing for local emergency medical services. Whatever we can do and need to do to invest in infrastructure to increase our acuity level and be better at managing that, we think is a great thing.”
Lola Butcher is a freelance health care writer based in Springfield, Mo.