THE TELEHOSPITALIST program developed by Gundersen Health System in La Crosse, Wis., was launched in 2018 as a purely virtual model in which telehospitalists worked with nurses at one of the five critical access hospitals in the Gundersen system. (Recently, some telehospitalists have started working those shifts from home.) But that initial model has now morphed into a collaboration where APCs on the ground work under a telehospitalist’s supervision.
That changed yet again when cross coverage at night was added, and again when the system added telehospitalist admission support. Several years on, the hub-and-spoke program continues to expand to now include five critical access hospitals, each with its own unique staffing. Some of those outlying hospitals continue to need virtual coverage as telehospitalists work with nurses; some have APCs working onsite Monday through Friday, with telehospitalists providing primary coverage on weekends. Still others have two APCs who alternate a seven-on/seven-off schedule.
One factor that has stayed consistent: The hospitalists in La Crosse as a whole—not the telehospitalists who work only days—provide virtual night coverage to their rural colleagues.
“Determining the right census is the same thought process every group goes through in their brick-and-mortar practice.”
~ Stephanie Carroll, MD
Gundersen Health System
“There’s an understanding within our group that night coverage is part of the care we provide,” says Stephanie Carroll, MD, who helped develop Gundersen’s telehospitalist program and serves as one of the rotating telehospitalists. Even those hospitalists who don’t choose to rotate through telehospitalist shifts “now have some degree with virtual admissions. Those of us who like it provide the daytime coverage, but we all do it when covering nights.”
The La Crosse-based hospitalist group now numbers about 30, with about 10 rotating through daytime telehospitalist shifts. While a few of the telehospitalists work full time, most—including Dr. Carroll—do tele-hospital medicine only part time.
APC oversight
Another area in which the Gundersen service has learned to be flexible: matching telehospitalist oversight to APCs’ experience and expertise. Telehospitalists serve as attendings across all five rural sites, reviewing and signing off on all notes. But in at least one of the critical access hospitals in the system, APCs with 20 years of experience don’t need hands-on supervision. In that hospital, the telehospitalists act more as consultants.
In addition, the telehospitalists and the experienced rural APCs have developed a three-month onboarding program for new APCs where they spend time working with the hospitalists in La Crosse while they’re beginning their rural shifts.
In addition to providing oversight for acute patients, the telehospitalists also cover rehab beds in several of the critical access hospitals.
As for a typical census on a telehospitalist shift, Dr. Carroll says that runs between 35 and 40. “But only 10 to 12 of those generally are acute patients, and the remainder are rehabbing patients,” she says. “The responsibilities for those are different.”
Determining the right census
How did she and her fellow telehospitalists arrive at that census? “The process has been organic,” Dr. Carroll says—one she likens to the decision-making all hospitalist groups go through arriving at a safe, sustainable census for in-person care.
“Determining the right census is the same thought process every group goes through in their brick-and-mortar practice,” Dr. Carroll explains. “It’s going to vary, and there will be days you’re overwhelmed and others when you’re quiet.” As for how many remote sites to cover, that depends on the type of care the telehospitalists need to deliver. “When we’re providing primary coverage without a local APC, we try to keep coverage to only two of the facilities out of five—although sometimes we may have to cover three.”
As for weekends, particularly if the telehospitalists have to provide primary coverage to all the affiliated hospitals, “we’re very careful with that. I do think there is a limit to the number of facilities that any one telehospitalist can work with, depending on the role and the collaboration with local clinicians.”
With telemedicine, Dr. Carroll adds, “it just takes a little while to understand what the workflow looks and feels like, and there’s probably more variability based on whether or not you have local providers.” Moreover, “your Saturday is going to be a little busier than your Monday because you’re providing more primary coverage.”
In 2022, Gundersen merged with Bellin Health, a health system with one critical access hospital of its own. While Dr. Carroll’s program hasn’t taken on telecoverage in that hospital, “that’s certainly in my mind as an opportunity for us to grow our practice.” She also points out that the telehospitalist service is already planning to expand into home hospital work.
“We’re looking to add a second telehospitalist team in 2024 to grow the home hospital program,” says Dr. Carroll.
As for expanding the telehospitalist service regionally beyond her own health system, Dr. Carroll says there are no plans right now to do so. But would tele-hospital medicine be scalable should the health system want to expand it? “Absolutely,” she says.
For more on telehospitalist services, read our additional case studies.
CASE STUDY 2: Growing interest in surge capacity
A national telemedicine company deploys telehospitalists in rural hospitals and in larger ones to manage surging census. Read more here.
CASE STUDY 3: Rural admissions and post-discharge visits
Telehospitalists in a Georgia health system cover not only critical access hospitals but post-discharge follow-up with patients at high readmission risk. Read more here.
CASE STUDY 4: Telenocturnist coverage
A national hospitalist company opts to outsource virtual night coverage rather than grow its now telenocturnist service. Read more here.
Telehospitalist challenges to expect
Challenges include having to navigate different formularies and figuring out how to spark hospitalist interest in telemedicine. Read more here.
Combining telemedicine with in-person care
A hospitalist enjoys making virtual patient connections while maintaining skills treating higher-acuity patients inhouse. Read more here.
Phyllis Maguire has been Executive Editor of Today’s Hospitalist since 2006. Based in Bucks County, Pa., her health care interests are hospital medicine and long-term care options. She also likes zydeco, hiking, and reading memoirs and romances.
