The passage of the Affordable Care Act in 2010 brought sweeping changes to the healthcare industry. Cost and coverage were widely debated before the bill was signed into law. But since the policies began taking full effect in 2014, a new challenge has emerged—access.

More than 9.3 million Americans have gained coverage since the law took effect, according to figures from the nonpartisan research firm Rand Corp. Medical facilities across the country have had to manage the increased patient volume, and some of the biggest strains have been felt by smaller, rural hospitals.

“We’re seeing an influx of patients coming into hospitals now,” says Diane Hilinski Schramm, RN, MSN, MSHCM, vice president of advisory services for HealthTrust Workforce Solutions℠. “Before, these patients sought care only when it got to a point where they had to. But with healthcare more available now, they’re seeking care for routine things that they wouldn’t have sought care for otherwise.”

As new patients flood the system, hospitals have had to change the way they provide access to meet the growing demands. Many are developing urgent care settings to reduce the number of emergency room visits. These changes require more staffing—something that’s especially hard for rural hospitals.

“You don’t have a large pool of staff living in those areas,” Schramm says. “And typically you don’t have the attraction for them to go there.” Physicians and nurses who are from these smaller communities often end up going to larger cities because the pay is better and the lifestyle is more inviting.

James Shodunke, materials manager at Gifford Medical Center in Randolph, Vermont, says his 25-bed facility faces similar staffing challenges. “There are two larger teaching hospitals in our area—one north of us, and one south,” he says. “It’s tough trying to pull staff to our facility because the area doesn’t have as much to offer.”

Finding Help

As these hospitals become busier, staff already stretched thin could reach their limit. Labor is one of the largest expenses in a hospital, accounting for as much as 60 percent of a facility’s operating costs, Schramm says. “That’s where HealthTrust Workforce Solutions℠ comes in. We help facilities meet productivity standards and budgets while still being able to provide quality care.”

Parallon utilizes technology to help facilities schedule their labor as well as analyze their daily productivity. “A lot of hospitals aren’t able to see productivity numbers until two weeks after the fact,” she says. “We have a tool that provides more real-time data to help facilities adjust staffing appropriately.”

Facilities that implement Parallon’s recommendations can experience savings of up to 8 percent on their total labor costs, Schramm says.

After staffing needs are determined, Parallon helps facilities find and hire contract labor such as travel nurses or locum tenens physicians—physicians placed in a hospital on a non-permanent basis. The company has negotiated contracts with more than 400 staffing agencies nationwide for travel nurses, and it has its own locum tenens division that finds physicians.

“Hiring locum tenens is very beneficial to rural facilities that have difficulty with physician shortages,” Schramm says.“Locums are often physicians from larger cities who have retired but want to keep their head and hands in medicine. Their knowledge and experience really can help these smaller hospitals.”

Hiring locum tenens is a solution for some facilities. But the growing number of patients coupled with the shrinking number of family care physicians have some health experts concerned that a “doctor gap” might be the industry’s next great hurdle.

Over the next 15 years, the United States will likely experience a shortage of between 124,000 to 159,000 physicians, according to Healthcare Finance News. Many of the shortages will be in specialty care. These five specialties will see the largest increase in demand from 2013 to 2025: vascular surgery, 31 percent; cardiology, 20 percent; neurological surgery, 18 percent; radiology, 18 percent; and general surgery, 18 percent.

“Given current trends,” healthcare experts Thomas Bodenheimer and Mark Smith wrote in the November 2013 issue of Health Affairs, “producing more adult primary care clinicians will not close the demand-capacity gap.”

Bodenheimer and Smith advocate empowering licensed personnel—such as registered nurses and pharmacists—to provide more care as one way to increase capacity.

Barbara R. Paul, M.D., senior vice president and chief medical officer of Community Health Systems Professional Services Corporation, recognizes the growing need to employ more healthcare extenders. As she explained in a recent The Source physician newsletter, “With expansion of healthcare access to more and more uninsured patients, the demand for physicians will be significant in the primary care arena. These future patients may not have received adequate coordinated care. They will be looking for, and really benefit from, primary care physicians, internists, nurse practitioners and physician assistants.”

Schramm agrees that facilities nationwide are utilizing more nurse practitioners and physician assistants to deliver care. “Nurses are often with patients longer, and therefore have outstanding assessment skills,” she says. “They work under physician supervision and, if they see that something is really wrong, they can bring in a doctor.”

Maintaining Quality

Staffing up to treat patients is the first hurdle. But ensuring your staff provides quality care is just as important.

“One big thing that hospitals have to worry about is readmissions,” Schramm says. “If patients have to come back because they left too soon, hospitals can’t be reimbursed. That’s why they have to make sure they have quality nurses.”

Shodunke faces the same challenge at Gifford Medical Center, but says his facility considers more than reimbursements when striving for quality care. The close-knit aspect of its small community makes the staff feel more accountable. “Most of the people we see are our neighbors and friends,” he says. “If we have an unsatisfied patient, that person might tell 15 others about [his or her] bad experience.”

Quality care often depends on developing an appropriate system for determining proper staffing levels. When nursing staffs are overburdened, patient care can slip. Schramm and her team analyze staffing and scheduling to maximize productivity and make sure the right positions within a hospital are filled at the right times. Her team looks at three months of both the lowest and highest census numbers at a facility to develop its core staffing level.

She offers this example: “Let’s say you have staff in a radiology department that comes in at 7 a.m., but the physician doesn’t come in until 9 a.m.,” she says. “You basically have two hours when the staff is not being as productive as they could.”

Parallon also helps identify census trends at a facility. These trends often are based on geography and can vary depending on the time of year. Florida facilities, for instance, may observe a spike in admissions during winter months. In some parts of the country, patients experience more respiratory problems during certain seasons. And flu season affects hospital census numbers nationwide.

“We help facilities develop a plan to meet these demands,” Schramm says.

Shodunke also takes into account seasonal spikes from a staffing and supply standpoint. “It can be difficult to get supplies to a rural area,” he says. “If something happens on a Thursday, we might be out of luck until Monday. We have to gear our supply orders around seasonal issues.”

That type of long-range planning will become more important for facilities as their patient volume continues to climb. “As enrollment increases and there are more admissions, it will be more of a stretch on hospitals,” says Schramm. “They must be astute to ensure that they’re providing quality care.”

For more information on ways HealthTrust Workforce Solutions℠ can help your hospital combat staffing challenges, contact Diane Schramm at

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