How Hospital Medicine Groups Can Get the Most From NPs and PAs

Larry Beresford

Disclosures

February 24, 2017

Nearly two thirds of surveyed hospital medicine groups that serve adults include nurse practitioners (NPs) or physician assistants (PAs) on the team, according to the 2016 State of Hospital Medicine Report from the Society of Hospital Medicine (SHM).[1] Whether these advanced practice providers (APPs) are being used most effectively is up for debate, however.

The conventional paired rounding model—a physician and APP practicing as a dyad—is not the most efficient one, says Tracy Cardin, ACNP-BC, SFHM, an NP in the Section of Hospital Medicine at the University of Chicago and a member of SHM's board of directors. Cardin sees a shift away from this traditional paired rounding model, where the physician and APP split up the caseload and the doctor comes in afterward and revisits every patient, toward models that maximize the scope of the APP's practice.

"You could conceivably have one physician act as a consultant to a team of three PAs/NPs, utilizing the physician for higher-level medical judgment while allowing the more routine aspects of care to be delivered by NP/PA providers," she says.

Longtime hospitalist consultant John Nelson, MD, says that more PAs and NPs should be incorporated into hospital medicine. "But I think many groups don't execute it very well. There's a tendency to just hire APPs and expect that they'll work with the physicians, or 'help them out,' without thinking through how that will work," he says.

The challenge for hospital medicine groups, he says, is to position APPs to either enhance the group's efficiency or advance other strategic goals. If one APP makes half or more as many visits per day as an additional doctor would, that represents an increase in productivity for a lot less money, he says. "Too often, it feels like NPs and PAs are just added to the staff without considering the return on investment. It doesn't position them to do their jobs effectively. Groups have them faxing records or just making patient satisfaction visits," Dr Nelson says.

Financial return on investment isn't the only metric for the APP's contribution, Dr Nelson adds. "You could be adding staff to reduce physician burnout; have them specialize in improving certain quality areas, such as sepsis or cardiac disease; or make some other contribution that you can measure and value. But you need to be thoughtful about it," he says.

A more effective approach could be assigning the APP to a specific setting or population, such as staffing an orthopedic unit or focusing on patients with complicated social dynamics. "Give them part of a practice to do largely on their own," Dr Nelson suggests.

Some groups have successfully used NPs and PAs to make their practices more effective. Here are three real-world examples:

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