HOW SMALL IS TOO SMALL?

John Nelson writes . . .

Recently one of our blog readers wrote in with the following question for our blogging team:

Our small general IM group (3) is interested in starting a hospitalist group for our small community hospital (50bed) because neither our group or our family practice groups can recruit without one. There are no hospitals our size that have hospitalists. Where do we start?

My blogging colleagues may have additional thoughts on this subject, but I’ll get the ball rolling with the following:

Hospitalist practices in small hospitals like yours are reasonably common.  I have worked personally with several such institutions.  However, the smaller the hospital the more the hospitalist program will tend to deviate from a “standard” or typical practice such as might be found in a larger hospital.  For example:

•    You might end up with a solo full-time hospitalist who works most weekdays and a portion of the nights and weekends, with the remainder of the coverage provided by local IM and FP doctors (e.g., you and your partners).    The moonlighting docs would typically be paid at a rate equivalent to the full time hospitalist.  A new doctor recruited to your group or the FP group might like the option to moonlight in the hospitalist practice to earn additional income while building a practice.  And sometimes mid-career IM and FP docs like to moonlight since they’re reluctant to abruptly walk away from hospital practice.

•    Small hospitals don’t typically have a hospitalist in-house at night.  Instead night coverage is provided on-call from home, and ED doctors often write admit orders.  This may sound like it is inconsistent with the whole hospitalist idea, but it is usually simply too expensive for small hospitals to pay a doctor to stay in-house at night when there is little work to do.

•    To ensure adequate patient volume for the hospitalist(s) it may be necessary for all, or nearly all PCPs to agree to refer patients.  The hospital can’t, and shouldn’t, try to compel any doctor to refer.  But it is possible that the idea will be too expensive and never get off the ground if docs are unwilling to commit to referring.  And PCPs should realize that they should generally refer all or nearly all patients, and not refer on a prn basis (e.g. refer only on nights and weekends, but “keep” weekday admissions from the office).

What is most reasonable at your hospital will be a function of patient volumes (is the typical hospital census around 50 or is it something a lot lower?), availability of subspecialists (intensivists, etc), the hospital’s ability to provide financial support for the hospitalist practice (a sine qua non in establishing a practice), and the politics and personalities on the medical staff.

What would you say?

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