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Hospitalists and the Changing Face of Rural Healthcare

Aug 29, 2017 01:43PM ● By The Hood Magazine

By: Alex Strauss

Hospital medicine is the fastest growing medical specialty in the history of American medicine. That is despite the fact that, since the term “hospitalist” was first coined in 1996, these physicians have often been defined in terms of their relationship to other physicians - i.e., the one managing patients for primary care doctors in order to 1) free up the primary care doctor’s time, 2) reduce the primary care doctor’s stress in running between the clinic and the hospital, 3) take certain less desirable tasks off the primary care doctor’s plate, etc.

Today, with the profession now 20 years old, hospitalists, who come from many different specialities including family medicine, internal medicine, pediatrics, even Ob/Gyn and cardiology, are being defined in terms of their own pivotal role in the medical system. The Society for Hospital Medicine defines a hospitalist as “a practitioner who is engaged in clinical care, teaching, research, and/or leadership in the field of hospital medicine.”

While the largest health systems in South Dakota have had hospitalist programs in place for some time, a growing number of rural facilities and smaller hospitals are also now coming on board. But hiring the hospitalists they want may not be easy; for every five open positions nationally, there is only one hospitalist to fill it.

MED spoke with several key players for a better perspective on how - and why -  hospitalists are changing the face of healthcare on the Great Plains.

Mian Javaid, MD, Prairie Lakes Health System, Watertown

 Mian Javaid, MD, hospital medicine specialist at Prairie Lakes Hospital in Watertown, discovered in his third year of residency that he was not cut out for spending his days in a clinic.

“I found out that I was not too happy in the clinic. In clinic, someone else was dictating your time,” says Dr. Javaid. “I was a lot more happy on the floor in acute situations, where I was better able to prioritize things based on what I thought was important.”

Dr. Javaid, who grew up and trained in New York, came to Prairie Lakes from Bismarck, North Dakota, where he still holds a full time hospitalist position. In order to provide maximum continuity for hospitalized patients, hospitalists typically work schedules that are more like nurses - longer hours but fewer days in succession or longer periods of time off. In some places, that means seven days of 12-hour shifts, followed by seven days off. Recently, the trend in larger centers is shorter, more frequent shifts.

Dr. Javaid’s regular road trips are just one example of the complex scheduling maneuvers that are often required to provide hospitalist care in facilities with a small daily census.

“We do mostly 12-hour shifts so your number of days is reduced,” says Javaid. “I spend ten days a month in Bismarck and ten to 12 days in Watertown, depending on what they need at Prairie Lakes.”

Prairie Lakes has six hospitalists (some of whom are locum tenens) and one nurse practitioner providing care 24/7 and benefitting both the hospital and community in multiple ways.

“Hospitalists are proving to be very valuable in terms of saving money,” he says. “It reduces the number of tests that get done because we can order what we need right when we need it. Smaller hospitals are also recognizing the benefits of always having one or two doctors in the hospital providing continuity.”

Javaid says nurses tend to feel more supported with a physician accessible any hour of the day or night. Primary care doctors enjoy the chance to focus on outpatient care (access to each other’s EMR system keeps both them and hospitalists in the loop). And, although some patients are initially skeptical, Dr. Javaid says they usually come around quickly when they understand what a hospitalist means for their care.

“If you tell people that you are there to provide continuity of care 24/7, they like that idea,” he says. “I have never had an experience where they said ‘we don’t want you’. When family has comfort, the patient has psychological relief which in turn helps them feel better.”

Matthew Werpy, DO, DIrector of Hospital Medicine, Regional Health Rapid City Hospital

Matthew Werpy, DO, Director of Hospital Medicine at Regional Health Rapid City Hospital, says a lot has changed for primary care physicians since he was growing up as the child of a family

  physician in Pierre. And those changes are driving the unprecedented growth in his own specialty.

“I think a lot of it has to do with the demands on primary care doctors today,” says Dr. Werpy.  “Doctors are seeing more patients in a shorter period of time. Hospitalists allow them to focus on those 30 patients a day that they are now having to see. These primary care docs cannot continue to do everything. It would be great if they could, but they can’t.”

But hospitalists are not just a safety net for doctors and their hospitalized patients. Werpy says patients who end up in the hospital without a primary care physician are also better served by a hospitalist program.

“Hospitalists have taken care of that large subset of patients,” Werpy says. “We may set them up with a primary care physician to go to when they are discharged, or set them up based on their ability to pay.”

With 26 daytime hospitalists, 9 nocturnists (nighttime hospitalists), and four NPs, the hospitalist program at Rapid City is one of the largest in the state and is still recruiting. And the larger the program, the more challenging - and critical - communication becomes.

“In South Dakota, we are not quite where we need to be in terms of developing a system of care around patients,” says Werpy. “We need a system that takes the patient from community into hospital into rehab and back into community without any hiccups along the way.”

At Regional Health, everyone on the care team receives a discharge summary including diagnosis, treatments, and recommended follow-up in an ongoing effort to support good communication and a “team approach” to care that is critical to the success of a hospitalist program.

“For this to work, we need strong outpatient primary care, strong hospital medicine, and strong primary care to go back to,” says Dr. Werpy. “Both parts are extremely important.”

Eric Hilmoe, Vice President of Operations, Sanford Health Network

How big does a facility have to be to sustain a hospitalist program? According to Eric Hilmoe, Vice President of Operations at Sanford Health Network, an average daily census of 10 is the minimum.

 “We use hospitalists primarily in Worthington, Thief River Falls, and Aberdeen, because they are big enough,” says Hilmoe, who says recruiting and retention, which are already challenging in rural areas, are big reasons why.

“A lot of it comes down to the ability to recruit new physicians to rural markets. A physician who practiced for 30 years assumes that inpatient care is part of their responsibility. But new physicians want better work-life balance. In order to provide them with the kind of lifestyle they want, we have to have hospitalists.”

But not all physicians feel this way. To help ease the concerns some may have about “handing over” their patients to another provider, Sanford has adopted a “hybrid” approach to hospital medicine in Aberdeen, where Advanced Practice Providers cover inpatient care only during the day while physicians are busy in the clinic. But Hilmoe does not expect that to last long term.

“Usually what we see is, once the primary care doctors have a level of comfort with how the hospitalist program works and they see how their patients are being managed, they typically want to move on to a full time hospitalist program,” he says.

Sanford is looking at other creative ways to use hospitalists in even smaller facilities, such as having a hospital medicine specialist cover both the hospitalized patients and the ER. In the meantime, the increased efficiency and responsiveness in the facilities where hospitalists are already in place is paying off for Sanford.

“In places where we have implemented a hospitalist program, our patients satisfaction scores have improved drastically,” says Hilmoe. “Patients like that we can respond to care needs faster and we can often even discharge patients earlier in the day.”

Tammy Hillestad, RN, Chief Nursing Officer, Brookings Health System

Brookings Health System’s hospitalist program has been in place since February, making it one of the newest programs in the state. Chief Nursing Officer Tammy Hillestad, RN, CNO, was a part of the planning process.

“For us, it was a twofold decision that was primarily physician-driven,” says Hillestad. “We had some discussion with the medical staff about quality of life and the challenge of caring for both clinic and hospital patients. So we started listening.” 

The committee concluded that patient care was likely to improve with a physician in house. But there was another consideration, as well.

“We had to look at the financial ramifications of an expensive program. And we had to consider, what financial advantages there could be,” says Hillestad. “To justify the cost, we would need more admissions and higher acuity cases. In our discussions, we felt like having someone in house made that a possibility.”

Brookings hired five hospitalists who rotate week-long shifts covering hospital patients from 8:00 am to 8:00 pm every day and on weekend nights. To ease patient concerns, they explained that hospitalists work in partnership with their primary care doctors. Six months after launch, ICU days, acuity, and admissions are all up, as hoped. “Our goal is for it to break even,” says Hillestad.

The program has worked especially well in the emergency department, where patients who are being admitted are able to meet face-to-face with the physician who will oversee their inpatient care.

A less-easily-measured result of the hospitalist program has been the formation of more cohesive care teams. “Hospitalists attend our daily huddle (care conference) where we discuss each patient,” says Hillestad. “Before, it was the team but without the physician.”

Jennifer Greco, MD, Chief of Specialty Medicine, Sioux Falls VA Health Care System

Jennifer Greco, MD, is another example of a hospitalist taking a leadership role within her health system. Greco, who started as a hospitalist with the VA in 2009, is now the Chief of Specialty Medicine, overseeing all inpatient hospital services and medical subspecialties, including the VA’s 7 full-time and two part-time hospitalists. Two hospitalists are in the hospital from 7:00 am to 7:00 pm and one covers the nighttime hours.

 With an average daily census of just 20 patients and a clinic connected to the hospital, Dr. Greco says the VA has been able to avoid some of the communication challenges of large, private sector hospitalist programs.

“As a hospitalist, if I have a question or if the patient says ‘Have you talked to my doctor about this?’, I can bop down to the clinic and ask,” says Dr. Greco. “It is a lot easier to track someone down than when you are working in a huge system.” The fact that the clinic and hospital share the same EMR system is icing on the cake, making discharge and follow-up much simpler than they might otherwise be.

The VA utilizes hospitalists for many of same reasons that private sector hospitals do - to free up clinic time for primary care providers, to increase efficiency, and to ensure timely patient care.

But Dr. Greco says hospital medicine is valuable in its own right as a subspecialty.

“As a primary care physician, you may be aware of sepsis, but if you don’t see a patient every day that is septic, you lose those skills,” says Dr. Greco. “For this reason, I believe that we are often more adept at caring for the sickest patients because we see them every day, we can stay up-to-date on the relevant literature, etc.”

While South Dakota area hospitalists are improving the quality of inpatient care and clinic doctors have enjoyed the ability to focus on their patients, Greco says both groups could do a better job of communicating with each other.

“I would like to see outpatient providers try to interact with hospitalists a little more,” say says. “If you know someone and you have met them, you are much more likely to do that handoff and to give them a call and says ‘I’m discharging Mr. Jones.’”

Also, it means a lot to patients for the hospitalist to be able to say ‘I’ve talking to your doctor, so I know all about you.’ That way, they don’t feel that their outpatient provider doesn’t care about them or their hospitalist doesn’t know them. You have instant trust.”