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By BETSY TAYLOR

The tucked-away northern Wisconsin town of Eagle River — population about 1,400 — draws visitors with its hundreds of miles of snowmobile trails and a towering ice castle that volunteers have constructed annually for decades by stacking blocks of ice cut from a nearby lake. The river community attracts summertime vacationers, too, but the same rural setting that makes it a getaway spot also poses significant physician recruiting challenges for Ministry Health Care, which runs a 25-bed critical access hospital there.

Historically, Ministry Eagle River Memorial Hospital has depended on a small group of primary care physicians who take care of their rural neighbors in and out of the hospital. When one of those doctors retired from practice or resigned from the hospital staff, hospital administrators have been left scrambling to fill the void. Ministry Health Care executives say the staffing challenge has been compounded in recent years by the competition for primary care physicians, who are in short supply and of a generation that values a work-life balance.

The staffing concerns at Ministry Eagle River Memorial mirror those at rural hospitals elsewhere in the nation. Ministry Health Care, a member of Ascension Health, is tackling the problem with a new staffing model that allows a nurse practitioner to fulfill the role of attending provider at the rural location. Hospitalists at Ministry Saint Mary's Hospital in Rhinelander, Wis., a larger community hospital located about 25 miles southwest of Eagle River, oversee the nurse's work and can examine patients using a telemedicine unit.

Dr. Robert Sookochoff, president of Ministry Medical Group, and Laura Magstadt, Ministry Eagle River Memorial Hospital's director of patient care services, will describe the staffing model during an Innovation Forum at the 2014 Catholic Health Assembly, June 22-24 in Chicago.

Competing for a scarce resource
There's a shortage of primary care physicians in the U.S., and that isn't expected to be corrected anytime soon. Only about

5 percent of new primary care doctors base their practices in rural areas, according to a 2013 study led by researchers at the George Washington University School of Public Health and Health Services in Washington, D.C.

"It took us more than three years to recruit a family practitioner to Eagle River, Wisconsin," noted Magstadt. And while small communities once relied on their doctors for office visits, middle of the night calls and hospital care, many physicians now want to work in a clinic setting, or a hospital setting, but not both, system leaders said.

Sookochoff said, "The problem we were trying to solve is how do we provide a low-cost hospitalist service in a rural critical access hospital, (a service) that is not reliant on a dwindling source of primary care physicians."

Adaptive problem solving
Ministry Health Care began planning the staffing model in 2010, but it didn't implement it until May 2013 because it first had to secure a waiver from the Wisconsin Department of Health Services, and it had to provide additional training to select nurse practitioners.

Regulators gave Ministry Health Care a three-year waiver from a state statute that requires that a physician, dentist or podiatrist be the attending physician at an inpatient hospital. The waiver allows nurse practitioners who are practicing within the structure of the program to fulfill the role of attending provider at Ministry Eagle River Memorial.

At the request of the regulators, Ministry Health Care sought opinions on its proposal from the state's Board of Nursing and its Medical Examining Board. The nursing board provided a letter of support after hearing a presentation on the model; the Medical Examining Board did not take the issue up, Magstadt explained.

Nurse practitioners — who are already licensed to diagnose patients' conditions and to prescribe medications — complete an additional six months of training before they begin work at Ministry Eagle River Memorial. During training, they work alongside hospitalists at Ministry Saint Mary's. Ministry Health Care is using a Mayo Clinic curriculum to train the nurse practitioners in inpatient skills. Magstadt said most nurse practitioners have skill sets focused on outpatient care, and disease management over the long term, but as an attending provider at a critical access hospital, the nurse practitioner must be adept at assessing whether a patient should be admitted or transferred to another hospital offering higher acuity care. At Ministry Eagle River Memorial, the nurse practitioner has a scope of practice limited to a common group of diagnoses, and the nurse practitioner follows evidence-based clinical protocols. Working with an outside company, Ministry Health Care wrote order sets outlining treatment plans covering all of the most common diagnoses at the rural hospital. The order sets also cover pain management, dehydration and other common issues. If a nurse practitioner wants to act outside of the order set, the practitioner first consults with a hospitalist via a telemedicine link.

Nurse practitioner Daniel Skeen, an advance practice nurse in the pilot program at Ministry Eagle River Memorial, estimates he uses the telemedicine link to consult with hospitalists at Ministry Saint Mary's about 20 percent of the time. He also consults with the family physicians who admit patients to Ministry Eagle River Memorial and are their patients' primary provider in the hospital.

Telemedicine link
Skeen can position a telemedicine unit to be the eyes, hands and ears of the consulting Ministry Saint Mary's hospitalists. The robotic system has high-resolution, 360-degree turning cameras that allow the hospitalist in Rhinelander to check an Eagle River patient's pupil reaction, to zoom in on a skin condition, and to listen to a patient's heartbeat, lung sounds or bowel sounds.

Patient response to the telemedicine model has been positive, Skeen said. "The sense is that it's very advanced. They're impressed with that," he said.

Ministry Health Care used telemedicine federal grant dollars for some of the initial technology costs. Sookochoff estimates that if a health system were adapting a similar model for two nurse practitioners at one rural hospital, training costs for the nurse practitioners and the doctors who will work with them through the telehealth link would be about $100,000. Capital costs, including the robotic technology, would be about $80,000.

Containing losses
Sookochoff said the care model is expected to run an annual net operating loss of about $125,000, based on what the hospital can bill for the nurse practitioner's services. That compares with an expected billing-to-costs shortfall of about $475,000 if hospital-employed physicians were providing the direct patient care, he explained. Ministry Eagle River Memorial has an average census in the five to six patient range.

Ministry Health Care estimates that over 10 years, the nurse practitioner program will be a fifth of the cost of a physician-staffed program. Sookochoff said that brings the model down into a range that's affordable for critical access hospitals facing physician staffing challenges. "It operates at a loss that's palatable at small hospitals," he said.

Ministry Health Care is recruiting three additional nurse practitioners to begin the six months of training for the program: one will be assigned to Ministry Eagle River Memorial, and the two others will be assigned to another hospital.

Sookochoff said the staffing model uses resources effectively and supports the system's mission. "Here, we believe in service, especially to the poor and to those who can least afford it. We live in a rural area. It's hard for people to travel." He added, "We're actually able to treat more people in a high-quality way in their hometown. I think that supports our value of 'presence'. It certainly is a huge satisfier to our patients."