The 4-1-1 on NPPs
I’m convinced it is smart for many hospitalist practices to include nurse practitioners and/or physician assistants. The most common problem I see is that a practice doesn’t execute this idea well. They may have the right idea to add these providers, but they fail to create the right job description, support, and management oversight.
While there are a variety of terms in common use, such as “mid-level” and “allied health professional,” I will use “non-physician provider” (NPP) to refer to both NPs and PAs.
The two most common reasons to add NPPs are a strategy to manage growth in the difficult physician recruiting environment and as a way to optimize practice value (provide the best care at the lowest provider cost).
Valuable Roles?
My anecdotal experience suggests most practices have the NPP function in ways that may not be optimal. Most commonly, the NPP works much like another hospitalist in the practice, admitting and “carrying” their own patient caseload. There is often an attempt to have the NPP care for patients that are somewhat less sick and complicated, or care for a smaller patient volume (though this varies a lot).
This is a great concept, but often proves difficult to implement well. The NPPs in such practices often say their caseload—and amount of supervision and interaction with the physician hospitalists—varies a great deal, depending on which hospitalist is on duty. At times, they may have little interaction, leading to a defacto independent practice. At other times, work done by the NPP is repeated by the physician hospitalist. In either case, the NPP is unable to contribute optimally to the practice.
NPPs in this situation often express uncertainty about their job description and who serves as their physician supervisor. If the NPPs in your practice say their job varies, depending on which doctor is on duty, you’re probably limiting the NPP’s contribution to the practice.
Some practices have the NPP manage only the discharge process (and not provide ongoing patient care), including dictation of the discharge summary, for most or all hospitalist patients. In such a system, the NPP may have had little or no involvement with the patient prior to discharge. A variation on this system is to transfer a patient to the care of the NPP (with physician oversight) a day or two before the anticipated day of discharge and when the acute illness has improved.
While reasonable people can disagree, the problem I see with an NPP dedicated to managing the discharge process is that discharge is often the most complicated visit. Managing it well requires knowing a great deal about the patient’s medical and social situation. Asking any provider, including a physician, to step in on the last day and handle this, and prepare a meaningful discharge summary, is very challenging.
While that is unavoidable in some cases, it seems to me a poor idea to create a system in which it happens routinely for all (or nearly all) patients. I worry that referring doctors may not be pleased if they routinely get discharge summaries prepared by someone who had little or no involvement with the patient prior to the day of discharge. How informative and reliable could such a summary be?
New Alternatives
A few practices have begun asking NPPs to function in less common roles, but ones that may contribute more to the practice and provide the NPP with greater satisfaction.
A common scenario is for the several, day-shift doctors to end their work around 7 p.m. when they’re replaced by a single night doctor. And the number of admissions and “crosscover” burdens tend to be greatest in the late afternoon and early night hours around this shift change. This regularly overwhelms the night doctor for the first few hours of the shift (and the ED gets backed up, and so on).
