Not surprisingly, the growth of hospitalist medicine has also been associated with growth in the utilization of mid-level providers (Nurse Practitioners primarily and Physician Assistants to a lesser extent). Key findings reported in the 2018 State of Hospital Medicine Report (published by the Society of Hospital Medicine):

• As group size increased, so did the presence of mid-level providers
• Most programs adopt a hybrid approach whereby some but not all services rendered by mid-level providers are billed independently

In our management and consulting experiences, we have observed a myriad of ways in which mid-level providers are utilized. It appears to us no two programs are exactly alike. We would categorize the various Mid-Level Provider models in hospitalist programs as follows (addressing day shifts only):

• Shared Daily Rounding Model
• Patient Initial Evaluation Model (H&P's, Transfer Assessments, etc.)
• Patient Discharge Process Model (Discharge Summaries, Care Transitions, etc.)
• Independent Patient Management Model - for identified sub-classification of patients
• Combinations of the above Models

There are also some programs where Mid-Level Providers essentially manage the entire hospitalist patient population with broad physician oversight. In such programs, the hospitalist physicians only intervene with the most critical patients.

Some models that work well in facility A do not work well in facility B. And there are some hospitalists and mid-level providers that are simply worlds apart in their perspectives on workable models.

Whatever model is adopted by a given hospitalist program should consider the following keys to success:

• Support by the host facility medical staff leadership
• Input and Support received by the hospitalist team at-large
• Input and Support received by the mid-level providers
• Clear division of responsibility between the hospitalists and mid-level providers
• Periodic reviews and willingness to adjust as necessary

We believe that Mid-Level Providers will and should continue to fulfill an important role in future hospitalists care delivery models. The greatest benefits, however, will be derived within those programs characterized by mutual respect, a well-designed plan, and open and ongoing communication.