Some hospitals are launching hospitalist programs that innovatively incorporate nurse practitioners (NP) to cut costs—but successfully integrating NPs into the hospitalist role means getting physicians on board and navigating regulatory hurdles, Lola Butcher reports for Hospitals & Health Networks.
A growing trend
According to Tracy Cardin, an acute-care NP and a hospitalist at the University of Chicago Medical Center, the use of NPs in hospitalist programs has been increasing for about 10 years. Nearly 65 percent of all adult hospital programs and 33 percent of pediatric programs employ either physician's assistants (PA) or NPs in some capacity, according to the 2016 State of Hospital Medicine Report from Society of Hospital Medicine.
Cardin added that the use of hospitalist NPs is likely to grow as hospital's shift to value-based payment models. "All hospital medicine practices rely on hospital funds transfer to survive," she said. "With hospitalist physician salaries going up in an era of shrinking reimbursement, that is not a sustainable business model."
Finding the right fit
As physicians and hospital leaders become more comfortable giving NPs more responsibilities, NP hospitalist programs are evolving—but there is no one-size-fits-all model, Butcher writes.
For instance, at Rusk County Memorial Hospital, a 25-bed hospital in Ladysmith, Wisconsin, an offsite physician oversees the NP-run hospitalist program. Rusk CEO Charisse Oland credits the program with saving the hospital. According to Oland, the NP hospitalist program alleviated the need for physicians at the hospital to be on call, which helped bolster recruitment efforts and successfully attracted more primary care physicians.
Other hospitals contract with an outside hospitalist firm, Butcher writes. For example, several small hospitals in Indiana and Ohio have contracted with Hospital Care Group (HCG). While the mix of physicians and NPs shift from hospital to hospital, the firm's "primary model is to have a physician there during the daytime and an NP covering that hospital either on-site or off-site during the night," according to Mark Drapala, HCG's CEO.
Meanwhile, the NP hospitalist at Pinckneyville Community Hospital works weekdays so that he can do rounds with doctors to provide "continuity of care throughout the day," Butcher writes. CEO Randall Dauby explained, "[Our NP hospitalist] is constantly in and out of the rooms, checking on each patient, regardless of their acuity level. The perceived care is better, the customer service is better, and the results are showing up on our Press Ganey scores."
Dauby also credits the NP hospitalist for improving physician satisfaction and significantly dropping 30-day readmission rates. For instance, the NP hospitalist takes medical histories, does EHR entry, orders tests, and writes discharge summaries—responsibilities that free up physicians to see more outpatients.
However, Butcher writes that launching an NP hospitalist program is not as simple as just swapping out physicians for NPs. According to Butcher, successful programs also think through regulatory challenges, care team structures, and governance issues.
For instance,hospitals interested in hiring NPs and PAs as hospitalists have to look both at and beyond scope-of-practice laws—which vary significant by state—to " other statutes and regulations that can have a significant impact on the utilization of advanced practice clinicians," according to Matthew Stanford, general counsel for the Wisconsin Hospital Association.
Butcher explains that many laws were written when only physicians managed patient care, some of the requirements can unintentionally limit other clinician's scope of practice—leading to potentially confusing situations, such as whether advanced practice clinicians can activate a power of attorney or admit a patient to a nursing home. CMS also has different billing rules for midlevel providers.
There are also internal governance challenges, such as those that deal with hospital bylaws. The hospitalist NP program at Rusk, for instance, reduced the admissions volume among physicians which threatened to block certain doctors from voting on hospital practices. "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.
Other issues to sort out involve NP's eligibility for leadership roles and whether NP notes need physician sign off, Butcher writes. And there is also the issue of physician support. But as Cardin put it, "What I find is that once [physicians] work with NPs and PAs, they love them, and the working relationship increases physician satisfaction" (Butcher, Hospitals & Health Networks, 4/10).
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In most hospitals, hospitalists care for over 50% of patients and are an inflection point for many of the metrics used in pay-for-performance programs. A high-performing hospitalist program is a key strategic asset, yet few hospital leaders feel they have fully leveraged their hospitalist program to advance outcomes.
With the right support and expectations, hospitalists can have a profound impact on quality and culture across the organization. However, there are many barriers hospitalist programs must overcome to optimize performance