For 10-bed Carilion Tazewell Community Hospital in Tazewell, Va. (population 44,000), mounting financial pressure recently prompted staff redeployment, equipment upgrades, and other efforts to rebuild patient volume that had been siphoned by hospitals in communities 25 or more miles away.
Central to the reorganization, says John H. Burton, MD, chair of emergency medicine for Tazewell’s seven-hospital parent company, Carilion Clinic, was to combine the ED with HM. One physician now covers both the ED, which averages about a visit an hour, and HM, reducing the number of physician FTEs employed by the hospital.
“Traditionally, we think of the emergency department doctor and the hospitalist, who are both paid by the hospital on a fixed basis, as separate roles and separate skill sets,” Dr. Burton says. In larger hospitals, ED docs generally need to be board-certified. “But doctors from family medicine and internal medicine, if trained, can practice very good emergency medicine,” Dr. Burton says. “It dawned on us we could fuse the positions. Caseload has to be manageable; this wouldn’t work in larger hospitals. But for us, it’s easily manageable by one physician doing both roles with the support of a midlevel provider.”
—John H. Burton, MD, chair of emergency medicine, Carilion Tazewell (Va.) Community Hospital
The fused service was launched in February. Long-range plans include a small onsite clinic for post-discharge follow-up, also staffed by the ED/HM physician on duty. “Our dream candidate is internal-medicine-trained and -boarded, but has also practiced in emergency medicine,” Dr. Burton says. “Hospitalists in many settings don’t have the emergency medical skill set—particularly pediatrics. What makes this approach a good fit for us is we already had physicians able to do both.”
A similar approach—combining the ED and HM on a single shift—was implemented earlier this year at Broaddus Hospital in Philippi, W.Va. (population 3,000), which has 12 acute beds and about 8,000 ED visits per year. “We don’t exactly have an abundance of family practice doctors in this area,” says hospital CEO Jeff Powelson.
In many cases, the PCPs continue to round in the hospital, but the ED/HM is able to pick up those who can’t, as well as unassigned patients. Powelson says the new structure helps PCPs who practice at multiple hospitals and can’t be everywhere at once. But if the ED/hospitalist had to cover all of the inpatients, the volume would become unsustainable for a single physician, he admits.
Six physicians are filling the new combined role (four FTEs) and rotating through 24-hour or split shifts. Powelson says communication has improved. In cases where the admitting ED physician also is the hospitalist, there is one less handoff to manage.
“We had to tweak our physician personnel a bit,” hospitalist Randy Turner, DO, says. “Some are not interested in doing this; others are very comfortable wearing both hats, maybe because they’ve done both before. We had to make sure the type of patients we care for wasn’t more than we can handle, and did we have the right personnel.”
John Nelson, MD, MHM, a hospitalist group director, practice management consultant, co-founder of SHM, and columnist for The Hospitalist, sees combined positions as “great ideas” for very small, low-volume hospitals. “[It’s] probably very good for patient care in those facilities,” he says.
Dr. Burton considers his hospitals new plan “innovative.”
“Unfortunately, working at a rural hospital that doesn’t meet federal qualifications for a critical-access hospital, we’re increasingly challenged by changes in the healthcare system,” he says. “We don’t want rural hospitals to go away. We want to serve patients in the same way, with the same level of quality, as urban hospitals. But practical problems in the healthcare system make that difficult.
“This model achieves the best of what we could hope for in this community, enabling us to pay higher rates and attract better physicians,” he says.
Larry Beresford is a freelance writer based in Oakland, Calif.