Who’s on Call Tonight?

Primary Care vs Long Term Care:  Who’s On-Call tonight?

As an employer of medical providers, I often must defend the fact that our physicians and nurse practitioners must take after hours call (and I am one of the more battle-scarred and grizzled on-call warriors).  Further complicating the situation is the fact that the recruitment (and retention) of Primary Care Providers is already a ridiculously competitive endeavor.  If you represent a smaller organization, it is even MORE daunting!

This is painfully evident when I see many “Outpatient Only” positions posted… which can also offer both competitive salaries AND NO ON-CALL duties…  The voice in my head says, “How can they pull that off?”  Every practice model I have experienced has included many afterhours needs…  for a multitude of reasons.  Likewise, there are many factors creating this afterhours burden for a medical practice:

  • Patients and loved ones simply need guidance after hours, often on the evening after their visit.
    • Questions arise at inopportune times.
    • Clarifications of treatment plans pop up.
  • Symptoms don’t magically resolve at 5 pm
    • In fact, some problems simply worsen, or declare themselves later in the day:
      • Elevated blood sugars in diabetics
      • Ankle swelling
      • Respiratory complaints
      • Pain
      • Sundowning
    • Pharmacy hours are limited.
    • Medical offices are already packed and overbooked, amid healthcare worker shortages.
    • Work and school schedules continue to conflict with medical provider availability.
    • Third party payers expect (require) a plan for after hours access… access that doesn’t default to the Emergency Room.
    • Third party payers and quality reporting organizations hold medical practices accountable for cost and outcomes (such as ER and urgent care visits)

The good news is that primary care has been busy innovating.  There are an increasing number of solutions to the after-hours conundrum:

  • Telehealth companies are increasingly available. Although there is variation in the accessibility after hours, as well as the cost.
  • Triage lines, staffed by trained nurses armed with effective protocols.
  • Extended hours
  • Affiliated walk-in clinics.
  • Self- scheduling software
  • Direct messaging, patient access portals, and other secure communication tools

However, as a LONG-TERM CARE & POST-ACUTE CARE Physician, I must conclude that there are numerous factors preventing most of these tools from being applicable:

  • Nursing Home regulations REQUIRE the nurses to speak to a MEDICAL PROVIDER for all new orders…
    • While there is some room for protocol-driven decision making, “the regs” require a doctor, advance practice nurse, or physician assistant to be available for real-time consultation.
  • Especially in a world affected by COVID-19, staff turnover is very high, caregiver fatigue is greater... and the result is a staff that is less familiar with these patients.
  • The long-term care and post-acute population are far more medically complex, and more frail, than the general primary care population.
  • Many of these patients were recently hospitalized… and we know the hospital length of stay (LOS) for hospitalizations is decreasing. The list of reasons for these acute/post-acute care episodes is daunting:
    • Strokes
    • Cardiac events (heart attacks, rhythm disturbances, heart failure)
    • COPD exacerbations
    • Orthopedic interventions (Hip, back, knee surgery)
    • Infections of skin, urinary tract, or respiratory tract
    • Cancer related illness or surgeries.
    • Joint replacement surgery
    • Worsening cognitive function
    • Falls, weakness and increased physical debility.
  • Many of these patients require medication regimens that require a greater level of vigilance and oversight.
  • Many of these patients are also having frequent laboratory and radiographic testing… the results of which are often critical, and they become available after medical offices close
  • For these reasons and others, “Nursing Home Call” is frankly one of the most dreaded aspects of training for medical students and residents.

As we can see, without a good on-call system for the long-term care and post-acute care population…  the default solution becomes a well-traveled path from the SNF (skilled nursing facility) to the ER.

So… forgive me while I put my “work spouses” and fellow “Nursing Home Call Heroes” on the top podium for a moment:  without you, the wheels would fly off of the primary care bus…  careening into the picture window of the board room!

Have a good day…. (because you know we’ll be on the phone at midnight!)