“The practice needs to thoroughly understand the legal environment early in the process,” says John Nelson, MD, MHM, hospitalist director at Bellevue (Wash.) Medical Center, partner in Nelson Flores Hospital Medicine Consultants, and SHM cofounder. “NPPs are not a ‘hospitalist lite’ that can function entirely like a hospitalist.”
Hospital bylaws, which can vary greatly by city, county, or state, are another important consideration before you hire an NPP.
“In some areas, NPPs may not be able to practice in the ICU,” Dr. Wilson says. “In others, the physician may be required to see the patient instead of consulting with the NPP. The idiosyncrasies of the individual hospital’s bylaws may impact the efficiency of the NPP/MD team.”
Environmental variables—namely, the personality of the physicians within the practice—should be considered before you head down the NPP path. It makes little practical or financial sense to spend the time and effort of hiring an NPP if the physicians still insist on doing all the work.
“[It’s] one of the most significant factors in successfully integrating an NPP program,” Dr. Wilson says. “Will [physicians] be able to tolerate some degree of uncertainty when letting others see their patients? Are they open to adapting to different practice styles? The thing we see most often in practices that use NPPs to their advantage is the recognition that there is an important role for the nonphysician at the bedside.”
Some physicians hesitate to work with NPPs, while others welcome the extra help and unique experience NPPs offer. Experts agree that forcing NPPs on a physician is not a good idea. They also agree that, especially when beginning a new program, group directors should let physicians who are interested in working with NPPs take the lead. As NPP use in the group matures, many of those who were at first unwilling can decide that there is a place for NPPs in their practice.
Case Mix Is Key
The types and kinds of patient seen might limit the use of NPPs in hospitalist practice. “Our experience is that acuity and complexity of the care, especially as it relates to diagnostic and therapeutic decision-making, makes it difficult for NPPs to function independently,” Dr. Parekh says.
Dr. Wilson agrees. “Depending on the specific attributes of the setting, a service with both high-complexity and high-acuity patients may be a more challenging environment to realize the efficiencies of NPPs,” he says. “There is a relationship between complexity, acuity, and physician involvement.”
Even so, a continuum of NPP use in HM practice is achievable. For example, as a patient improves, an NPP might be able to take on a larger role in treatment by participating in discharge planning. In more acute patients, the NPP can save valuable physician time by coordinating with consultants, staying on top of treatments, and consolidating clinically important data for the physician.