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The New Reality of the Mid-Level

One of the service lines that Creative Healthcare Solutions offers our clients is talent acquisition, and we can concede that’s usually industry speak for “help me locate a physician.” It’s this service line, maybe more than the others, that gives us some of the best pulse readings on the industry, because it’s changing in fundamental ways.

It will come as news to no one who’s been paying attention that there is a doctor shortage in North America. Some of this has been covered by making it easier to recruit and onboard H1/J1 docs; but really – the answer has been found in mid-level providers. There is virtually no scenario, whether it’s within a health system, a two-doc-shop, or a house call group, where healthcare providers are not beginning to staff mid-levels to physicians 2-1. Again, for those who have been keeping up, this is not news.

It does provide prelude to a real issue that could be hitting the house call sector of health delivery – the autonomy of the mid-level. Seeing as how this is a growing service line, it will continue to be an issue. Most guidelines for mid-levels were developed for a facility setting; a controlled setting where the mid-level and supervising physician (SP) were in the same geographic area for most of their time.

But what about when the SP and the mid-level are not in the same geographic area? If it’s a campus issue, they can usually utilize telemedicine to mitigate this. But that becomes very difficult in the domicile of the homebound patient, most of whom live in less-than-desirable conditions and definitely ones that do not facilitate a wifi signal.

Most Boards of Nursing (BON) haven’t developed guidelines for utilizing mid-levels for house calls. We’ve worked with a few, and the best response we can get is “just do your best.” Not the most comforting advice when audits are becoming the national sport of health care … for instance, most BON guidelines state that the SP must have a “meaningful relationship” with the patient. What qualifies that? Chart review? Visits more than every six months? Teleconferencing? It becomes very tricky to balance the regulations with the practicalities of running a practice.

Perhaps the biggest obstacle facing the house call component is paperwork oversight. Currently, the two most important pieces of paperwork to a home health agency are the Plan of Care (also known as a Medicare 485 form) and the Face-To-Face evaluation form that accompanies a new patient (or re-certified patient). It’s these two forms that get the home health agency reimbursed. It’s for good reason that a provider needs to sign off on it – it creates a checks and balances system to confirm that the HHA in question is not running up tabs for unneeded services. But a mid-level cannot sign off on either of these documents.

There is absolutely zero reason why this should be the case. It actually hurts the home health agencies, because it creates a delay in patients getting scheduled and paperwork being returned. The mid-level is usually in contact with the patient the most – trusted with most of their clinical oversight – yet not trusted to sign a piece of paper confirming their work. If they have a proper scope of care agreement, and their SP is diligent about chart review, there is very minimal risk for granting the mid-level this responsibility.

As we continue our national debate on healthcare and how best to care for our patients, we also need to look at the central component of this: providers. How do you utilize them? How can we help them? And how do we keep them from being stretched too thin? Giving mid-levels a little more autonomy is a step in the right direction.

Some things to think about,