Hospitalist NPs...Any others out there?

ALCCRN · Mar 9, 2010

I am interested in any responses...I will graduate in May and would like to propose a position of this type to the hospital I work for. Are you in a state which requires a collaborative practice agreement?

Advanced Practice Columnist / Guide · Mar 10, 2010

I've done some short-term Per Diem work as a Hospitalist NP. It was part of a "Mid-Level Provider Sevice" at a community hospital that doesn't offer a residency program. We were a combined group of NP's and PA's who work with Internal Medicine attendings and provide 24-hour coverage of patients admitted under the primary service of the Internal Medicine attendings.

The job is pretty straightforward as the role is pretty much like a House Officer or Resident-substitute. The early mornings are spent going through the patient list and rounding with the attendings, looking at chest films, and other diagnostic test results. The NP's and PA's write their daily progress notes and per the hospital's policy, the attending's add an attestation in the end of the note. Plans are finalized after rounds and whatever tests or consults are decided upon, the NP's and PA's facilitate this. After rounds, the NP's and PA's continue to carry the service pager and phone.

Pages and phone calls are typically questions from nurses, calls about changes in status, calls about abnormal labs, things of that sort. There are also calls from the ER for admissions and calls from the ICU for patients that are ready to be transferred to the floor. The NP's and PA's, do the exam, write the H&P, call/page the attending, and then write the admission orders after discussing the case with the attending.

This particular group did not do procedures but I could see how a similar group could grow in a way where some procedures could be added to the skillset (i.e., PICC lines, central lines).

ALCCRN · Mar 10, 2010

Juan- How small is the hospital you did the Per Diem work in? My hospital is a 180 bed hospital, but I have a feeling they would not go for paying someone to be here around the clock. We are rural and there isn't a residency program around for MILES!

Advanced Practice Columnist / Guide · Mar 11, 2010

It is a newly-built 300-bed acute care hospital in a suburban setting in Southeast Michigan. At the time, I was working full time in the ICU in a large urban teaching hospital and both the hospital I worked full time at and the one I worked Per Diem at are part of the same parent organization or corporation. Credentialing was streamlined enough as there was an established "Mid-Level Provider Council" that represented the issues surrounding non-physician providers so the entire organization is already familiar with the NP/PA role.

This new hospital was envisioned as a community-based medical center with a private-practice model in terms of physician staffing. The IM physicians we rounded with were not hospitalists per se, they kept a primary care private practice and had hospital admitting priviledges when the hospital opened. The hospital and the physicians saw the benefit of having a group of non-physician providers who are familiar with hospital medicine routines as many of the IM physicians have not been doing hospital rounds in a while. They have been active community physicians who provided primary care to the surrounding suburb. They actually hired PA's and NP's with significant acute care or in-patient hospital experience which ended up being a good fit for the new hospital.

The ICU in the same community hospital ended up adopting a similar NP/PA model with Intensivists so I quicky transferred to that service so I really just briefly worked in that hospitalist role.

Advanced Practice Columnist / Guide · Mar 11, 2010

I will graduate in May and would like to propose a position of this type to the hospital I work for. Are you in a state which requires a collaborative practice agreement?

You would have to somehow show the benefit of adding your skillset as a nurse practitioner to an existing service already offered in the hospital you are working for. The Hospitalist concept has become popular in most large academic medical centers and some community hospitals. In its pure sense, a Hospitalist is a physician who admits a hospitalized patient (peds or adult) under his primary service during the hospital stay. This takes into account the fact that patients can have their own primary care physician that they see in the community who does not round while they are in the hospital. The Hospitalist corrdinates the medical care while the patient is hospitalized and on discharge, communicates the hospital course to the primary care physician for continuity.

I think one of the reasons why the hospitalist model has become popular is because of the push for evidenced based medicine and quality care in hospitals. It is always good when someone is in charge of ensuring that meds are started per guidelines for patients admitted under certain DRG's (CHF, COPD, asthma, etc.). Also, when someone is there to admit ER patients to the floor right away so that ER congestion is avoided or when someone is there to discharge a patient in a timely manner so the patient ends up being happy with the hospital's efficiency, the hospital ends up winning points. It also helps nursing staff immensely when a trained provider is present at any time from within the hospital when things arise in hospitalized patients such as changes in status, deterioration in condition, and things of that sort. Obviously, the value is far greater in hospitals that do not have residents. However, academic medical centers also utilize this hospitalist concept for residency training.

It's easy for a physician logistically to be a hospitalist. Many graduates of IM residencies actually work as hospitalists while waiting for their preferred slot in a fellowship program. There are no barriers for them as admitting proviledges are easily granted to physicians. Medicare also has this rule that all hospitalized patients should be under the care of a physician during his or her hospital stay. NP's on the other hand, typically wouldn't have priviledges to admit a patient under their primary service, again, because of that Medicare rule unless a collaborative arrangement is made in paper. NP's who do work in these kinds of practices typically have to work with an existing group of hospitalist physicians, or be part of a group of providers rounding with attending IM physicians like we did in Michigan.

ALCCRN · Mar 11, 2010

Juan- Thanks for your reply. We already have Physician Hospitalists, but I thought I might could introduce the idea of a non-physician Hospitalist.

efy2178 · Mar 14, 2010

You would have to somehow show the benefit of adding your skillset as a nurse practitioner to an existing service already offered in the hospital you are working for. The Hospitalist concept has become popular in most large academic medical centers and some community hospitals. In its pure sense, a Hospitalist is a physician who admits a hospitalized patient (peds or adult) under his primary service during the hospital stay. This takes into account the fact that patients can have their own primary care physician that they see in the community who does not round while they are in the hospital. The Hospitalist corrdinates the medical care while the patient is hospitalized and on discharge, communicates the hospital course to the primary care physician for continuity.
I think one of the reasons why the hospitalist model has become popular is because of the push for evidenced based medicine and quality care in hospitals. It is always good when someone is in charge of ensuring that meds are started per guidelines for patients admitted under certain DRG's (CHF, COPD, asthma, etc.). Also, when someone is there to admit ER patients to the floor right away so that ER congestion is avoided or when someone is there to discharge a patient in a timely manner so the patient ends up being happy with the hospital's efficiency, the hospital ends up winning points. It also helps nursing staff immensely when a trained provider is present at any time from within the hospital when things arise in hospitalized patients such as changes in status, deterioration in condition, and things of that sort. Obviously, the value is far greater in hospitals that do not have residents. However, academic medical centers also utilize this hospitalist concept for residency training.
It's easy for a physician logistically to be a hospitalist. Many graduates of IM residencies actually work as hospitalists while waiting for their preferred slot in a fellowship program. There are no barriers for them as admitting proviledges are easily granted to physicians. Medicare also has this rule that all hospitalized patients should be under the care of a physician during his or her hospital stay. NP's on the other hand, typically wouldn't have priviledges to admit a patient under their primary service, again, because of that Medicare rule unless a collaborative arrangement is made in paper. NP's who do work in these kinds of practices typically have to work with an existing group of hospitalist physicians, or be part of a group of providers rounding with attending IM physicians like we did in Michigan.

Good point. I just got hired as a NP hospitalist in Cardiology. There is a collaborative agreement and I will work with physician hospitalists. But when NPs can't get admitting priviledges, it would be nice if they could admit to NP hospitalist especially if for something general. Like IV antibiotics for cellulitis.