Hospitalists in Rural Hospitals

The hospitalist movement has typically been associated with urban hospitals, which have used these physicians to support community doctors, assume care for unassigned patients, and improve patient flow and quality of care.

But what about rural hospitals? Do hospitalists provide similar benefits there or is it an entirely different environment with its own set of challenges and opportunities?

To answer these questions, researchers conducted a survey of 402 rural hospitals with 100 beds or less in the U.S. Most had at least one hospitalist on its staff, although several had none. A total of 350 hospitals responded to the survey.

The results?

  • The most common reason for using hospitalists was that the primary physicians either requested it or required that the hospital do it by refusing to provide inpatient coverage. Other reasons for using hospitalists included the cover call and give physicians time off, improve quality of care and allow primary care physicians to focus on their outpatient clinical practices. Several hospitals said the establishment of a hospitalist program was a key factor in their ability to retain current physicians and recruit new ones.
  • Internal medicine was cited as the most common hospitalist specialty among small rural hospitals, but over half of the hospitals said they use family  physicians as hospitalists, while nearly a quarter use physician assistants, nurse practitioners, or both in the hospitalist role.
  • Hospitalist provide inpatient care 24 hours a day/7 days a week in 41% of the hospitals. They also frequently play multiple roles, providing care in the emergency department (17%), outpatient department (29.5%) and clinics or physician offices (29.5%).
  • Rural hospitalists care for adult medical patients in all of the hospitals and add surgical patients in most hospitals. However, they are less likely to care for pediatric patients, obstetric patients or newborns.
  • The vast majority of the respondents believe that hospitalists have had a positive impact on the quality of care in their hospital, and none believed that had a negative impact. The positive aspects mentioned included ability to respond quickly to changes in patients’ conditions and the amount of time they spend with patients. Other benefits included hospitalists’ expertise and ability to handle more acute patients and improvements in hospital quality and patient safety scores. Respondents also mentioned improved teamwork and communication with nurses as a result of having hospitalists.
  • The assessment of the financial impact of hospitalists were mixed. Two thirds reported either a wholly positive financial impact or both positive and negative impacts. The most frequently reported positive financial impacts related to increases in admission, fewer transfers to other hospitals, and improved abilities to treat higher acuity patients. The most common negative financial impacts were the hospitalist program costs more than the revenue directly generated by hospitalists and, as a result, had to be subsidized.
  • Almost three quarters of hospitals reported that hospitalist use made it easier to recruit and retain primary care physicians. Respondents also mentioned that hospitalist use provides work-life balance for primary care physicians and improves their quality of life.
  • Survey respondents reported that nearly all admitting physicians were very satisfied or satisfied having hospitalists care for their patients. Similarly, the majority of patients were reportedly very satisfied or satisfied with hospitalists’ care. In the 87.88% of hospitals where some or all the hospitalist live in their community, respondents were significantly more likely to report that patients were satisfied with the hospitalists, compared with the 12.2% of hospitals where none of the hospitalists lived in the community.

“… having hospitalists may be the most important factor in the hospital’s ability to remain open and continue providing inpatient care.”

The researchers concluded by saying that hospitalist programs have potential to help address rural primary care workforce shortages and may also help rural hospitals document and improve the quality of care they provide. And while inpatient revenue directly generated by hospitalists may not cover the direct costs of their salaries or contracts, the researchers suggested that using hospitalists may allow small rural hospitals to provide a greater volume of inpatient care and handle more complex patients. In some cases, “having hospitalists may be the most important factor in the hospital’s ability to remain open and continue providing inpatient care.”

Med Care Res Rev. 2014 Aug;71(4):356-66. doi: 10.1177/1077558714533822. Epub 2014 May 14.
The Use of Hospitalists by Small Rural Hospitals: Results of a National Survey.
Casey MM1, Hung P2, Moscovice I2, Prasad S3.