How to increase inpatient census

[redfish1891]

Hey everyone,

I am applying to an inpatient job at a small community hospital in a rural area. One of the areas that they are struggling with currently is keeping their beds full. They don't have a physiatrist currently, the CMO is acting as the medical director. The CEO asked me how I would work to increase the census. I wasn't really sure how to answer that question. They have a max capacity of 17, currently averaging around 8 -10. Has anyone else built up their census, if so how did you do it?

I'm excited about the job as it is a .5 inpatient and .5 outpatient job, I will hopefully be working the inpatient floor in the morning and doing MSK with injections, TENEX, PRP and EMGs in the afternoons.

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[RangerBob]

Are you going to manage the unit alone? First question is are you sure you want to increase capacity? 17 patients is a solid census (I find 14 ideal) with good pay (plus any director stipends). Adding on another half day of clinic sounds like a very busy day. If you're doing director duties as well, then I would hope they're offering you a very, very good salary.

As far as building up the census, that is primarily the job of the consult liaisons (if you have them) or the consult physiatrist (which most units don't have). If you're the medical director you can certainly meet with the heads of the local IM group, trauma, ortho, and neurosurgery and let them know to refer their patients to acute rehab instead of SNFs. The advantage you have is if you don't have a full unit, then you can take their patients once their medically stable. If they're having to wait to get patients into SNFs, then that's a selling point.

I find the surgeons are the most likely to appreciate acute rehab vs SNF, because they actually see their patient in follow up and they see the difference we provide vs SNF.

 

[redfish1891]

Are you going to manage the unit alone? First question is are you sure you want to increase capacity? 17 patients is a solid census (I find 14 ideal) with good pay (plus any director stipends). Adding on another half day of clinic sounds like a very busy day. If you're doing director duties as well, then I would hope they're offering you a very, very good salary.

As far as building up the census, that is primarily the job of the consult liaisons (if you have them) or the consult physiatrist (which most units don't have). If you're the medical director you can certainly meet with the heads of the local IM group, trauma, ortho, and neurosurgery and let them know to refer their patients to acute rehab instead of SNFs. The advantage you have is if you don't have a full unit, then you can take their patients once their medically stable. If they're having to wait to get patients into SNFs, then that's a selling point.

I find the surgeons are the most likely to appreciate acute rehab vs SNF, because they actually see their patient in follow up and they see the difference we provide vs SNF.

Those are all good points, thank you. I will have internal medicine managing medical issues so I would focus on only rehab management and director duties. It is a 20 hour per week position they have posted so I thought that adding in additional clinic time would be reasonable but it may not be. Thank you for the insight.

 

[Dansk2011]

You could do evals outpatient for inpatient admissions if they qualify based off diagnosis but those can be challenging to get accepted if they have insurance. Meet with the hospital case managers about sending referrals but that will also end up in them likely sending referrals for patients that would be more appropriate for SNF. Unfortunately census is usually reflective more on population density and competition. And as mentioned above isn't necessarily your responsibility. I would also agree that 17 beds with half day outpatients without help, even if you are only doing rehab related stuff, might be hard to balance, especially if you are also doing administrative work. I think having 10, maybe 12 patients is better as that is manageable in a half day, but that also depends on how much you are being expected to see in the clinic daily. Been curious about those types of jobs as they sound great in theory....when you are off as in vacation who covers and how easy is it to get someone to cover? What happens if they don't find coverage....are you screwed? How about holidays? What are you doing about call?

 

[redfish1891]

Those are also good questions. I would have no call, just rehab rounding and admin. The previous medical director and hospitalist are supposed to cover in case of vacations. I didn't ask about holidays.

I will ask some more directed questions about the time burden of the admin portion and how many patients they expect to be seen in clinic. Thanks for your wisdom. I appreciate it.

 

[RangerBob]

Those are all good points, thank you. I will have internal medicine managing medical issues so I would focus on only rehab management and director duties. It is a 20 hour per week position they have posted so I thought that adding in additional clinic time would be reasonable but it may not be. Thank you for the insight.

Is IM primary? That can make a big difference.

We have IM coverage on all patients (PM&R is primary). When the census is closer to 20 it’s a busy day unless there are no admissions.

Up 17 inpatients plus director duties is more than 20hrs/week. Even 10 patients with director duties would go over that.

 

[RangerBob]

Those are also good questions. I would have no call, just rehab rounding and admin. The previous medical director and hospitalist are supposed to cover in case of vacations. I didn't ask about holidays.

I will ask some more directed questions about the time burden of the admin portion and how many patients they expect to be seen in clinic. Thanks for your wisdom. I appreciate it.

Get that in writing! If you have no call then presumably you're a consultant, not attending. That makes life easier.

Is this an employed position or independent contractor?

I would get it in your contract that you'll get x weeks coverage per year and that it's on the hospital to arrange coverage. I would not rely on others saying they'll cover your patients.

 

[DMBandFan86]

My first job was at a small rural hospital...

They also had a census that was about 8-12 and wanted to expand to 18+. But it was a dead-end job. There was no room to expand within the rural population and they were being outcompeted from all the other rehab options (which were 1-3 hours away). We tended to keep patients way past length of stay to keep the census up (which was no problem with our CEO). The unit thrived on taking CHF, COPD patients and keeping them for 3-4 weeks, then bringing the same people back every so many months.

They also gave me on promises of an outpatient clinic and expansion. But then they didn't support it and proactively limited my outpatient expansion. So I left. It was, however, a very easy job with decent pay, but didn't have a good 5-10 year plan.


So, when they are asking you to increase census, it may be a red flag. Obviously, the prior medical director, the current program director and CMO were unable to get the census up. Your only answer may be to keep people longer (increase LOS) and take on more nursing-home type patients (given you can stay in compliance with Medicare). Also depends on what type of patients your hospital can care for (i.e. do you have neurosurgery in house?).

I agree with the above. Get everything in writing in your contract and hopefully you are going to be paid well. I would also ask for data. Make sure you know what the average census and LOS was over the last several years or decade so you can see what the trend it. Also know where patients are going if they don't get treated locally and what the CMO is doing to keep those patients in house.

 

[redfish1891]

Thank you for your feedback, everyone. You have given me a lot more to think about than I had anticipated. I have a phone call scheduled with the hospital later this week and will ask directed questions regarding these topics.

 

[Momentum70]

I have worked inpatient in primarily rural settings. This will be repeating some of what is said above.

1) A census if full of 17 is a full time job. If you get it full then on multiple days you will be discharging from a bed and filling it with an admit. IF you are the primary attending that means admin orders, med recs, etc and discharge paperwork also. It is not just rounding. Its fielding all the calls from nursing, therapists, families. Its team conferences, family conferences, consulting other services. In a rural setting you typically dont have that much support. You are neuropsych, you are psych, you are insert whatever service they dont have.

2) You said it was 1/2 out and 1/2 inpatient, I agree that at current average 8-10 it is 1/2 and you will not generate enough RVU off that to make a decent salary, but you should also think long term. My first rural job I decided to wait on starting outpatient and a few months into it I realized I had zero time and was making enough just off inpatient.

3) To supplement your income and generate admissions make sure you get on staff at the major hospital or hospitals near you and do inpatient consults. Case managers discharge to the quickest and easiest way as this is how they are directed by their bosses. Many times for IPR if they think will get denied they wont even try. Also many insurance companies may require a peer to peer which which the primary surgeon/hospitalist either wont do or is awful at doing. Make sure you introduce yourself to case managers and the surgeons/hospitalists and let them know if you do consult you will handle those. They will appreciate you handling this extra work and remember as a physiatrist you are much better at it.

4) In reference to number 3, get to know those hospitalists and surgeons. Make sure you have their cell and they have your cell. Let them know what you can do for them as far as management and increasing outcomes. A good example is when I started at one location multiple surgeons had a poor feeling about our place and steered patients away from us. But myself and the hospitalist I was teamed up with worked to change that perception. It changed from those surgeons telling CM and patients not to go to us, to those surgeons urging patients and telling CM to try us first.

5) Along with all these extra admits means looking at a lot more prescreens. You need good liaisons that will get you the information quick and have good communication with those case managers. After initial intros it is not your job, nor do you have the time to be calling each case manager daily asking about patients. Liaisons should be doing that.

6) Unsure where you are in the process but if they expect you to build something up then you should get some guarantees. Places I have seen and worked I was able to get 1 year guarantee minimum and my goal always is to beat that. Remember if you build it up this hospital/corporation will make a lot more money. They have incentive to do it and help you and if they are not willing to assist you at the beginning with some sort of guarantees then I would be very apprehensive.

Feel free to PM me for any advice.

 

[MissouriPMRdoc]

Those are all good points, thank you. I will have internal medicine managing medical issues so I would focus on only rehab management and director duties. It is a 20 hour per week position they have posted so I thought that adding in additional clinic time would be reasonable but it may not be. Thank you for the insight.

sent you a private message with some thought and an opportunity. Feel free to let me know if you have any questions.