Maximizing Hospital Bed Utilization in Rural Communities using a Telemedicine Hospitalist Model

In rural areas of North Central Washington, like many rural areas, small access hospitals are becoming less and less used, while hospital beds in urban areas are often in short demand. How do we leverage this underused resource?

Confluence Health is a non-profit health care system dedicated to providing care to the people in a four county region of North Central Washington. It operates two hospitals – one 197 bed referral hospital (Central Washington Hospital, or CWH) and one 20 bed medical-surgical and acute rehabilitation hospital. CWH runs over 90% capacity and is frequently on diversion. This raises many issues. First, patients from rural areas are forced to go to cities 100-150 miles further away, causing greater hardships for their families. Financially speaking, in January alone we lost $6-9 million in known hospital charges from a lack of beds. The subspecialty outpatient followup care for cardiology, oncology, radiation, ancillary testing, etc., is unknown, but can be arguably the same amount. This could result in an annual loss of charges leaving the four county region of $72-216 million, with net revenue loss in the $38-130 million range. Using charge capture data, we know that 21% of all inpatient charges for the population of these four counties happen outside the four counties – 21-28% for specialties such as orthopedics and general surgery. While some of this is personal preference and highly specialized care, much of this is from lack of inpatient beds.

At the same time, there are multiple rural access hospitals left nearly empty. Specifically, there are two hospitals in the North with 25 licensed beds each; their average census is 4-5. More and more, primary care providers do not want nor feel comfortable providing inpatient care, and therefore even moderately sick patients are referred to CWH for basic inpatient care. This leads to bed issues, diversions, and a loss of patients, many of whom are complex and should be served by Confluence Health.  There are financial losses for these rural hospitals as well, struggling to stay out of the red. In fact, one rural hospital to our East could be closed within the year. An attempt to have a hospitalist service there failed due to lack of invested providers, frequent turnover of providers, and low inpatient census.

In July of 2017, we will be piloting a TeleHealth inpatient service. The model will include Acute Care Nurse Practitioners (ARNPs) on site with offsite Hospitalists providing Telemedicine consultative services and overnight Telemedicine admitting and cross cover services. Utilizing on site ARNPs keeps the care personal; having a well developed and integrated hospitalist team providing expertise should allow sicker patients not requiring procedures to stay locally. If successful, we envision spread to a second hospital in the North. The hope is to double the inpatient census at each hospital (from 4-5 to 8-10 each). This provides local care many patients want, much needed income for the rural hospitals, and room for the highly complex, high revenue, subspecialty care at CWH.

I am looking for insight into the issues in an effort for this model to succeed. Issues such as –

  1. Patient selection
  2. Patient satisfaction
  3. Patient safety
  4. Telemedicine downtime
  5. Billing issues

Has anyone provided inpatient care via Telemedicine, and if so, what were the unforeseen problems you had?



Implementing a value based health care delivery model

Participant comments on Maximizing Hospital Bed Utilization in Rural Communities using a Telemedicine Hospitalist Model

  1. Hello
    Have you considered partnering with a Family Practice Residency Program – the residents could complete a rotation at the rural hospital sites and support the Nurse Practitioners. Patients from the rural sites could be repatriated back once their acute phase of their hospitalization is completed. Perhaps the smaller hospitals sites market share should be targeted at patients requiring sub-acute, rehabilitation and convalescence care.

  2. Hi Jim,

    I find your model very interesting, and would be glad to hear more about your experiences. We are piloting similar concept in the Helsinki university hospital. Some of our wards provide intensive telemedicine care to schizophrenia patients in nursing homes around our district. We see many advantages in the fact that patients stay physically at their nursing home while getting intensive and specialized psychiatric treatment.

    We think that chronic schizophrenia patients in nursing homes, forensic patients in prisons and mentally retarded patients with psychiatric symptoms are especially suited for this model. We select patients with milder symptoms, and those for whom moving from their nursing home might be harmful.

    Patient experiences are good for the first patients, and no safety issues in these patients yet. As this is still a pilot we dont have a billing system. I believe this is a very important way of taking the most out of specialized inpatient units – and one major step towards our future mental health system.

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