Riverwood Healthcare
Center
A change from the traditional approach to
physician staffing
Tim Arnold MD
Family Medicine Physician
Mike Delfs
Chief Operating Officer
Riverwood Healthcare Center
Background
 CAH hospital in Aitkin MN.
 3 - provider based rural health clinics.
 9 employed Family Medicine Physicians.
 4 employed Family Medicine NP’s.
 Family Medicine Physicians are paid on RVU’s so
any changes have to have little/no impact on
production.
How do we meet the needs of the
Hospital and Clinic?
Previous system
Every provider rounded on their own patients in the am.
Scrambled to get it done and to clinic on time. variable numbers of
patients.
Mad rush to get it done, nursing staff overwhelmed.
Signed out to who ever you could find if you where not there.
Received calls from hospital nursing throughout the day.
Ran back to the hospital at lunch and after clinic to finish or find
families to talk to.
How do we meet the needs of the
Hospital and Clinic?
Inpatient
How do we round in the a.m. on inpt’s and get to the
satellite clinic?
Admissions during the day from ER and surgery?
Family needs aren’t always satisfied at 8am.
Efficiency?
Nursing needs during clinic hours.
How do we meet the needs of the
Hospital and Clinic?
Clinic
How do we implement longer clinic hours?
How do we schedule better?
How do we maintain focus and clarity of jobs
tasks?
Hospitalist Coverage
 The only real option traditionally used is a Hospitalist.
 Hospitalist coverage is common in larger and/or more
urban hospitals.
 Cost of this traditional model is prohibitive in rural settings
($222,964 average yearly compensation per physician).
 Can be problematic to attract Internal Medicine trained
physicians to rural areas.
 Riverwood began looking at a variation on the Hospitalist
Model (Rounder System).
Hybrid Hospitalist Model
Rounder system, 2 providers daily, IM and FP.
Each provider takes a week at a time functioning
as a hospitalist. Once per 6-8 weeks for FP and
every other week for IM.
7am to 4:30pm responsible for all hospital work.
1-2 half clinic days that week.
How did we get here?
Tried to solve the above problems.
Worked on process flow.
Tried to improve communication.
NO RESULTS!!!!
How did we get here?
Presented idea to the group.
Worked on over coming fears about loss of
patient control.
Explanation to patients.
What are the benefits and problems?
Schedule rounding assignments out for one year.
Rounder system
What has happened?
Improved patient care.
Immediate evaluation, re-evaluation for change
in status.
Same provider most days.
Family satisfaction.
Follow up on interventions.
Rounder system
What has happened?
Improved nursing communication.
Patients have responded very well to the
change.
Consistency and time at the bedside.
Rounder system
What has happened in the clinic?
More time, 30min to 1 hour more per day.
Focus has improved, no calls from the hospital
floor.
No admissions during the day.
No clinic “call day.”
Clinic Volumes
 Physician’s time ranges from .5 to .8 FTE so “day”
does not necessarily mean 8 hours per day/40
week however there are no FTE changes for the
years listed below.
 FY
Days
Appts
Per/day
04
619
7,617
12.31
05
651
8,367
12.85
06
645
7,815
12.12
07
606
8,750
14.44
08
565
9,229
16.33
Geriatrician Program
 Partnered with North Clinic Geriatric Services to explore a
care model employing a physician to assess patients in
the nursing home.
 The premise is that MD’s will be able to see more patients
in the clinic with more consistent patient care in the
Nursing Home.
 North Clinic has favorable relationships with HMO’s who
administer the MSHO program. Based on those
relationships as well as regulatory guidelines for the
program services such as resident/family planning,
regular medical checks and some clinic level services are
paid for.
Geriatrician Program
 Riverwood employs a physician to act in this role as a
Geriatrician.
 Physician is backed up after hours/weekends/vacations
by the North Clinic Geriatricians.
 There is a care coordinator that helps coordinate the care
(reimbursable as a per-member-per-month under MSHO
guidelines).
 The program has broken even since it’s inception during
FY 07-08.
Nursing Home Changes
No nursing home faxes and calls during the day!!!!!!!!!
Little to no after hours calls from the nursing homes!!!!!
Very favorable feedback from the nursing homes – no
“phone tag” with MD’s only to start over at 5:00 with
whoever is on call, MD is right down the hall if there are
questions.
One consistent person to talk to about a transfer to or
from the nursing home.
Nocturnist Model
 Issue: quality of life for rural physicians.
 Hospital began exploring potential options to
decrease the call burden for the physician group.
 Proactively have begun trying to plan for the newer
generation of Family Medicine physicians who are
likely to be less accepting of the burden of call and
lack of flexibility a rural setting may present.
Nocturnist Model
 Looked at; community call pools with neighboring
hospitals, hospitalists and NP’s.
 Eventually settled on a “Nocturnist” model with 24
hours week dedicated to hospital work and the
remaining as clinic days.
 Nocturnist is a cost effective alternative for hospitals
to help in alleviating some of the burdens that call
produces for physicians
Nocturnist Model
NP with previous paramedic experience as well as hospital
work
She takes first call on admissions and all after hours work
Presentation to the call M.D. for discussion
ICU admission we may need to come in.
OB maybe covered by the FP on-call or the OB on-call
SLEEP, SLEEP. ahh to Sleep!
Nocturnist Model
Pros
Sleep!, Family time, Less pressure
Cons
Still on-call
Can’t leave town, drink a beer or go out
fishing!!! Some of the “mental harness” is not
lifted by this.
Conclusions
 Riverwood is not unique in trying to figure out
alternative coverage models for hospital work, call
or nursing homes.
 With expectations of residents graduating today
including: opt-in or opt-out of call, flexibility in work
schedules and pay commensurate with urban
practices CAH’s are going to need to continue being
innovative as the challenges of attracting physicians
to rural areas are becoming greater.
Riverwood Healthcare
Center
 Questions?