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All Hands on Deck


 

As hospitalist groups evolve, they seek ways to make the best use of support staff to improve patient care and efficiency.

A look at hospitalist groups around the country shows there is no one perfect formula for putting together the best support staff. Rather, the choices groups make are tailored to their specific needs and their relationship with their hospitals.

Support staff members can include secretaries, clerical workers, case managers, social workers, administrators and administrative assistants, office managers, nurses, nurse practitioners, and physician’s assistants.

New Approaches

One trend is the use of registered nurses in hybrid nursing/administrative roles that require medical knowledge and hospital savvy.

Brian Bossard, MD, created a nurse coordinator role in 2003 to provide support to the 18 hospitalists he directs at Inpatient Physician Associates, a group that provides care to patients at BryanLGH Medical Center in Lincoln, Neb.

The group’s three nurse coordinators serve as liaisons with patients and their families and with the hospital’s nursing staff and ancillary staff. The nurse coordinators expedite discharge management by initiating discharge orders, justifying medications, and fielding any questions or issues that need to be discussed with doctors. They keep track of the group’s 18 hospitalists and determine who is available to take on new admissions. It’s an often-complex process of knowing who’s where on rounds and whether they’re busy with difficult cases.

Before the nurse coordinator roles were established, physicians were in charge of figuring out who would take the next patient. “That physician would take all the information, but that may not be the physician available to take care of the patient,” says Dr. Bossard. “That physician would have to call another physician and give the same information—which occupied our doctors’ time. The nurse coordinators are really a time-saving feature.”

Clinical care coordinators—who help maintain communication with patients’ primary care physicians during and after discharge—cut his hospital’s 30-day, 72-hour readmission rate in half within a year, says William Ford, MD, director of the hospital medicine program at Temple University School of Medicine in Philadelphia.

At the hospital medicine program at Temple University School of Medicine in Philadelphia, six clinical care coordinators, all trained RNs, play a similar role for the program’s 23 hospitalists.

William Ford, MD, medical director for Cogent Healthcare directing the program at Temple University, credits the clinical care coordinators, who help maintain communication with patients’ primary care physician during and after discharge, for cutting the hospital’s 30-day and 72-hour readmission rate in half within a year’s time. He says coordinators have played a significant role in boosting the group’s overall efficiency. “Our doctors can see three to five more patients a day because of the time the clinical care coordinators save them,” he says.

Some companies providing hospitalist services have relied mainly on office manager-type staff members to take care of clerical tasks and ensure the flow of information between hospitalists and primary care physicians. “Practice coordinators” play this role at the seven hospitalist groups run by The Schumacher Group’s Hospital Medicine Division of Lafayette, La.

David Grace, MD, area medical officer for Schumacher’s hospital medicine division, says practice coordinators are also in charge of collecting data on patients’ length of stay and level of satisfaction and ensuring accuracy in coding and documentation of diagnoses.

Practice coordinators are not required to have nursing degrees, as the job doesn’t include direct patient care. But he looks for applicants with a background in healthcare and an understanding of medical terminology. “Although practice coordinators don’t provide clinical care, the position improves the care delivered by the hospitalists,” he says.

Strike a Balance

One trap hospitalist groups fall into is hiring more support staff than they need, says John Nelson, MD, a principal in Nelson/Flores, a hospitalist management consulting firm, and the medical director of the hospitalist practice at Overlake Hospital Medical Center in Bellevue, Wash.

In his consulting work, Dr. Nelson has seen secretaries file huge volumes of reports and spend their time creating charts and spreadsheets no one will look at again. “It’s very unusual for a hospitalist group to need any sort of medical records kept separately from the hospital,” he says. “So support staff may be doing busy work that doesn’t benefit the practice.”

His advice? “Think critically about whether adding that person is really likely to make the practice better. Challenge yourself to justify any support person you’re considering adding. Make sure every element of the job description contributes to the practice.”

The need for support staff often depends on the hospitalist group’s working relationship to the hospital. Julia Wright, MD, is director of hospital medicine at the University of Wisconsin Hospitals and Clinics (UWHC) in Madison, an academic hospital medicine group of 11 physicians and one advanced practice nurse practitioner. She says the group is assisted by support staff working within the Department of Medicine.

Her part-time program assistant, who tends to secretarial duties such as setting up meetings and assisting with policy development and scheduling, is employed by the primary care department. “We have a benevolent arrangement with the hospital,” she says. “It allows us to do more research and teaching. When we want to put forward an initiative, we usually have the person power and interest and the support to do it.”

Another trend in hiring among hospitalist groups is employing midlevel practitioners, such as nurse practitioners and physician’s assistants. Dr. Ford worked with a physician’s assistant when he was a hospitalist at Union Hospital, a 120-bed community hospital in Elkton, Md. He called midlevel practitioners, who make $70,000 to $90,000 a year —about half the average pay for a hospitalist—a “windfall.”

“They see less-acute patients,” he says. “Patients with stable pneumonia still generate the same billing code as a sicker patient who takes more time and expertise, so midlevels can be more efficient providers from that aspect.”

But this strategy can backfire, according to Dr. Nelson. “On paper, giving nurse practitioners patients who are less sick is logical,” he says. “But in practice, it’s hard to divide up the responsibilities efficiently every day, and there is often a lot of inefficient or unnecessary overlap in work done by the MD and the NP.”

At UWHC, Dr. Wright has found it useful to create a specific definition of the advanced practice nurse practitioner’s role, using feedback from the nurse practitioner and the group’s hospitalists. “We came up with a document that looked at patient complexity, diagnoses, patient volume, and the nondirect patient care issues she is able to help with,” Dr. Wright says. “It’s posted so everyone can remember what kinds of things she can do.”

Sometimes, hospitalist groups can’t make full use of nurse practitioners and other midlevel providers because of hospital regulations. Matthew Szvetecz, MD, head of the hospitalist program at Kadlec Medical Center in Richland, Wash., says he would like to hire nurse practitioners, but hospital bylaws prevent nurse practitioners from writing orders. “If we have to give that kind of direct level of supervision, we might as well take care of them ourselves,” he says.

Dr. Szvetecz’s program has 13 adult hospitalists, four intensivists, and four pediatric physicians. Support staff members include a coordinator in charge of secretarial and administrative assistant duties, a coder who helps with billing, a nurse coordinator, and an executive director. He says the support staff helps contain costs and prevents physicians from spending too much time on administrative duties.

But as a group, “it’s understood that we may not break even or generate positive cash flow,” he says. “Like most hospitalist groups, we have to be subsidized as far as the upfront cash flow, but there are benefits on the back end as far as reduced lengths of stay and better documentation.”

Caveats

Dr. Bossard cautions against letting support staff take over certain duties. The group has avoided letting anyone but physicians take calls from referring primary care physicians, or make calls to primary care physicians at the time of discharge.

“We want to market ourselves as service oriented and felt that placing an intermediary in the communications process isn’t a good thing to do,” he says. “We don’t think it’s good to have secretaries triage calls from physicians. It takes a lot of the physicians’ time, but that’s time well spent.”

Dr. Wright says efficiency and cost containment can improve according to how well the hospitalist group works with the hospital infrastructure and how invested hospitalists and support staff feel in the success of their program. “If they know they’re valued and they feel like they have a say in the work they do, they’ll be more invested in the work they do,” she says. “That usually leads to more efficiency, in my experience.”

Though it’s important for hospitalist groups to work closely with hospitals, Dr. Nelson warns hospitalists not to copy the administrative structures and systems they see in hospitals. “It’s too easy for practices to make mistakes based on what is going on in hospitals,” he says. “They need to critically think about what’s needed in their practice.” TH

Lisa Phillips is a medical writer based in New York.

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