As hospitals and health systems strive to diversify their service locations to include not only more inpatient facilities but also an array of outreach clinics, skilled nursing facilities and even patients’ homes, some practice leaders are concerned about the ramifications of spreading their clinical teams too thin. They worry that expecting their physicians to be everywhere all the time is contributing to professional dissatisfaction and burnout, potentially affecting both staff morale and patient care.
To ease the pain, savvy cardiology leaders are implementing creative staff deployment strategies while staying the course toward site diversification and expansion.
It starts, they told CVB, with understanding that the challenge is multifactorial.
Multiple catalysts, universal challenge
Terri McDonald, vice president of consulting for the American College of Cardiology’s MedAxiom consulting arm in Neptune Beach, Fla., says a convergence of issues beyond expansion initiatives lies behind the push to staff up in cardiology. “Our aging population and the burden of cardiovascular disease create a near-perpetual demand for cardiovascular care,” she explains. “Advancements in technology and treatment have expanded the percentage of patients eligible for cardiovascular interventions.”
Unfortunately, she observes, there isn’t sufficient bandwidth in the cardiovascular physician workforce to cover the demand. And there’s not much relief in sight: MedAxiom’s 2019 Cardiovascular Provider Compensation and Production Survey revealed that one in four cardiologists is over the age of 61. “General, noninvasive cardiology had the highest percentage of physicians in this age group, at 31 percent in 2018,” McDonald explains. “Based on the projected number of physicians departing the workforce annually, the number of new fellows entering the workforce annually and the continued growth in demand for care, the report predicts that access to cardiologists will worsen over the next decade.”
“The situation is somewhat taxing,” says Thomas E. Noel, MD, president of the cardiology division at Southern Medical Group in Tallahassee, Fla. “We have 16 cardiologists and five cardiothoracic surgeons. We want to grow and to serve expanding subspecialty needs in a wider base of communities, but resources can only go so far.”
Even hospital systems with larger staffs of general and invasive cardiologists as well as more cardiac surgeons are feeling the pain. “We’re being pulled in a lot of different directions, not only within the system and in outreach locations, but to be part of broader-based care teams—for example, transplant evaluation,” says Penny Vigneau, MSW, MBA, senior administrator of heart and vascular services at Tampa General Hospital (TGH) in Florida.
TGH is tackling the challenge by partnering with area private practices as well as the University of Southern Florida Health (USF) to create the Heart & Vascular Institute at Tampa General Hospital. A leadership council of representatives from all three entities has developed a five-year strategic plan for the entity. “In year 1, we will evaluate which structural/legal models will allow us to integrate across these entities, producing the greatest alignment and results,” Vigneau says.
To meet heightened demand for care and expand into cardiac MRI without spreading its team too thin, Southern Medical Group teamed up with a local radiology practice to form a cooperative cardiac MRI service line. “It has proven to be a more productive, less stressful approach for us and them,” than would have been the case had either practice initiated such a service on its own, Noel says.
Adopting a team model
Hospitalist programs and subspecialization have created silos of care in cardiology, McDonald notes. She advocates instead adopting models where cardiology is a “team sport” played in “lanes” (teams of professionals). “Creating lanes, rather than silos, allows individual subspecialists to do work at the top of their training,” she explains. “These lanes work in parallel, intersecting when needed to plan and deliver care. For example, general and advanced imaging physicians, not interventional cardiologists, drive work in the noninvasive imaging space. This better allows interventional cardiologists to focus on the demands of that subspecialty.”
Smaller systems and cardiology practices may need to handle general cardiology demands by assigning subspecialists to more than one “lane,” McDonald concedes. Even so, she says, following a lane-based model results in better resource utilization than maintaining silos. Another effective strategy is adding advanced practice providers (APPs) to teams and assigning them structured roles, such as seeing return patients; operating heart failure, atrial fibrillation or other specialty clinics in collaboration with supervising physicians; or managing complex inpatient rounding services.
CHI Heart Health Institute, based in Omaha, also has adopted the team approach. It has four care teams that serve Creighton University Medical Center as well as community hospitals and outreach locations in northeast Nebraska and southwest Iowa. Each team comprises four to six cardiologists, two APPs, dedicated nurses and a scheduler. One APP per team is assigned to rounds, the other takes clinic duties.
“Teams spend half their time at our main hospital and half of it in the field,” explains Jeff Carstens, MD, MBA, CHI’s vice president of medical operations. “This structure lets us expand smarter, plus everyone gets better coverage without [resources] becoming too strained from traveling to multiple sites. There’s also more job satisfaction—and better patient care—because cardiologists are freed up to handle new and complex cases while APPs who work in clinic can concentrate on follow-up cases.”
Centra Health System’s Stroobants Cardiovascular Center in Lynchburg, Va., also follows a team model, relying mostly on APPs to see patients who require follow-up less than 12 months after treatment, explains Medical Director Chad Hoyt, MD. New patients and those who need follow-up care at or after the 12-month mark are seen by cardiologists. “We also heavily utilize APPs for device clinics, hospital rounding teams, call services during the day, etc.,” Hoyt notes.
Besides the team model, Stroobants Cardiovascular Center follows what it finds to be a smarter approach to staffing than assigning all cardiologists to all sites. Noninvasive cardiologists see patients at Stroobants and handle most of the travel necessary to provide care at the system’s satellite clinics because, Hoyt explains, “they can do imaging and stress testing there.” Conversely, electrophysiologists, for example, are rarely assigned to travel to clinics because moving between facilities would impinge on their procedure time.
“We do send procedural cardiologists to satellites, but to a lesser degree,” Hoyt says. “We also rely on our APPs to cover our follow-up patients at the ‘home base’ while we are away at satellites.”
UT Southwestern Healthcare System in Dallas, which includes six hospitals located across 45 miles and a seventh facility scheduled to opening in December, takes a similar, “smarter” approach to staffing satellites. “With a big coverage area like ours, you can lose economies of scale if you draw from one pool of cardiologists to handle everything,” observes Rebecca Napier, MBA, chief administrator. Instead, in some areas, the hospital system employs cardiologists who want to work part-time or have scaled back their practices.
Napier also describes smart satellite staffing strategies she’s seen at another hospital. Instead of stretching its staff resources to offer cardiovascular surgery services in a rural area, the hospital acquired a local practice and hired a cardiovascular surgeon to work in a community hospital there. The hospital also had physician liaisons who drove faculty back and forth to clinics and other points of service so they could work or sleep in the car. “It was incredibly effective, because we could cover a bigger footprint and at the same time achieve increased provider satisfaction,” Napier says.
Offering financial rewards
Asking cardiologists to travel to distant clinics—especially clinics with high no-show rates or less-than-full patient loads—can be a recipe for disengagement and burnout, warns Hoyt. To minimize such physician dissatisfaction while maximizing staff resources and supporting quality patient care, Centra Health has in certain instances guaranteed physicians a minimum number of RVUs for each day spent at a satellite location. Alternatively, it has paid cardiologists a guaranteed lump sum per diem for work at a satellite—that’s in addition to the RVUs produced that day.
UT Southwestern Healthcare also has offered financial rewards when physician resources were being stretched to cover demanding clinical needs. “It’s no remedy for fatigue, but it’s a way of letting doctors know we recognize that they’re working hard, so they’re being rewarded,” Napier says. “It does remove some of the sting from overwork.”
Tapping into telemedicine
Like many hospitals, CHI Heart Health Institute has begun experimenting with telemedicine, in its case as a strategy for efficiently supporting community hospitals. “In one community hospital, we’ve cut back our services from Monday through Friday to Monday, Wednesday and Friday,” Carstens reports. “On Tuesdays and Thursdays, when we aren’t there and there is a need, we will conduct a telemed consultation. We’re also doing telemed consults for a rural hospital. It’s baby steps, but so far it’s going well. Telemedicine is a good solution for extending inpatient services without the logistical complications.”
Telemedicine has its own issues, but its appeal is growing, especially now that the government and payers have begun making efforts to ease regulatory and reimbursement burdens (see related story). While it may turn out to be a key component of hospitals’ efforts to diversify their sites of service, it’s unlikely to become a panacea for the obstacles sometimes associated with growth. Sources told CVB there simply is no one-size-fits-all solution for every practice. “It’s trial and error, and there will be challenges,” Carstens concludes. “But by trying new strategies until we find the right ones, we will see benefits in better care for our patients and a more effective way to deliver it.”