Comparing an on-site nurse practitioner with telemedicine physician support hospitalist programme with a traditional physician hospitalist programme

Abstract

Introduction

Since 2010, more than 75 rural hospitals have closed in the USA and more than one-third are at risk of closure due to lower patient volumes, lower funding levels, decreased hospital revenue and lower physician employment pools. Telemedicine can provide new models of care delivery that maintain quality and reduce cost of healthcare in rural populations. The purpose of this project was to evaluate a cross-organizational pilot program by comparing a NP/telemedicine physician hospitalist programme with a traditional physician hospitalist model to assess effects on length of patient stay, mortality rates, readmission rate, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) ratings of provider communication, and total hospital costs.

Methods

The Standard for Quality Improvement Reporting Excellence (SQUIRE) guidelines were followed. Using a one-year retrospective chart review, average length of stay, mortality rates, 30-day readmission rates and provider communication ratings were compared between hospitalists that were nurse practitioners working with physicians through telemedicine support and physicians alone.

Results

There was no statistically significant variance in average length of stay, mortality rates, 30-day readmission rates, or provider communication ratings on HCAHPS surveys compared to the NP or physician hospitalist.

Discussion

This new model of care demonstrates that telemedicine can be used to provide safe and efficient physician support from a regional hub medical centre to nurse practitioners practising as hospitalists in rural Critical Access Hospitals at up to 58% cost savings while maintaining quality of care and increasing access to community-based physicians.

Keywords

Hospitalist telemedicine telehealth nurse practitioner care delivery critical access hospital staffing technology rural underserved hospital-based healthcare value initiatives hospital medicine care models value-based care models care initiatives provider communication hospital costs length of stay hospitalist service physician shortage rural health primary care access

Introduction

Problem description

Rural hospital closures significantly affect both the economic and physical health of communities. Since 2010, more than 75 rural hospitals have closed in the USA.¹ In addition, more than one-third of rural hospitals, 673 facilities, are at risk of closure due to lower patient volumes, lower funding levels, decreased hospital revenue and lower physician employment pools.^1–3 Forty-one percent of rural hospitals are currently operating at a loss resulting in a six-fold increase in the rate of rural hospital closures between 2010 and 2015.¹

Rural communities are estimated to have a shortage of 45,000 physician providers by 2020, a crisis affecting over 90 m rural Americans.⁴ Seventy-seven percent of rural counties nationwide are identified as Primary Care Health Professional Shortage areas and 9% of rural counties have no physicians at all.³ If the current rate of closure continues over the coming 10 years, 11.7 m patients are at risk of losing direct access to healthcare. Related loss of employment includes 99,000 direct healthcare jobs and an additional 137,000 community jobs totalling US$277 billion lost in gross domestic product to rural communities.¹

In response to this shortage, the hospitalist role is increasingly being allocated to nurse practitioners (NPs) in collaboration with physician support, a shift that is supported by federal healthcare organizations. Forty-two percent of academic medical centres report using NPs on hospitalist teams.⁵ The Institute of Medicine’s landmark 2010 report, The future of nursing, includes recommendations to allow advanced practice registered nurses (APRNs) to practice to the full extent of their education and licensure in order to increase access to, and quality of care in, our struggling healthcare system.⁶ Subsequently, the Veteran’s Administration has proposed a system-wide policy of allowing full practice authority by NPs regardless of state regulations that may provide barriers to full practice.⁷ NPs in hospital-based care have been shown to be a valuable resource by reducing length of stay and improving hospital profit compared to physician hospitalists, without increasing readmissions or mortality.^8–10

Available knowledge

In 1997 Congress created the Critical Access Hospital (CAH) designation as part of the 1997 Balanced Budget Act in response to rural hospital closures in an attempt to improve financial viability of certain small hospitals and improve access to healthcare. Currently, 1339 CAHs provide medical care to communities across rural America. The criteria for CAH designation includes having 25 or fewer acute inpatient beds, being located more than 35 miles from another hospital, maintaining an average length of stay of 96 h or less for acute care patients and providing 24/7 emergency care services.³ Benefits of CAH status designation include cost plus 1% reimbursement from Centers for Medicare and Medicaid Services (CMS); this reimbursement model improves the chances of small rural hospitals with low average patient census numbers remaining financially viable.

Thirty-five percent of rural hospital closures since 2010 involved CAHs. Each CAH on average contributes 150 jobs to the local economy and invests US$7.1 m into its local community through benefits, wages, and salaries.³ Rural patients are a particularly vulnerable population with a greater proportion of patients being poorer, underinsured or uninsured, and more likely to experience chronic disease than urban residents. Although only 20% of Americans live in rural areas, 60% of trauma deaths occur in rural counties where patients already travel twice as far as urban residents to reach healthcare services.³ Closure of rural hospitals will further decrease access to emergency services in addition to decreasing already limited access to primary care and specialty services.

Rationale

Rural hospitals are increasingly implementing hospitalist programmes to provide continued inpatient care with hospitalist use by CAHs more than doubling from 2005 to 2009.¹¹ Hospitalist programmes have been shown to positively impact quality of care, decrease lengths of stay, improve core measures and national patient safety goals, and decrease hospital costs.^2,12 These programmes are staffed by hospitalists who are traditionally physicians whose primary focus is the care of hospitalised inpatients. Use of hospitalists allows community-based physicians to focus on outpatient clinical practices, an important factor in recruitment and retention of primary care physicians in rural communities where physician shortages are greatest.¹¹

Telemedicine is the use of medical information exchanged from one site to another via electronic communications for the health and education of the patient or healthcare provider and for the purpose of improving patient care. It is increasingly used in rural CAHs as a strategy to continue to meet patient-care needs when local physician services are not available. One example is the tele-stroke evaluation which is currently used by facilities throughout rural Montana to provide real-time evaluation of patients with stroke symptoms by a neurologist.¹³ The ‘stroke bot’, a real-time video device, allows a remote neurologist to directly communicate with and observe patients with stroke symptoms that present to rural CAHs across Montana. The neurologist has the capability to control movements of the stroke-bot, including the ability to zoom the camera in on details such as pupil size and facial movements. Another example is night coverage of intensive care unit (ICU) patients which is also increasingly allocated to telemedicine. Off-site physician intensivists provide video monitoring of critical patients and remotely direct nursing staff in patient-care interventions.¹² Telemedicine use continues to evolve and expand with over half of all US hospitals now using some form of telemedicine.

Advanced practice NPs are licensed, independent providers trained in high-quality, cost-effective, patient-centred assessment, diagnosis and treatment of complex medical problems across an array of health care settings. The specialty group of acute care nurse practitioners (ACNPs) evolved in the 1990s to focus on the care of acutely ill patients in the inpatient hospitalised setting. Sixty-five percent of adult hospitalist programmes employed NP/Physician Assistants (PAs) in 2016.¹¹ PAs are licensed healthcare professionals who collaborate with physicians in providing patient care. NPs working together with physician teams have been shown to provide care to hospitalised patients that is equally proficient and safe compared to physician hospitalists.^8,9,14 The rationale for this project is that NPs working together with physician hospitalists through telemedicine can provide care in rural CAHs that is equally proficient and safe as traditional physician hospitalist models.

Specific aims

The purpose of this project is to evaluate a cross-organizational pilot programme by comparing an on-site NP with a remote telemedicine physician support hospitalist programme with an on-site traditional physician hospitalist model to assess effects on length of patient stay, mortality rates, readmission rates, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) ratings of provider communication, and total hospital costs. Using telemedicine to provide remote physician support of on-site NP hospitalists who provide direct patient care may serve as a new model of care for other rural CAHs seeking to maintain financial viability and access to care in rural communities. Using the Standard for Quality Improvement Reporting Excellence (SQUIRE) guidelines, we evaluated the quality of the programme by comparing care provided by hospitalists who are NPs working with telemedicine support from remote medical doctors and on-site medical doctors.

Methods

Context

In early 2015, the community-based Board of Directors of Cabinet Peaks Medical Center (CPMC), a small non-profit CAH in rural Montana, reached out to Kalispell Regional Medical Center (KRMC), the closest regional hub facility, for assistance in sustaining providers to staff the CPMC hospitalist programme. Given prior difficulty with physician retention and inability to successfully recruit new physician providers, three NPs were hired by KRMC to train for and subsequently implement a cross-organizational pilot project. This new model of care used telemedicine to provide remote physician support from KRMC to NP hospitalists providing direct patient care on-site at CPMC. Prior to implementation of the NP/Physician Telemedicine Hospitalist Model, three rotating locums physicians maintained CPMC’s local on-site inpatient services.

This project collected and analysed data from CPMC between April 2016–May 2017 to assess for effects of the newly implemented NP/physician telemedicine hospitalist model on indicators of patient care quality compared to the prior locum physician model. During the project’s timeframe, the NP/physician telemedicine model provided approximately 75% coverage of the hospitalist service with the remaining 25% of time covered by the locums physician model. The hospitalist service at CPMC provided care to patients 18 years of age or older admitted to observation or inpatient status, with an average daily census of 3.45 inpatients. The average patient age was 60.1 years and the top five admitting diagnoses included pneumonia, Congestive Heart Failure (CHF), stroke, Chronic Obstructive Pulmonary Disease (COPD) exacerbation, and alcohol withdrawal. Medicare covered 52% of patients with 39.5% having private insurance and 8.5% of the patients uninsured.

Intervention

The intervention for this quality improvement programme was using NP hospitalists with physician telemedicine support in place of locum physician hospitalists. Each NP underwent extensive training at the KRMC hub facility, including establishing collegial relationships with physician providers at KRMC. At KRMC, each NP became familiarised with local and regional resources and practiced using video and telephone communications for collaboration on complex patient care management. NPs attended the American Academy of Physician Assistant’s ‘Hospitalist Bootcamp’ which provided evidence-based continuing education on commonly encountered topics in hospital-based medicine. After this initial training period, the NP providers transitioned to providing direct patient care at CPMC with continued support by physician hospitalist providers located 90 miles away at KRMC.

Every morning the NP provider texted, called or real-time video-conferenced a report of each patient admitted to the CPMC hospitalist service to a designated KRMC physician hospitalist. Electronic medical records from both facilities were directly accessible across facilities, allowing the remote physician hospitalist to review patient data and NP documentation regarding each case. The physician was available by text, telephone or video throughout the seven-day hospitalist shift and provided consultation on all admissions, discharges and transfers as well as any patient care concerns that might develop throughout the day. Direct live video conferencing between the patient at CPMC and the physician hospitalist at KRMC was facilitated by the on-site NP for certain high-acuity cases, complex diagnostic dilemmas, or dynamic social factors that benefited from direct physician involvement.

Study of the interventions

A meta-analysis of literature evaluating the quality of hospitalist inpatient care delivery identified length of stay (LOS) and total hospital costs as the two primary measures used to assess the efficiency of hospitalist care.¹⁴ Minimising LOS, while not compromising quality of care, results in lower total cost and increased profit for hospitals.⁸ A significant portion of total hospital costs include salaries for physician hospitalists, which have increased 26% since 2010. Current median physician hospitalist salaries of US$278,472 are a significant financial burden to already struggling CAHs with small daily censuses. This burden is increased when it is assumed a minimum of three hospitalists are required to safely run a hospitalist programme. NP hospitalists are less than half the cost, with median compensation US$106,246 nationally in 2015.¹¹ In addition to efficiency of care, clinical outcomes of treatment are most commonly represented in the literature by mortality rates, all-cause readmission rates and patient satisfaction rates.¹⁴

In order to assess the impact on patient care of using an NP/physician telemedicine hospitalist model in place of the locum physician hospitalist model, six independent variables were assessed: average LOS, 30-day readmission rates, mortality rates, and three HCAHPS provider communication scores. Data was calculated for each of the three NP hospitalists and each of the three locum physician hospitalists at CPMC and then collated into two groups representing both the CPMC NP/telemedicine hospitalist model and locum physician hospitalist model. Data was then tested for statistically significant differences on each independent variable between the two groups. In addition, total hospital cost for implementation of both CPMCs NP/physician telemedicine and the locum physician hospitalist model was calculated and described.

Measures

LOS refers to the time a patient spends in a single episode of hospitalization, and is one of the primary efficiency indicators used by hospitals and insurance providers. CPMC’s database calculates average LOS on a monthly basis by attending provider, representing an average LOS for all patients discharged by the corresponding provider during that month. Mortality rates, the most commonly used quality measure, refers to those patients that expire during their hospital stay and are often further categorised by expected vs not-expected, and cause of death. Mortality rates are used to demonstrate aspects of care such as prevention of and response to complications, emphasis on patient safety and timeliness of care. CPMC database presents mortality rates as any death that occurred while the patient was hospitalised, without further categorization. Readmission rates for this study are defined in accordance with the standard benchmark used by the CMS as patients admitted to a hospital within 30 days after being discharged from an earlier hospital stay.¹⁵

Communication between the hospitalist and patient is one of the most influential care dimensions on patients’ perceptions of quality of care.¹⁶ The HCAHPS survey measures ‘provider communication’ with three questions pertaining to providers’ treating patients with courtesy and respect, listening carefully to patients, and explaining things in a way patients could understand. While there is no reliability or validity data published on use of HCAHPS, the survey data remain the national standard in data collection methodology for measuring patients’ perspectives on hospital care and are included in the measures that CMS uses to calculate value-based incentive payment structures for hospitals included in the Patient Protection and Affordable Care Act of 2010.¹⁵

As required by federal compliance guidelines, CPMC keeps all LOS, 30-day readmission rates, mortality rates and HCAHPS provider communication scores in secured data collection files. These measures are tabulated by CPMC staff for each individual provider on a monthly basis. Patient-identifying information was removed from this data for a one-year period and subsequently provided to a licensed statistician for descriptive statistical analysis.

Analysis

One independent samples t-test and five chi-square tests of independence analyses were completed to assess the impact associated with use of a NP/physician telemedicine hospitalist model versus a locum physician hospitalist model on six dependent variables: LOS, 30-day readmission rates, mortality rates, and three HCAHPS communication scores assessing provider communication. When using independent samples t-test and chi-square tests of independence a p-value less than 0.05 indicates statistically significant evidence to reject the null hypothesis and accept the alternative hypothesis that there is a dependence or an association between the two variables.¹⁷ An independent samples t-test and five chi-square tests of independence were applied to the above listed independent variables to evaluate how likely any observed difference between the data sets is associated with use of the NP/physician telemedicine hospitalist model.

Ethical considerations

This project was reviewed prior to implementation by the administration of participating facilities, CPMC and KRMC, as well as the University of Alabama’s Office for Human Research Protection, the academic institution to which this project is presented. All three reviewing bodies have identified that this project is not human subject research and is subsequently exempt from full Institutional Review Board review. Since this project provides data on quality and performance measures of employees of both CPMC and KRMC, the administrations of both facilities were consulted and approved the use of this data for the purpose of this project. Data is collated into groups to protect identification of individual providers. Potential conflicts of interest could include that the author of this study is a member of a group being presented in this project. This potential conflict has been mitigated by careful participation of clinical and academic advisors as well as professional statistical analysis of collected data.

Results

There were six participants in total with three (50.0%) that were NPs supported by physicians through telemedicine and three (50.0%) that were independently practicing locum physicians. There were 353 (31.5%) patients seen by physicians and 766 (68.5%) seen by NPs. Each participant independently staffed the hospitalist service and provided care for all patients admitted to the hospitalist service during their respective scheduled shifts. Modifications to the intervention during the project included a decrease in hours that the NP hospitalist service accepted admissions from the Emergency Department in efforts to reduce work hours in a 24-hour period and improve retention of NP hospitalists. Additionally, cross-training of multiple physician telemedicine providers at KRMC during the project allowed for increased flexibility in scheduling NP/physician telemedicine hospitalist coverage at CPMC. No unintended consequences were identified to be associated with the intervention.

There were six dependent variables (LOS, re-admission rate to hospital, mortality rate and three HCAHPS doctor communication questions) that the NPs and physicians were compared on, based on the implementation of a locum physician hospitalist service and a NP hospitalist service with physician support through telemedicine at CPMC. The data was gathered from April 2016–May 2017, and there was no missing data.

LOS

LOS was measured as a 24-hour day which is a ratio variable. When two groups are independent (NP and MD) and the dependent variable being evaluated is a ratio (24-hour day), an independent samples t-test can be used.¹⁷ The independent-samples t-test is used to determine if a difference exists between the means of two independent groups. As seen in Table 1, using equal variances assumed, the results indicated that there was not a significant difference between the groups length of stay mean (M) of NPs (M = 2.82, standard deviation (SD) = 2.494) and length of stay means of physicians (M = 2.55, SD = 3.059), t (1118) = –1.492, p = 0.136. This means that the there was no difference between a locum physician hospitalist service and a NP hospitalist service with physician support through telemedicine at CPMC on patient LOS.

Table 1.

Independent samples t-test on length of stay.

Levene’s test for equality of variances			t-Test for equality of means
						95% Confidence interval limits of the difference
	F	p	t	df	p	Lower	Upper
Length of stay
Equal variances assumed	0.005	0.942	–1.492	1118	0.136	–0.277	0.186
Equal variances not assumed			–1.608	826	0.108	–0.277	0.172

Hospital all-cause readmission rate

The variables of group (NP and physician) and hospital re-admission rate (re-admitted and non-readmittance) are both nominal variables that have discrete proportions. The chi-square test can be used to test a variety of sizes of contingency tables by this question, focusing on a contingency table that is 2 × 2, also referred to as a r × c contingency table.¹⁷ In order to see if hospital re-admission rate is independent or dependent of group, a chi-square test of independence was used. As seen in Table 2, the results were that the association of variables of group (NP and physician) and hospital re-admission rate (re-admitted and non-readmittance) was not statistically significant at X²(1) = 0.254, p = 0.614. This means that the readmission rate was independent or had no association with group as a locum physician hospitalist service and a NP hospitalist service with physician support through telemedicine at CPMC.

Table 2.

Group by hospital re-admission rate crosstabulation.

Readmission Rate by %		Non-Re-Admission Rate by %		Total
Group	Nurse Practitioners	1.83% (N=14)	98.17% (N=752)	100% (N=766)
	Physicians	2.28% (N=8)	97.72% (N=345)	100% (N=353)

Mortality rate

The variables of group (NP and physician) and mortality rate (mortality and non-mortality) are both nominal variables that have discrete proportions. In order to see if mortality rate is independent or dependent on group, a chi-square test of independence was used. As seen in Table 3, the results were that the association of variables of group (NP and physician) and mortality rate (mortality and non-mortality) was not statistically significant at X²(1) = 0.422, p = 0.506. This means that the mortality rate was independent or had no association with group as a locum physician hospitalist service and a NP hospitalist service with physician support through telemedicine at CPMC.

Table 3.

Group by mortality rate crosstabulation.

		% Mortality Rate	% Non-Mortality Rate	Total
Group	Nurse Practitioners	1.7% (N=13)	98.3% (N=753)	100% (N=766)
	Physicians	2.3% (N= 8)	97.7% (N=345)	100% (N=353)

Physician communication

The HCAHPS was administered to patients and there were three questions asked in the physician communication section which were as follows:

How often did doctors treat you with courtesy and respect?

How often did doctors listen carefully to you?

How often did doctors explain things in a way you could understand?

The comparison was between group and the HCAHPS physician communication rating (always and less than always) which are both nominal variables on all three questions. As seen in Table 4, on question 1, the results were that the association of variables of group (NP and physician) and HCAHPS physician communication rating (always and less than always) was not statistically significant at X²(1) = 2.580, p = 0.108. This means that the HCAHPS Physician communication rating was independent or had no association with group as a locum physician hospitalist service and a NP hospitalist service with physician support through telemedicine at CPMC.

Table 4.

Group * physician communication 1 crosstabulation.

		Percent Always	Percent Less than Always
		Achieved	Achieved	Total
Group	Nurse Practitioners	85% (N=651)	15% (N=115)	100% (N=766)
	Physicians	76% (N=268)	24% (N=85)	100% (N=353)
Total		161% (N=919)	39% (N=200)	200% (N=1119)

As seen in Table 5, on question 2, the results were that variables of group (NP and physician) and HCAHPS physician communication rating (always and less than always) was not statistically significant at X²(1) = 1.202, p = 0.273. This means that the HCAHPS physician communication rating was independent or had no association with group as a locum physician hospitalist service and a NP hospitalist service with physician support through telemedicine at CPMC.

Table 5.

Group * physician communication 2 crosstabulation.

		Percent Achieved	Percent Less than Always
		Always	Achieved	Total
Group	Nurse Practitioners	75% (N=575)	25% (N=191)	100% (N=766)
	Physicians	68% (N=240)	32% (N=113)	100% (N=353)
Total		143% (N=815)	57% (N=304)	200% (N=1119)

As seen in Table 6, on question 3, the results were that variables of group (NP and physician) and HCAHPS physician communication rating (always and less than always) was not statistically significant at X²(1) = 0.347, p = 0.556. This means that the HCAHPS physician communication rating was independent or had no association with group as a locum physician hospitalist service and a NP hospitalist service with physician support through telemedicine at CPMC.

Table 6.

Group * physician communication 3 crosstabulation.

		Percent Always	Percent Less than Always
		Achieved	Achieved	Total
Group	Nurse Practitioners	66% (N=506)	34% (N=260)	100% (N=766)
	Physicians	62% (N=219)	38% (N=134)	100% (N=353)
Total		128% (N=725)	72% (N=394)	200% (N=1119)

Cost of implementation

The estimated annual cost of implementation of the NP/physician telemedicine hospitalist model at CPMC is US$410,000 for a calendar year. The estimated annual cost of implementation of a locum physician model at CPMC averages US$575,000, ranging as high as US$975,000 depending on costs of physician travel and locum company rates. Use of the NP/physician telemedicine model has resulted in an average annual savings of US$165,000–565,000 for CPMC. The estimated cost of employing full-time physician hospitalists at CPMC is US$572,442 annually. CPMC has been unable to implement this model of care in recent years due to inability to recruit or retain hospitalist physicians. The NP/physician telemedicine model offers a cost saving of US$162,442 compared to full-time employed physician hospitalists.

Discussion

Summary

Key findings include that no statistical difference was found between NP hospitalists with physician support through telemedicine and traditional on-site locum physician hospitalists on LOS, mortality, readmission rates or HCAPHS provider communication scores. Additionally, NP hospitalist programmes with physician telemedicine support can be provided at a 29–58% reduction of cost compared to on-site locum physician models. NP/physician telemedicine models demonstrate a 28% cost savings over traditional full-time employed physician hospitalist models. Particular strengths of this project include the presentation of a new model of care in which NP hospitalists with physician telemedicine support maintain patient-care quality and efficiency while offering rural CAHs financially viable options for offering access to inpatient medical care in rural communities.

Interpretation

The implementation of a NP/physician telemedicine hospitalist programme is directly associated with maintaining standards of patient-care quality while reducing total hospital costs. Initial structure of the NP hospitalist programme at CPMC was modelled after programmes previously implemented in Wisconsin and promoted by the Wisconsin Hospital Association. Rusk County Memorial Hospital (RCMH) is a CAH in rural Wisconsin with a service area population of 18,000, similar in size to CPMC.¹¹ RCMH also struggled with recruitment and retention of hospitalist physicians which resulted in plummeting hospital revenue and patient satisfaction scores and jeopardised the future of inpatient services.¹¹ After implementation of an NP hospitalist programme in 2014, RCMH saw an increase in admissions, a 24% increase in patient satisfaction scores, decreased emergency department (ED) transfers, and increased revenue by nearly US$3500 per day. RCMH’s chief executive officer (CEO) attributes saving their hospital to their NP hospitalist programme.

In addition to improved hospital services, Rusk County saw an increase in primary care physician recruitment to the community which directly increased access to outpatient primary care medical care for its residents. Improved physician recruitment and retention was directly attributed to eliminating the need for community physicians to assume the role of on-call hospitalists. RCMH reports increasing trends in patient acuity as ED physicians gained confidence in their NP hospitalist colleagues, thus allowing more patients to receive medical care in their home communities. RCMH is currently implementing its own telemedicine pilot project, similar in structure to the model presented in this intervention, in an effort to increase access to specialty service consultations for locally hospitalised patients.¹¹

Limitations

Contextual elements potentially affecting internal validity of the project include attrition associated with acquisition of additional NP providers over the course of the intervention. Each NP or physician hospitalist independently provided care during their time scheduled to cover the hospitalist service. The NP/physician telemedicine hospitalists provided the majority of hospitalist services during the year, managing a total of 68.5% of patients admitted to the service. One NP was initially hired to begin the programme and provided coverage of the hospitalist service for two out of four weeks or 50% of the time. Two additional NPs were added to the service over the course of the year of study. Within the group of NP hospitalists, the initially hired NP cared for 584 patients admitted to the NP hospitalist service compared to an alternate NP hired later in the year who provided care for only 85 patients.

The data provided by CPMC identified the attending provider associated with each patient based on reports indicating the last provider registered to that patient, correlating with the provider responsible for discharging the patient. The provider discharging the patient is independent from the provider responsible for the majority of days of care provided. The registration process identifying the attending provider was assumed to be consistent with organizational policy, however this variable was not controlled by the research team.

Given that this NP/physician telemedicine hospitalist model is currently implemented at only one rural CAH in the region, options for adjusting the sample size of providers implementing this novel intervention were unavailable. Analysis of larger sample sizes of data could have provided more opportunity to assess for statistical differences in outcome measures. CPMC is largely representative of similar CAHs in rural Montana, sharing similar average daily census numbers, service area populations, and remote distance from regional hub medical facilities. However, this project represents a single institution, thereby limiting generalisability across organizations.

Conclusions

The use of telemedicine to provide remote medical services is rapidly expanding throughout healthcare. This project demonstrates that telemedicine coupled with allowing NPs to practise at the full extent of their education and licensure provides a financially viable model of care for rural CAHs to provide safe and cost-effective inpatient hospitalist services. Telemedicine facilitates partnership between regional hub medical centres and outlying rural facilities allowing rural CAHs to remain open and to maintain patient access to medical care in their own communities. This type of collaborative NP practice with physician support through telemedicine has the potential to spread into other contexts such as ED staffing in CAHs and development of specialty practice integration into rural settings. Suggested next steps include implementation of this pilot project in other surrounding rural CAHs and amongst additional regional hub medical centres to assess for similar outcomes. Further evaluation of the collaborative relationships between NPs and physicians could be explored with consideration for assessing effects of deescalating physician support and increasing NP independence in accordance with full practice authority.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

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