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The 4-1-1 on NPPs

From: The Hospitalist, September 2008

Mid-level providers a certain help—when utilized correctly in HM

by John Nelson, MD, FHM, FACP

Dr. Nelson

I’m convinced it is smart for many hospitalist practices to include nurse practitioners and/or physician assistants. The most common problem I see is that a practice doesn’t execute this idea well. They may have the right idea to add these providers, but they fail to create the right job description, support, and management oversight.

While there are a variety of terms in common use, such as “mid-level” and “allied health professional,” I will use “non-physician provider” (NPP) to refer to both NPs and PAs.

The two most common reasons to add NPPs are a strategy to manage growth in the difficult physician recruiting environment and as a way to optimize practice value (provide the best care at the lowest provider cost).

Valuable Roles?

My anecdotal experience suggests most practices have the NPP function in ways that may not be optimal. Most commonly, the NPP works much like another hospitalist in the practice, admitting and “carrying” their own patient caseload. There is often an attempt to have the NPP care for patients that are somewhat less sick and complicated, or care for a smaller patient volume (though this varies a lot).

This is a great concept, but often proves difficult to implement well. The NPPs in such practices often say their caseload—and amount of supervision and interaction with the physician hospitalists—varies a great deal, depending on which hospitalist is on duty. At times, they may have little interaction, leading to a defacto independent practice. At other times, work done by the NPP is repeated by the physician hospitalist. In either case, the NPP is unable to contribute optimally to the practice.

NPPs in this situation often express uncertainty about their job description and who serves as their physician supervisor. If the NPPs in your practice say their job varies, depending on which doctor is on duty, you’re probably limiting the NPP’s contribution to the practice.

Some practices have the NPP manage only the discharge process (and not provide ongoing patient care), including dictation of the discharge summary, for most or all hospitalist patients. In such a system, the NPP may have had little or no involvement with the patient prior to discharge. A variation on this system is to transfer a patient to the care of the NPP (with physician oversight) a day or two before the anticipated day of discharge and when the acute illness has improved.

While reasonable people can disagree, the problem I see with an NPP dedicated to managing the discharge process is that discharge is often the most complicated visit. Managing it well requires knowing a great deal about the patient’s medical and social situation. Asking any provider, including a physician, to step in on the last day and handle this, and prepare a meaningful discharge summary, is very challenging.

While that is unavoidable in some cases, it seems to me a poor idea to create a system in which it happens routinely for all (or nearly all) patients. I worry that referring doctors may not be pleased if they routinely get discharge summaries prepared by someone who had little or no involvement with the patient prior to the day of discharge. How informative and reliable could such a summary be?

New Alternatives

A few practices have begun asking NPPs to function in less common roles, but ones that may contribute more to the practice and provide the NPP with greater satisfaction.

A common scenario is for the several, day-shift doctors to end their work around 7 p.m. when they’re replaced by a single night doctor. And the number of admissions and “crosscover” burdens tend to be greatest in the late afternoon and early night hours around this shift change. This regularly overwhelms the night doctor for the first few hours of the shift (and the ED gets backed up, and so on).

Relief in the form of an NPP functioning in a “swing shift” role—working from the mid-afternoon until around midnight—may make more sense for some practices than having a physician hospitalist work this shift. The NPP would be responsible for admitting patients (all of whom would be seen by the in-house supervising MD that night) and functioning as the first responder for all “crosscover” issues. The practice could have an NPP work this shift seven days a week, and all other patient visits could be made by the MD hospitalists (i.e., the NPP would not have their own “service” of patients to round on daily).

An NPP could also be put in charge of a consult service, such as serving as the main hospitalist consultant on orthopedic patients that need medical consultants. In this role, the NPP would work nearly all his/her time on a single floor, such as the orthopedic floor, and get to know the orthopedic physicians and nursing staff well. This close communication and working relationship would make the NPP well accepted and effective. While physician oversight would still be required, the NPP would likely take mental ownership of issues, such as response times to consult requests, rates of VTE prophylaxis, perioperative beta-blocker use, etc. This could lead to a rewarding role for the NPP and might result in better clinical performance because it would be “owned” by a single person. It is easy to envision a role like this on other units, such as psychiatry or an in-hospital skilled nursing unit.

Lastly, the NPP might be asked to own issues, such as glycemic control or CMS core measure performance for all hospitalist patients (or all patients in the hospital). He or she might see all diabetic patients daily and adjust glycemic therapy as appropriate, but all of those patients would have a separate MD hospitalist see them daily to care for all other problems.

Room for Opinions

There aren’t much data to guide decisions about the right or best role for NPPs in hospitalist practice. For various reasons including local culture, some practices may function best without including NPPs. Yet, many, or most, practices should thoughtfully consider high value roles for NPPs. I think it is important to avoid a knee-jerk response of simply adding NPPs in the role of additional hospitalists, and instead considering less traditional or novel roles. That is just my opinion (informed by considerable experience with a lot of practices) and reasonable people can see it differently. I’m interested in hearing from anyone with an opinion about optimal NPP roles within hospitalist practices.

Next month I’ll offer comments on the economics of NPPs and thoughts about patient satisfaction with NPPs. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. He is also part of the faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.


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