Top 5 Tips for Building an NP and PA Hospitalist Service
By Author Julie Zupancic, MSN, RN, DNP, NNP
Editor Elizabeth Moran, MSN, RN, CPNP-PC
Advanced Practice Provider (APP) leadership poses many challenges. In particular, there is an ongoing debate regarding who APPs should report to in the organization: nursing or medicine? Given this ambiguity, Erin Dugan, newly appointed Director of APPs at Levine’s Children’s Hospital (LCH) of North Carolina—an entity of Atrium Health, has questions as she transitions into this new role in which 50% of her time will now be dedicated to administrative oversight of both inpatient and outpatient APPs. Should the APPs report to nursing or medicine? Or, should they report to both nursing and medicine in what is considered a “hybrid” model? Should APP leaders have their own service line?
At LCH, the reporting structure is to medicine. Erin will be part of the senior medical group leadership team for Children’s Service Line and report directly to the President. There is also a Center for Advanced Practice (CAP) at Atrium Health which encompasses all APPs within the larger system. However, Cheryl Graves, former Director of APPs at St. Louis Children’s who now works on the Pediatric Complex Care APP Pilot Program, also shares her first-hand experience of this topic in which the reporting structure differed.
Whereas Erin will report to medicine at her organization, Cheryl reports to nursing. Both understand that the reporting structure can greatly impact the leverage an APP leader has when building and growing an APP hospitalist service. Key components to consider are: who the APPs report to, how they are scheduled, what areas they cover, if they can they cross cover, what their schedule is, and how much autonomy they have—just to name a few of the important considerations.
In seeking answers to her questions, Erin shadowed the APPs in her hospital in order to attain a better understanding of APP utilization and staffing models. In total, the hospital staff includes approximately 120 inpatient and 60 outpatient APPs in the 234 bed facility. Of these, there are 18-20 APPs on the hospitalist team. Erin found that the APPs were practicing to their fullest scope, i.e. performing procedures, billing, etc., and that there is adequate ancillary support for non-APP issues.
Likewise, Cheryl reviewed the hospitalist role at St. Louis Children’s, which has 250 beds and 150 APPs. Initially, the APP team covered the inpatient neurology unit at St. Louis Children’s. It soon grew to three inpatient units with neurology hospitalists/complex care and hybrid roles. At this time, Cheryl transitioned to the manager of the department. Her job was composed of 80% clinical and 20% administrative time, which unfortunately made it challenging to support the needs of the APPs. The APPs had to care for complex patients and though they were under the supervision of the attending, ultimately worked independently. What she discovered was low job satisfaction due to a lack of support.
Cheryl’s experience helped to identify five components necessary to build a successful hospitalist service in which APPs report high job satisfaction:
- Schedule: 12-hour rotating shift schedules are necessary and inevitable to provide continuity of care for patients. How APPs are scheduled, though, largely plays into job satisfaction. For APPs who work in roles that require night coverage, limiting night and weekend shifts to 30% of their time leads to higher levels of satisfaction and retention. While those in leadership roles should keep this in mind, APPs in new roles should also understand that roles can change as the demand for the APPs change—flexibility is key! For example, Cheryl’s hospitalist team changed from days only shifts to 12-hour days and nights. The patients covered changed as well. Initially the APPs worked seven days a week for neurology. Eventually the APPs were covering additional service lines. APPs and physicians need to remain flexible to adapt to the changing demands for APPs, while delicately balancing the fact that higher job satisfaction is related to less weekend and night coverage.
- Flexibility: APPs who work in inpatient roles and have the opportunity to self-schedule and block their time in 3-4 days or nights in a row report being overall more satisfied with their level of flexibility as opposed to those who do not have this ability. The APPs schedule 2-3 months in advance and then change shifts with each other occasionally as needed. APPs are not shift workers in the traditional sense that they clock in and clock out; often they work beyond their scheduled shift lengths to meet unexpected patient care needs or to satisfy organizational or practice expectations. They stay longer beyond their scheduled times based on the needs of the patients. APPs also need to remain flexible to the evolution of their roles as confidence in the scope of practice of the APP grows. APPs become an increasingly valuable part of the team as physicians and trainees understand the level of care the APPs can provide, and with that can come greater responsibility.
- Staffed by Teams: Inpatient healthcare environments demand high performing teams. A hospitalist team typically includes the attendings, fellows, residents and the APPs. Key characteristics of high performing teams are role clarity, common goals, clear metrics, good communication, and professional development for team members.
At St. Louis Children’s, Cheryl replaced one resident on each team with an APP hospitalist. There were two services: one service continued to cover neurology, and the other service was more general medicine with 24/7 coverage by APPs and hospitalists. This second service included GI, endocrine, ID, genetics, rheumatology, and pulmonology. There were usually 12-18 patients in total. Staffing was census-based. When looking at metrics, the team could see that productivity was optimized at 6-8 patients for each APP. If there were more than 18 patients, the team understood that good patient care was the common goal and they agreed that it wasn’t safe to work under these conditions. In these circumstances, it made the decision easy to pay someone a bonus shift. Interestingly, 2.6 APP full-time employees (FTEs) was equal to one resident position. This information helped when optimizing staffing during times when the team was short-staffed. *Though it may have seemed that the APPs functioned at the senior resident/fellow level, it is important to note that although the APPs shared many of the same responsibilities as the senior resident and fellow, fundamentally their role was different. The more the team understands these differences, the better the team dynamics.
The staffing model at Cheryl’s institution included four teams: two resident teams and two APP hospitalist teams. The teams didn’t provide 24/7 coverage—they covered 7am to 11pm. There was no overnight coverage; this ensured that the teams were being utilized to their fullest potential. Erin’s institution’s staffing model also included four teams. Teams A and B were covered by the residents, and teams C and D were covered by the APPs. Erin suggested utilizing the teams that were already established and shifting a person from the main campus to the pediatric service if coverage was needed in that area. The APP service was then more efficient, and used to manage FTEs and justify positions as quality metrics supported this hybrid clinical role.
- Continuity of Care: APPs can provide continuity of care, but are not satisfied with a resident replacement role. They thrive and provide the highest value when they are given time to engage in quality, research or education projects for professional development. Neither St. Louis Children’s or Levines Children’s are at the point where they provide the time for professional development. Cheryl had the opportunity to create an APP-only service, which provided patient continuity. The resident replacement role was not satisfying for the APPs due to the lack of continuity of care, but the inpatient and hybrid APPs felt they had visit-to-visit continuity. For example, the same APP would cover inpatient and outpatient for the transplant service. Not only did this provide the APP with more role satisfaction, it also provides the patient with better continuity of care.
- Billing: When billing is optimized for the APP, the organization is able to capture more patient payments for service. As such, APPs also bring in more revenue for the institution. In addition, APPs who bill for their services experience a higher level of visibility and respect within the organization. At St. Louis, the APPs could do procedures independently, but were not billing for them yet. Cheryl felt that more education was needed on the unit in regards to billing. Not billing for services was found to lead to job dissatisfaction.
Some considerations are:
- Support: Both Erin and Cheryl believe that both being supported in their leadership roles, as well as ensuring that they support the APP leaders who report to them, are critical components to building a service line of APP hospitalists. Both nursing and medicine can play a role in pushing forward initiatives in their respective domains. Though it is the responsibility of nursing leadership to help APPs grow both personally and professionally, the Chief Medical Officer should also help APPs partner with physician leadership. In doing so, the role of the APP is better communicated and institutions can build strong, collaborative teams which foster the development of the APP role and captures all billing. When necessary, APPs could also have their own service line in order to strengthen advanced provider services.
- Unit-focused or hospital-wide: Many organizations start with unit-focused APPs. For example, at Cheryl’s organization APP hospitalists were unit-focused and a core group in the service would not rotate, however some of the APPs could cross cover patients on the neurology or medicine services. This allowed for greater flexibility to staffing demands. For instance, inpatient hospitalist APP could be called to perform all the procedures, such as lumbar punctures. New APP hospitalist programs should consider starting with unit-focused APPs and expand as their team grows both in size and comfort with the role.
In conclusion, regardless of the reporting structure, key stakeholders in the organization need to be supportive of the advanced practice providers. The APPs need to understand what their role is, have adequate staffing ratios, and be recognized as a valuable part of the team. The APP leader should align with the Vice-President of Nursing and the Chief Medical Officer to make sure that goals are aligned. It is essential that she or he is supportive of the staff’s personal and professional goals, as this support does indeed have the power to trickle down and influence job satisfaction for all APPs.