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.