NURSE PRACTITIONER

HOSPITALIST PROGRAM

Charisse Oland, Chief Executive Officer Rusk County Memorial Hospital

Dr. Debra Frenn, Chief Patient Care Officer

TODAY’S OBJECTIVES To understand

APN hospitalist models in a rural setting

Cultural engagement by medical staff and others

Effect on quality, patient satisfaction and operations

Regulatory requirements for start up Please note that the views expressed by the conference speakers do not necessarily reflect the views of the American Hospital Association and Health Forum.

10 primary care MDs in 2010; 5 in 2015

1 Independent clinic and multiple specialists in 2010

Opened Provider Based Rural Health Clinic in 2014

2013-15 dynamic radical change

RUSK COUNTY MEMORIAL HOSPITAL

RUSK COUNTY MEMORIAL HOSPITAL

Federally Qualified Health

Shortage area (FQHS)

18,000 population in

primary service area

ADC 6-8, including swing

beds

ED 5,500 visits per year Robert Wood Johnson Foundation, & University of Wisconsin Population Health Institute (2015). Retrieved from http://www.countyhealthrankings.org/sites/default/files/state/downloads/2015%20Health%20Outcomes%20-%20Wisconsin.png

RWJF AND INSTITUTE OF MEDICINE – REPORT

ON THE FUTURE OF NURSING

Nurses should be full partners with physicians

Nurses should practice to the top of their license

Achieve higher levels of education and improve

the educational system for a seamless

educational progression

Effective workforce planning and policy making

Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Retrieved from http://books.nap.edu/openbook.php?record_id=12956&page=R1

WHY START A HOSPITALIST PROGRAM NOW?

Hospitalist: newer specialty term

First cited in a New England Journal of Medicine

article in 1996.

More than 50% of hospitals have a hospitalist

program

Many CAH use APNs due to primary care shortage

Primary focus is to improve the quality of care

through system change

Wachter, R. M. and Goldman, L. The Emerging Role of Hospitalist in the American Healthcare System; New England Journal of Medicine (1996) 335: 514-7.

IMPROVE RURAL PHYSICIAN RECRUITING

Of the 2,050 rural counties in the United

States, 77% have primary care shortages

One challenge in recruiting is the lower amount

of “time away from work” in a rural area i.e.,

On Call schedule

Doescher, M.P., Skillman, S.N. &Rosenblatt, R.A. (2009) The Crisis in Rural Primary Care (Policy Brief). WWAMI Rural Health Research Center.

WHY CHANGE NOW?

Loss of 6 primary care MDs in 2 years

Suspension of OB services

New replacement hospital 45 miles away

Independent physician group, also in radical change

Recruiting challenge: call burden

Decreased market share 2010: 43%, 2013: 21%

NUMBER OF MDs : PATIENT DAYS

0

2

4

6

8

10

12

14

16

0

500

1000

1500

2000

2500

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

# P

hys

icia

ns

Acu

te C

are

Inp

atie

nt

Day

s

10 Year History

Total AcuteCareInpatientDays

# Physicians

Hospitalists

DYNAMIC RADICAL CHANGE:

THE “QUADFECTA” 2014

Hospital opened own clinic (PBRHC)

APN Hospitalist Program launched

ED physician group replaced

Remodeled facilities “Fresh Eyes”

patient-centered care

Influence the continuum of care and outcomes

STRATEGIC GOAL – GROWTH PILLAR

We will be led by highly qualified providers

(physicians and extenders) with appropriate

number and compliment for the level of services

and programs expected to meet community

needs.

APN HOSPITALIST PROGRAM GOALS

↓ Call burden for MDs

↑ MD quality of life and recruiting potential

↑ Clinical quality outcomes with standardized

protocols and continuity of care

↑ Patient satisfaction

Retain community support

and market share

TRIPLE AIM

Improve experience of care

Decrease per capita cost

Improve population health

Haering, J. (2015, July 31). Why having a physician advisor is a good idea. (Web log content). Retrieved from http://blog.resonantadvisor.com/why_physician_advisor

Ministry–Eagle River Memorial Hospital, WI

2 APNs 12 hour shifts

DHS waiver telemedicine model

Wisconsin administrative code DHS 124.04(3)(a)

Nurse practitioner hospital pilot program

Aspirus-Medford, WI

24/7 with 3 ANPs

7 days on, 14 days off

Collaborating physician (FP) Rounding

EXPLORATION OF MODELS

VARIATION IN MODELS

APN:MD mixed model Job description: Excludes ED and/or clinic coverage

Difference: First responder vs. unit based vs. traditional

Telemedicine collaborating physician

Onsite collaborating physician

Scheduling Shift: 12 hour (day vs night) vs 24 hour

Pattern 7/14 vs 5/5/5 vs. ?

Backup coverage incorporated into plan

Salary/benefits; per diem locums

PHASE ONE PLANNING

Medical staff support

Board support/business

plan

Enabling medical staff

bylaws

Staff education

Community education

MEDICAL STAFF ENGAGEMENT

Meetings with independent

physician group clinic

management

Participation in site visits

Opinion polls

Attorney meetings

MEDICAL STAFF ENGAGEMENT

Bylaws revision team: Chief of Staff, ED

physician, CEO, Chief Patient Care Officer and

Quality Manager

Chief of Staff updates at monthly medical staff

meetings

Medical staff invited to participate in APN

interviews

Hospitalist Criteria: Physician Opinion Scale (1 = No and 5= Yes)

No 1 2 3 4 5 Yes

1. The hospitalist program will speed up the time to admission. 2 1 1 2

2. The hospitalist program will decrease the current burden of call. 2 1 3

3. The hospitalist program will increase quality scores. 2 2

2

4. The hospitalist program will increase the number of admissions from our ED.

3 1 2

5. The hospitalist program will help recruitment of new providers. 1 5

Number of Respondents: 6

Inpatient Model of Care: Decision Grid

02-26-14

MODEL Better

consistency &

continuity (span

of hospital stay)

Increased

coordination

(handoff to

outpatient

setting)

Quality of life

for providers

Increase in

patient census

Increase in

acuity

Cost Effectiveness Clinic

Consistency and

Flow

Enhance

Recruitment of

new providers

Optimize Utilization

Review

Day Time Only Coverage

(Physician or NP/PA) $$

Night Time/Weekend

Only (Physician or

NP/PA) $$$

Full Time Hospitalist

24/7 (Physician or

NP/PA, or combination

of current staff) $$$$

REGULATORY/LEGAL

State laws: Wisconsin Administrative Code DHS

124.04(3)(a)

CMS rules and regulation

Swing bed provisions

Medical staff

bylaws

Wisconsin Hospital Association (2015). Retrieved from http://www.wha.org/pubArchive/special_reports/RH2015review.pdf

REGULATORY/LEGAL

State APNP Practice Act

Collaborating Physician Agreement-Contract

Primary Care Collaborator

Emergency Physician Contract

Authenticate admissions only

Wis. Stat. §35.93, Ch. N 8

COLLABORATING PHYSICIAN ROLE

Available by phone 24/7

Backup physician

Joint rounding

Monthly quality chart review

Sign off on H&P and discharge summary

ED physician sign off on authentication for

admission

MEDICAL STAFF BYLAWS KEY PROVISIONS

Active staff privileges/voting rights for APN

May not be an officer

Active staff privileges/voting rights for ED physicians

Collaborating agreement to authenticate admissions

Active staff privileges for no/low volume admitters who serve on committees

Option to admit and follow own patients

Peer review (OPPE/FPPE)

CRITERIA FOR APN CANDIDATE SELECTION

Acute care experience with practicums

Hospitalist experience preferred

ACLS certified

Excellent work history

and references

Cultural fit

Collaboration/communication

skills

Pratt, S. (2015, March 18). 3 Steps to help you become the perfect candidate. (Web log content). Retrieved from http://www.socialtalent.co/blog/page/23

ORIENTATION PLAN

Hospitalist “Boot Camp” one week

Shadow APN at another CAH one week

Complete competency assessment

Collaborating physician mentoring time

General hospital orientation

TEAM CULTURE

APN available 24/7 to answer questions and concerns

Code response availability

No ED tuck-in orders

Multidisciplinary team rounding

Improved access for discussion of admissions

Increased nursing interaction and education

Increased patient and family interaction and education

APN EXPECTATIONS

Sleep space and work space

Communication expectations with primary care

provider re their patients (admission/daily

care/discharge process)

Orientation process (complete skills assessment,

attend hospitalist boot camp)

Involvement with design and testing of CPOE

order sets, P&P, optimizing workflows, etc.

MULTIDISCIPLINARY TEAM ROUNDING DAILY

MD collaborator during orientation, periodically thereafter

APN—generally done independently

Nursing leader

Occupational Therapy

Physical Therapy

Pharmacist

Case Manager

STANDING ORDERS

Admission orders

Top 10 inpatient

diagnoses

What worked

Barriers to

implementation

Top DRGs 2013 Top DRGs 2015

1 SIGNS & SYMPTOMS W/O MCC

REHABILITATION W CC/MCC

2 REHABILITATION W CC/MCC REHABILITATION W/O CC/MCC

3 ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC

CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC

4 REHABILITATION W/O CC/MCC

SIMPLE PNEUMONIA & PLEURISY W CC

5 FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS, & THIGH W/O

KIDNEY & URINARY TRACT INFECTIONS W/O MCC

6 TRAUMA TO THE SKIN, SUBCUT TISS & BREAST W/O MCC

ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC

7 KIDNEY & URINARY TRACT INFECTIONS W/O MCC

SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC

8 OTISIS MEDIA & URI W/O MCC

HEART FAILURE & SHOCK W CC

9 OTHER FACTORS INFLUENCING HEALTH STATUS

OTITIS MEDIA & URI W/O MCC

10 SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC

SIMPLE PNEUMONIA & PLEURISY W MCC

EARLY IMPLEMENTATION SUCCESSES &

CHALLENGES Successful recruiting

NP projected growth: 28% from 2012-2022

One of 3 had delay in obtaining WI license and DEA number

Old EMR increased documentation time/challenge for implementing clinical pathways

Nursing staff not familiar with more acute patients

Wisconsin Hospital Association (2015) Wisconsin Health Care Workforce 2014 Report. Retrieved from http://www.wha.org/Data/Sites/1/pubarchive/reports/2014WorkforceReport.pdf

EARLY IMPLEMENTATION SUCCESSES &

CHALLENGES

Equipment Needs

Evaluate current equipment

Need for additional equipment for higher acuity

patients

May need more BiPap equipment

More telemetry for higher acuity patients

Ventilator

Respiratory equipment

EARLY IMPLEMENTATION SUCCESSES &

CHALLENGES

Educational needs

Assessment of higher acuity patients

Tertiary care nurse educator provided 2-day

educational sessions

Working with a chest tube patient

Care of the pediatric population

High volume back up plan

Difficulty finding part-time providers to fill in for

illness

YEAR ONE OUTCOMES

Patient satisfaction

Quality improvements

CMI : Heart Failure

Stabilize market share

Patient continuity for

the clinic start up

YEAR ONE OUTCOMES

Outpatient program feeder/growth – Imaging

and Lab

Cardiac Rehab days

increased

Employee/physician

satisfaction: anecdotal

Successfully recruited

2 MDs to our clinic

2013 Quality Dashboard

Hospital WideSerious Safety Event Rate per 1,000 Patient Days ↓ 0% 0% 0% 2.6% 0% 0% 0%

Hospital Acquired Pressure Ulcer Rate ↓ 0% 3.2% 1.69% 4.7% 4.3% 4.9% 6.3%Hospital Acquired Infections per 1,000 Patient Days ↓ < 1 0.60% 1.10% 4.7% 1.4% 0% 0%

Falls ↓ N/A < 4 1.75% 11% 4.3% 11% 4.2%Medication Errors ↓ N/A N/A < 1% 0.002% 0.001% 0% 0.3%

Hand Hygiene Compliance Rate ↑ 80% N/A 90% 93.5%

Complications n=102 n=111 n=123 n=128 30 Day All Cause Readmission Rate per 100 Patient Days ↓ N/A 17% 1.1% 7.5% 10.9% 7.4% 4.2%

Patient Satisfaction n=27 n=39 n=29 n=26Communication with Doctors ↑ 81% 83% 83% 85% 77% 84% 77%Communication with Nurses ↑ 78% 82% 82% 82% 74% 83% 78%

Cleanliness of Hospital Environment ↑ 73% 79% 80% 88% 85% 89% 89%Pain Management ↑ 71% 72% 75% 74% 56% 78% 70%

Patient Experience n=27 n=39 n=29 n=26HCAHPS - Overall Rating (% responding 9&10) ↑ 70% 74% 85% 56% 55% 68% 63%

HCAHPS - Willingness to Recommend (% Definitely Yes) ↑ 71% 74% 74% 46% 38% 64% 39%

Total Inpatient Admissions (Acute, Swingbed & Newborn) ↑ 111 131 142 146Total Inpatient Days (Acute, Swingbed & Newborn) ↑ 637 703 638 704

Total ED visits ↑ 1572 1209 1297 1232Total UC visits ↑ 274 244 320 246

Total Other Outpatient Visits ↑ N/A N/A N/A 6694 5995 6334 6776Employee Turnover ↓ 5% 8.4% < 5% 2.3% 4.1% 4.3% 41%

Operating Margin ↑ 2.5% 1.5% 1.5% 0.5% 2.8% 2% 1.7%Days Cash on Hand ↑ 160 150 150 118.9 138.4 124.5 110

Patient SafetyPreferred

DirectionNational

FY 2012

Q3

FY 2012

Q4

Clinical QualityPreferred

DirectionNational State

RCMH

Goal

Operational Excellence

Preferred

DirectionNational State CAH

RCMH

Goal

Service ExcellencePreferred

DirectionNational State

RCMH

Goal

FY 2013

Q1

FY 2013

Q2

FY 2012

Q4

State RCMH

Goal

FY 2013

Q2

FY 2012

Q3

FY 2012

Q4

FY 2013

Q1

FY 2012

Q3

FY 2012

Q4

FY 2013

Q1

FY 2013

Q2

FY 2013

Q1

FY 2013

Q2

FY 2012

Q3

PATIENT SATISFACTION

HCAHPS 2014 Q2 2015 Q4

Definitely recommend hospital 61% 75%

Hospital rated high (9-10) 57% 71%

Communication with nurses 81% 78%

Communication with doctors 84% 88%

Pain control 68% 80%

2014 Q2 & 2015 Q4 HCAHPS DASHBOARD

QUALITY IMPROVEMENTS:CORE MEASURES

STABILIZE MARKET SHARE

-3 MDs

-3 more MDs

+1 MD in July

CARDIAC REHAB DAYS INCREASED

0

50

100

150

200

250

300

350

400

450

Q1 Q2 Q3 Q4

Nu

mb

er

of

Vis

its

Cardiac Rehab Phase II Visits 2013-2015

2015

2014

2013

CASE MIX INDEX IMPACT

2013 2014 2015

Acute 1.0374 1.0330 1.0673

Swingbed 1.1268 1.1396 1.1667

0.9500

1.0000

1.0500

1.1000

1.1500

1.2000

Cas

e M

ix I

nd

ex

Annual Case Mix Index

INPATIENT ADMISSION IMPACT

0

10

20

30

40

50

60

70

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Nu

mb

er

of

Ad

mis

sio

ns

Admissions by Year 2013-2015

2013: Total 5312014: Total 4442015: Total 528

Admissions Summary

2014 2015

Acute Admits 339 420

Swing Bed Admits 105 108

Total Outpatients 24,427 27,903

Riverside Clinic Visits 503 3,184

ED Visits 5,409 5,693

UC Visits 1,071 814

OUTPATIENT/ANCILLARIES IMPACT

Outpatient Lab & Imaging (Jan-Nov)

2014 2015 Difference % Change

Imaging 11,754 13,054 1,300 11%

Lab 24,331 36,403 12,072 49.6%

PHASE TWO: NEEDS OF A GROWING PROGRAM

Respiratory Therapy added

Patient Navigator added (RN)

Daily operations handoff 0730 with Hospitalist,

ED, collaborator and nursing

PHASE TWO: NEEDS OF A GROWING PROGRAM

Role delineation between hospitalists and

nurses/skills assessment

Rehiring APN for cultural fit

Increasing part time staff for back up support

FINANCIAL IMPACT

Direct costs:

2014 estimated 3 full time APNs (excludes locums/per

diem costs)

Impact:

Maintaining volume/market share est. $3,500/day

↑ Ancillary and outpatient revenue

$ 290,000 - 410,000 - 20,000

($140,000)

Revenues: Salaries/Ben:

Expenses:

* 2014 estimate cost

WHAT WOULD WE DO DIFFERENTLY?

Clinical pathways completed

and in place

Anticipate increased acuity

Anticipate new equipment

needs

Back up staffing plan for

illness/unanticipated gaps

CMO on the leadership team

Ridgley, S. K. (2015, March 12) Presentation preparation—The second P. (Web log content). Retrieved from http://www.ihatepresentations.com/presentation-preparation-second-p/

OUR CONSIDERATIONS

Did we capture appropriate admissions?

Do our physicians support the program?

Has the call burden decreased?

Were we able to recruit MDs with a Hospitalist

Program?

Did we establish the clinic?

LESSONS LEARNED

KEY factors in program design:

Medical staff support and transition plan

Staffing model

Physician champion

Collaborating physicians/APN relationship

APN experience vs credential

Medical/legal risk tolerance

State laws

LESSONS LEARNED

Disengagement of other primary care providers

Backup support plan for illness, high census,

burnout

Cultural fit and teamwork among hospitalist

group and others

Keeping pace with growing demand

Sharing with others creates new knowledge

SUMMARY: OBJECTIVES MET APN hospitalist models in a rural setting

Multiple models to fit organization/MD expectations

Cultural engagement by medical staff and others Positive when collaborating toward agreed upon

model

Effect on quality, patient satisfaction and operations Quality & satisfaction exceeded with positive $$

impact

Regulatory requirements for start up Vary by state rules and Med staff bylaws

GOOD THINGS TAKE TIME

REFERENCES

Doescher, M.P., Skillman, S.N. &Rosenblatt, R.A. (2009) The Crisis in Rural Primary Care (Policy

Brief). WWAMI Rural Health Research Center.

Haering, J. (2015, July 31). Why having a physician advisor is a good idea. (Web log content).

Retrieved from http://blog.resonantadvisor.com/why_physician_advisor

Institute of Medicine. (2010). The future of nursing: Leading change, advancing health.

Retrieved from http://books.nap.edu/openbook.php?record_id=12956&page=R1

Pratt, S. (2015, March 18). 3 Steps to help you become the perfect candidate. (Web log content).

Retrieved from http://www.socialtalent.co/blog/page/23

Ridgley, S. K. (2015, March 12) Presentation preparation—The second P. (Web log content).

Retrieved from http://www.ihatepresentations.com/presentation-preparation-second-p/

REFERENCES (CONT.)

Robert Wood Johnson Foundation, & University of Wisconsin Population Health Institute (2015).

Retrieved from http://www.countyhealthrankings.org/sites/default/files/state/downloads/

2015%20Health%20Outcomes%20-%20Wisconsin.png

Society of Hospital Medicine. Nurse practitioners and physician assistants: The role of nurse

practitioners and physician assistants in hospital medicine (2015). Retrieved from

http://www.hospitalmedicine.org/Web/Membership/Nurse_Practitioners_and_Physician_Assi

stants/Web/Membership/non_physician/NP_PA/role_of_nurse_practitioners_and_physician_

assistants.aspx

REFERENCES (CONT.)

Stiefel M, Nolan K. (2012). A Guide to Measuring the Triple Aim: Population Health, Experience of Care,

and Per Capita Cost. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for

Healthcare Improvement

Wachter, R. M. and Goldman, L. The Emerging Role of Hospitalist in the American Healthcare System;

New England Journal of Medicine (1996) 335: 514-7.

Wisconsin Hospital Association (2015). Retrieved from http://www.wha.org/pubArchive/

special_reports/RH2015review.pdf

Wisconsin Hospital Association (2015) Wisconsin Health Care Workforce 2014 Report. Retrieved from

http://www.wha.org/Data/Sites/1/pubarchive/reports/2014WorkforceReport.pdf

Wis. Stat. §35.93, Ch. N 8