Boon or Bust?

Nurse practitioners work as part of on-site hospitalist team

More NPs are opting to take advantage of new acute care programs that can prepare them for work in a hospitalist model.

More and more hospitals are using in-house physicians and nurse practitioners to monitor patient care.

“Is this the wave of the future? Yes, because it is already the wave of the present,” said Robert Wachter, MD, president of the National Association of Inpatient Physicians and chief of medical services at UCSF, where 20 percent of last year’s internal medicine residents chose to follow the school’s hospitalist track.

“The forces promoting it are only accelerating it,” Wachter said.

Staff nurses and nurse practitioners on the hospitalist team can contact the primary care physician for background information, but the hospitalist makes the decisions once the patient is admitted.

Because a nurse practitioner usually admits the patient, the advent of hospitalist teams heralds a crop of new job openings. The NP also performs some emergency procedures and helps the hospitalist monitor the patient.

Some medical schools have begun offering hospitalist residencies, a fair indication of how the establishment views the long-term prospects of the field.

More NPs are opting to take advantage of new acute care programs that can prepare them for work in a hospitalist model. Jill Howie, MS, NP, RN, is director of the acute care nurse practitioner program at UCSF’s School of Nursing, the first school to offer such a degree.

“There is an undeniable argument that hospitalists and NPs are more efficient and more competent, and they deliver higher-quality care,” Howie said.

“It’s a very logical fit for NPs,” said Jan Towers, PhD, NP, RN, director of health policy for the American Academy of Nurse Practitioners and a family nurse practitioner in Maryland. “NPs work well [on hospitalist teams] because they understand the nursing aspect. They can enhance the nursing care from the standpoint of the nursing staff, and having the consistency of working with the same people is a good thing.”

But Kay McVay, RN, president of the California Nurses Association, said the hospitalist plan is rife with flaws.

“I think it’s a terrible trend,” McVay said. “This is a designed function of managed care where the HMOs have taken the care of the patient out of the care of the family physician. It’s a money-saving device, and not necessarily for the benefit of the patient.”

McVay argues that young hospitalists just out of their internship or residency often lack the experience and knowledge to effectively manage the sickest patients. But she said the disruption in continuity of care is the most troubling aspect.

Proponents argue that the upside of the hospitalist model is the availability of the team and the efficiency of having bedside nurses coordinate care with a physician or NP, instead of tracking down a separate physician for each patient.

Mitchell Wilson, MD, medical director of Community Inpatient Medicine Service at the University of Texas Medical Branch at Galveston, is considered the nation’s expert on integrating nurse practitioners into existing systems.

“In the hospital, there are all manner of congruent processes that need to happen, and these processes all compete at once for the provider’s attention,” Wilson said. “If there is an NP on the team, it enables the [physician] to do more things at once and be in more places at once, and this really cuts down on length of stay. Patients feel like they are getting more care. [NPs] aid in maximizing patient care in a less resource-intensive manner. The model can really optimize efficiency.”

Hospitalists are quick to dispute that the hospitalist model is a function of managed care, although they acknowledge HMOs usually favor hospitalists. Wachter said preliminary studies show a 15 percent reduction in hospital costs and length of stay where hospitalists are used.

“One of the most flawed reasons for criticizing the hospitalist model is that it is a provision of managed care, that it has spread like an evil virus. That’s not true at all,” said John Nelson, MD, founder of the NAIP and a hospitalist since 1987 in Gainesville, Fla. “It has grown very healthily in places with no managed care influence.”

McVay disagreed. “You need to know the inner dynamic of the family situation when you are treating the patient,” she said. “When you go to your physician—who knows you, knows your problems—you get the proper care.”

The discontinuity in patient care is a legitimate criticism, Nelson said. But Wachter and others said the criticism is “overrated” and that the “benefits of the model outweigh the risks.”

“In good systems, that discontinuity is bridged by simple human courtesy and good information systems,” Nelson said. “That controversy was driven by [primary care physicians] who were not excited about giving up patient responsibilities, but it has died down considerably.”

Stephanie Tabone, RN, director of practice for the Texas Nurses Association, pointed out that “the continuity of care problem can be there if you don’t have an organized group that doesn’t have a good system to communicate with the [primary care physicians].”

Besides money, time is critical, Nelson said. Having few hospitalized patients can make a trip to the hospital inefficient and difficult to squeeze in with a full slate of office appointments.

Nelson’s practice is driven by referrals from other physicians who have determined that caring for hospitalized patients is counterproductive to their practice.

“The model wouldn’t exist if [primary care physicians] didn’t support it,” he said.