Practice Economics

Specialization Teams Offer Providers Opportunity, Strengthen HM Group Integrity


 

Of the 2.7 million visitors who visit Mount Rushmore each year, some unknowingly enlist in the Rushmore (elevation 5,725 feet) stress test. Having their acute coronary syndrome at the foot of the faces can be a memorable event, providing a subsequent introduction to Rapid City Regional Hospital’s (RCRH) ED, with an average door to balloon time of 70 minutes. Other tourists, including Harley Davidson riders at the annual motorcycle rally in nearby Sturgis, S.D., find their way to RCRH as one of 750 annual trauma admissions.

The ED is one of the busiest in the state, evaluating more than 50,000 patients a year. In many cases, it is the hospitalist team that provides care for visitors and the 375,000 people served by RCRH, which includes western South Dakota, the Black Hills, three Sioux Indian reservations, Ellsworth Air Force Base, and regions of North Dakota, Wyoming, and Nebraska.

The hospitalist program at RCRH originated in 2004 with three physicians: pulmonologist Stephen Calhoon and internists Gerald Hepnar and Greg Smith. They recognized the increasing demand for inpatient management of unassigned inpatients, together with diminishing community physician resources, as an opportunity to launch the program.

With exceptional support from our chief medical officer and infectious-disease specialist, the HM group has since grown to employ 20 physicians, six nocturnists, and five nurse practitioners. We care for an average of 140 patients daily in our 370-bed facility.

With exceptional support from our chief medical officer and infectious-disease specialist, the HM group has since grown to employ 20 physicians, six nocturnists, and five nurse practitioners. We care for an average of 140 patients daily in our 370-bed facility.

—Rita McGauvran, hospitalist, nurse practitioner, Rapid City (S.D.) Regional Hospital

The hospitalist group at RCRH is comanaged by Tony Blair and Robert Houser. During the day, eight physicians each care for approximately 16 patients, with an average seven-on/seven-off schedule that starts at 7 a.m. and ends at 5 p.m. One physician provides additional swing-shift coverage. The service is capped, to protect patients, and depending on the census. Three nocturnists and a nurse practitioner manage the night shift, 5 p.m. to 7 a.m. They work 10 shifts a month, with a monthly average of 390 admissions at night. Kristi Gylten provides administrative support, and we have a dedicated coding and billing staff to keep the entire program moving forward.

With growth came the need for restructuring. Initially, a two-team focus allowed close interdisciplinary communication with physicians, pharmacy, social work, and nurse practitioners as they met each morning to plan the day. As the group expanded, however, providing care on a team-based model was logistically less possible, due to the increasing numbers of patients and providers. The original team approach has since transitioned to each physician managing their own caseload and communicating, as needed, with support staff.

There are advantages in a larger group, and Dr. Houser believes that new areas of opportunity are now available. One such area is physician specialization. Interested hospitalists at RCRH are designing a consultative-based medicine delivery system, exploring an intensivist option, expanding the nocturnist program, and beginning a geographically based model for hospitalist patients offering continuity of location, staffing, and improved delivery of care. During the first six months of the pilot geographical model, nursing and patient satisfaction scores have skyrocketed, and cost savings already are apparent.

These interdisciplinary concentrations offer providers the options to pursue individual professional interests, while at the same time strengthening and preserving the groups’ integrity. Academically, medical students and family practice residents continue to be mentored by physicians with teaching interests as they rotate through the service.

One example of a hospitalist sub-group is our chronic inpatient service. This team was created within the last year to care for a subset of longer-term patients who are managed independently by two nurse practitioners in collaboration with Dr. Houser and Marc Aldrich, MD. The goal of the chronic team service is to provide continuity of care for patients and families, with a reduced length of stay. Many are difficult-to-place patients who have few family or material resources, live in rural locations, have dialysis needs, have wound-healing issues, are quadriplegic, etc. This team is supported by a dedicated pharmacist and social worker who meet with providers daily to analyze therapy, set goals, and measure progress.

Ongoing projects for the entire group include developing a comanagement model with the orthopedic and neurosurgery inpatient service, continuing to optimize computer order entry, exploring outreach to community physicians and facilities, and visiting other HM programs to learn more about geographical models.

In such a varied and rural location, the HM program at RCRH continues to grow and adapt to meet the challenges. Feel free to visit; you will be one of millions.

Rita McGauvran, hospitalist, nurse practitioner, Rapid City (S.D.) Regional Hospital

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