Riverwood Healthcare Center A change from the traditional approach to physician staffing

Tim Arnold MD Family Medicine Physician

Mike Delfs Chief Operating Officer

Riverwood Healthcare Center Background  CAH hospital in Aitkin MN.  3 - provider based rural health clinics.  9 employed Family Medicine Physicians.  4 employed Family Medicine NP’s.  Family Medicine Physicians are paid on RVU’s so any changes have to have little/no impact on production.

How do we meet the needs of the Hospital and Clinic? Previous system Every provider rounded on their own patients in the am.

Scrambled to get it done and to clinic on time. variable numbers of patients. Mad rush to get it done, nursing staff overwhelmed.

Signed out to who ever you could find if you where not there. Received calls from hospital nursing throughout the day. Ran back to the hospital at lunch and after clinic to finish or find families to talk to.

How do we meet the needs of the Hospital and Clinic? Inpatient

How do we round in the a.m. on inpt’s and get to the satellite clinic? Admissions during the day from ER and surgery? Family needs aren’t always satisfied at 8am. Efficiency? Nursing needs during clinic hours.

How do we meet the needs of the Hospital and Clinic? Clinic

How do we implement longer clinic hours? How do we schedule better? How do we maintain focus and clarity of jobs tasks?

Hospitalist Coverage  The only real option traditionally used is a Hospitalist.  Hospitalist coverage is common in larger and/or more urban hospitals.

 Cost of this traditional model is prohibitive in rural settings ($222,964 average yearly compensation per physician).

 Can be problematic to attract Internal Medicine trained physicians to rural areas.

 Riverwood began looking at a variation on the Hospitalist Model (Rounder System).

Hybrid Hospitalist Model Rounder system, 2 providers daily, IM and FP.

Each provider takes a week at a time functioning as a hospitalist. Once per 6-8 weeks for FP and every other week for IM. 7am to 4:30pm responsible for all hospital work. 1-2 half clinic days that week.

How did we get here? Tried to solve the above problems. Worked on process flow. Tried to improve communication. NO RESULTS!!!!

How did we get here? Presented idea to the group. Worked on over coming fears about loss of patient control.

Explanation to patients. What are the benefits and problems? Schedule rounding assignments out for one year.

Rounder system What has happened? Improved patient care. Immediate evaluation, re-evaluation for change in status.

Same provider most days. Family satisfaction.

Follow up on interventions.

Rounder system What has happened? Improved nursing communication. Patients have responded very well to the change. Consistency and time at the bedside.

Rounder system What has happened in the clinic? More time, 30min to 1 hour more per day. Focus has improved, no calls from the hospital floor. No admissions during the day. No clinic “call day.”

Clinic Volumes  Physician’s time ranges from .5 to .8 FTE so “day” does not necessarily mean 8 hours per day/40 week however there are no FTE changes for the years listed below.

 FY Days Appts Per/day

04 619 7,617 12.31

05 651 8,367 12.85

06 645 7,815 12.12

07 606 8,750 14.44

08 565 9,229 16.33

Geriatrician Program  Partnered with North Clinic Geriatric Services to explore a care model employing a physician to assess patients in the nursing home.

 The premise is that MD’s will be able to see more patients in the clinic with more consistent patient care in the Nursing Home.

 North Clinic has favorable relationships with HMO’s who

administer the MSHO program. Based on those relationships as well as regulatory guidelines for the program services such as resident/family planning, regular medical checks and some clinic level services are paid for.

Geriatrician Program  Riverwood employs a physician to act in this role as a Geriatrician.

 Physician is backed up after hours/weekends/vacations by the North Clinic Geriatricians.

 There is a care coordinator that helps coordinate the care (reimbursable as a per-member-per-month under MSHO guidelines).

 The program has broken even since it’s inception during FY 07-08.

Nursing Home Changes No nursing home faxes and calls during the day!!!!!!!!! Little to no after hours calls from the nursing homes!!!!! Very favorable feedback from the nursing homes – no “phone tag” with MD’s only to start over at 5:00 with whoever is on call, MD is right down the hall if there are questions. One consistent person to talk to about a transfer to or from the nursing home.

Nocturnist Model  Issue: quality of life for rural physicians.  Hospital began exploring potential options to decrease the call burden for the physician group.

 Proactively have begun trying to plan for the newer generation of Family Medicine physicians who are likely to be less accepting of the burden of call and lack of flexibility a rural setting may present.

Nocturnist Model  Looked at; community call pools with neighboring hospitals, hospitalists and NP’s.

 Eventually settled on a “Nocturnist” model with 24 hours week dedicated to hospital work and the remaining as clinic days.

 Nocturnist is a cost effective alternative for hospitals to help in alleviating some of the burdens that call produces for physicians

Nocturnist Model NP with previous paramedic experience as well as hospital work She takes first call on admissions and all after hours work Presentation to the call M.D. for discussion ICU admission we may need to come in. OB maybe covered by the FP on-call or the OB on-call SLEEP, SLEEP. ahh to Sleep!

Nocturnist Model Pros

Sleep!, Family time, Less pressure Cons Still on-call Can’t leave town, drink a beer or go out fishing!!! Some of the “mental harness” is not lifted by this.

Conclusions  Riverwood is not unique in trying to figure out alternative coverage models for hospital work, call or nursing homes.

 With expectations of residents graduating today including: opt-in or opt-out of call, flexibility in work schedules and pay commensurate with urban practices CAH’s are going to need to continue being innovative as the challenges of attracting physicians to rural areas are becoming greater.

Riverwood Healthcare Center

 Questions?