Implementing hospital medicine a challenge for critical access hospitals
Only a decade ago, some questioned the benefits and sustainability of hospital medicine (HM). Today, over 80 percent of hospitals with 200 or more beds have an HM program, and most hospitals with fewer than 200 beds either have an organized HM program or are seeking to develop one.
For critical access hospitals (CAHs), the progression toward organized HM services has been a bit more deliberate. Indeed, the executive teams at most CAHs struggle with the issue of HM implementation on a daily basis. Community size, difficulty in provider recruitment, slower PCP acceptance, and more challenging ROI achievement are some of the more common reasons for less HM use in CAHs.
There are, however, strong drivers for CAHs to implement the HM model, such as:
- the loss of patients to larger regional institutions, resulting in a steady, sustained decline in CAH patient volume,
- local PCPs’ displeasure in caring for marginal cases that could be managed locally if there were a dedicated physician with the requisite skill set present and available, and
- patients’ desire to be treated at their community hospital to receive care from trusted and familiar healthcare providers—and to be closer to family and loved ones.
Promising HM models for the CAH
An emerging HM model that appears to be a promising option for many CAHs: the emergency department-hospital medicine (ED-HM) hybrid model, which relieves PCPs of the burden of unassigned—and some assigned—patient referrals.
ED-HM hybrid programs share some common themes. And, in most circumstances, the system requires two FTEs per day for sustained success. But each CAH builds its ED-HM program to satisfy its unique needs and circumstances. And the ED-HM collaboration has been framed in a number of ways; usually with the actual provider staffing and schedule depending on both the ED and in-house patient activity. As a result, there are slight variations among hybrid models. The models below highlight two of the more common arrangements.
Model #1: Two FTEs, an ED physician plus a hospitalist
Both physicians are in-house from 8 a.m. to 5 p.m. Both can be off-campus from 5 p.m. to 8 a.m., but one must remain on call at all times for admissions and cross-coverage of inpatients—responding to all patient-related issues and functioning as the house physician—with one covering 5 p.m. to 12 a.m. and the other 12 a.m. to 8 a.m.
Essentially, the two providers collaborate and 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, they discuss patient status, making certain that all members of the care team (e.g., nurses, social workers, and case managers) are up to date on the plan of care.
Model #2: One house physician who functions primarily as an ED provider, but also continues care by rounding on inpatients.
This model can be accomplished only in an environment with very low patient volume that hovers at around five patients or fewer on the service at any given time. In most instances, there is a non-physician provider (NPP) available at targeted times of increased patient activity.
Both models above also will usually engage a few of the local PCPs for the rare case of disasters or an overwhelmed service. As the inpatient service gains acceptance within the community, the overall service volume will inevitably increase, requiring adjustments to meet the needs of the patients, PCPs, and institution.
– O’Neil J. Pyke, MD, SFHM