A possible solution to the inpatient staffing challenge faced by Critical Access Hospitals today

Just over a decade ago, some questioned the benefits and sustainability of Hospital Medicine (HM). Today, most hospitals have an organized HM program or they are seeking to develop one. In effect, over half of all US hospitals now utilize hospitalists, with over 80 percent of hospitals with 200 or more beds having a HM program.

For Critical Access Hospitals (CAH), the progress towards HM organized services has been a bit more elaborate. Community size, difficulty in provider recruitment, slower PCP acceptance and more challenging ROI demonstration are a few of the more discussed reasons for less HM use. One driver of the HM model in these smaller communities however, is the loss of patients to larger regional institutions, resulting in a steady, sustained decline in the CAHs patient volume. Indeed, the executive teams at most CAHs struggle with this issue on a daily basis. In many cases, the local PCPs voice discomfort carrying for some marginal cases, most of which could be managed locally if there was a dedicated physician present and available with the requisite skill set. Patients themselves also want to stay local at their community hospital, allowing better access to family and loved ones, while in the midst of reliable and familiar healthcare providers.

Recently, one very promising option has emerged for CAHs. It is the ED – Hospitalist Hybrid Model; relieving the PCP burden of unassigned and some recruited patient referrals. Each program is exclusively built to satisfy the needs of the relevant hospital, but there are a few common themes that exist. The models below highlight two of the more common arrangements.

Model # 1

2 FTE per day model with an ED physician plus a hospitalist physician both in house from 8am – 5pm. From 5pm – 12am, the hospitalist can be off campus, but keep on call for admissions and cross-coverage of inpatients. From 12am – 8am the ED physician responds to all patient related issues and functions as the House Physician.

Model # 2

Single House physician who functions primarily as an ED provider, but also continues the care by rounding on inpatients. This can only be accomplished in a very low patient volume environment where the inpatient volume hovers around 5 patients on the service. In most instances, there is a Non-Physician Provider (NPP) available at targeted times of increased patient activity.

This ED – Hospitalist collaboration has been framed in a number of ways, but usually the actual provider staffing and schedule will depend on both the ED and in-house patient activity. In most circumstances, the system will require 2 FTEs per day for sustained success. Essentially, the two providers jointly and effectively function as a single unit, managing the patients within the institution. As expected, the key to success is proper communication. Throughout the day both providers engage in a structured dialogue about the patients. At all transition points, patient status is discussed, making certain that all members of the care team (nurses, social workers and case managers) are up to date on the plan of care.

Both models above will usually also engage a few of the local PCPs for the rare case of disasters or just an overwhelmed service. As the inpatient service gain acceptance within the community, the overall service volume will inevitably increase requiring adjustments to meet the needs of the patients, PCPs and institution.