Getting the most from advanced practice providers

Hospitalists team up with nurse practitioners and physician assistants.

Physician assistants (PAs) and nurse practitioners (NPs) are regular faces on hospital teams, with roughly 40% of the former and nearly a third of the latter in the U.S. working in hospitals, according to recent estimates.

Yet there is scant research about the impact of advanced practice providers (APPs) on inpatient care, said Nita Kulkarni, MD, ACP Member, associate clinical practice director for the division of hospital medicine and medical director for the physician assistant program at Northwestern University's Feinberg School of Medicine in Chicago. “Most of the research that has been done consists of small single-center studies that are not generalizable.”

Dr. Kulkarni was co-author of an editorial in the October 2014 Journal of Hospital Medicine concluding that while current evidence shows that APP-based care with physician collaboration in the inpatient setting can be comparable to physician-only care, more research is needed to define the best practices for utilization of APPs in hospital medicine. A paper published in the same issue found that the presence of APPs on inpatient teams in 118 Veterans Health Administration hospitals did not alter patient or nurse satisfaction or consistently improve the perception of care coordination.

Photo by Thinkstock
Photo by Thinkstock

“We need to look at measurable goals when examining the impact of APPs in hospital medicine. This includes outcomes such as length of stay but also quality measures such as percentage of patients receiving venous thromboprophylaxis or days of urinary catheter use. We don't necessarily expect these outcomes to be better than care provided in a physician-only model but they should certainly be comparable,” said Dr. Kulkarni.

What APPs bring to a hospitalist team depends on whom you ask, said Dana S. Mann, MD, a hospitalist and physician supervisor of APPs at Mayo Clinic in Rochester, Minn. “It depends on what their roles are and what the relationships are between physicians and [APPs], and that can differ between institutions and within an institution.”

Potential roles

To successfully add APPs to the team, a hospitalist program should clearly define their responsibilities before hiring. “You have to first understand your reasons for incorporating APPs into your model. Is it to increase the number of patients seen by your service? Is it to decrease physician workload? Do you want APPs to focus on admitting, discharging, observation patients, or all of the above?” said Dr. Kulkarni.

One factor in that decision may be state and hospital regulations. “It's critical to know the regulations governing scope of practice. It only takes one person to have a wrong assumption to negate all the advantages that physician assistants can bring,” said Josanne K. Pagel, MPAS, PA-C, president of the American Academy of PAs, clinical associate professor of medicine at Case Western Reserve University School of Medicine, and executive director of physician assistant services in the Cleveland Clinic Health System.

“State regulations for oversight of APPs vary. Some level of oversight by physicians is still required by states and often hospitals,” said Denise Brown, MD, vice president of CEP America, a company based in Emeryville, Calif., that provides acute care management and staffing nationwide.

At Mayo, APPs round with physicians. “They carry the service pager, and having someone else highly skilled do that for the physician and be available to answer nursing questions enables the physician to spend uninterrupted time creating a plan of care for the more complex patients,” said Dr. Mann. The goal is for APPs to have an autonomous but collaborative role with physicians.

Other hospitals give them additional responsibilities. “More organizations are allowing and enabling APPs to see patients on their own,” said Dr. Brown. At ProMedica Toledo Hospital in Ohio, “If patients have no comorbidities or complications, APPs can discuss a case with a physician, but the physician does not have to see the patient directly. If the case is simple and the patient is not having an unexpected course, the APPs don't need a lot of oversight,” said Cecilia Choi, MD, regional medical director of hospitalists.

At Rush University Medical Center in Chicago, APPs have gradually taken on such responsibilities, according to Suparna Dutta, MD, MS, MPH, assistant professor and associate division chief in the division of hospital medicine.

“At first we had two APPs, fresh out of school, functioning as residents, rounding together and doing work like calling consults and calling orders in. As APPs improved and we grew the service, they were able to expand into more fulfilling roles with more autonomy with their own patients where they have first crack at making decisions with oversight and backup as needed,” she said.

Now APPs care for 8 patients on a 16-patient inpatient service at the hospital, said Dr. Dutta. “The attending physician takes the 8 most complex cases, and the APPs take the other 8, performing examinations, diagnosing, and prescribing. It has helped our physicians be much more efficient.”

At Northwestern, hospitalists see all patients whose care is being managed by APPs, so APP involvement has not affected physician patient load. However, Dr. Kulkarni does believe that APPs lighten the physician workload by taking the initial history and physical, performing medication reconciliation, recording information in the medical record, calling consults, managing day-to-day care, discharging patients, and writing discharge summaries, among other things.

“When you're working on a team with an APP, you're able to spend more quality time with your patients discussing medical issues, rather than spending the majority of your time interacting with the electronic medical record. It helps to have someone with you who can also do those other patient-related tasks so that you can increase your face-to-face time with the patient,” said Dr. Kulkarni.

She noted that Northwestern is considering options that might enable physicians to see more patients, such as allowing APPs to see a portion of patients on their own without physician involvement. “These could be straightforward observation patients or patients admitted to our service by subspecialty teams with a specific care plan already in place,” she said.

APPs can be particularly effective in developing relationships with patients and their families, Dr. Choi noted. “Hospitalists don't see patients until the patients come to the hospital and are not always taught how to sit down and build that trust. APPs can sit with the patient and use soft skills to get to know the patients and families, discuss the plan of care, and answer questions.”

In addition to daily clinical care, APPs can participate in the other activities of the hospitalist service, suggested Dr. Kulkarni. “Get them involved in division meetings. For example, we expect all our APPs to present at our weekly hospital medicine journal club. We also encourage them to become involved in quality improvement projects, join the leadership group, or teach APP students,” she said.

Pitfalls to avoid

To get maximum value from a hospitalist team, it's important that all clinicians work to the top of their licenses. Cindy Cooke, DNP, FNP-C, president of the American Association of Nurse Practitioners, noted that “a multidisciplinary focus utilizing the talents of physicians, NPs, and PAs practicing to the full scope of education and clinical training” is the best way to address inpatients' complex needs. Ms. Pagel recommended thinking hard about what you expect from the people you hire. “Do your needs assessment,” she said. “If you're looking for someone to write things up like a scribe, a PA would not be the right choice. You'd be underutilizing their skills and training.”

Such underuse can lead to turnover. Dr. Brown noted that if APPs aren't given enough responsibility are asked to perform the same mundane tasks without variation, “the good ones go somewhere else. Just like we want an assortment of things we do over the course of the month or year, so do APPs.”

It's possible to err in either direction in the delegation of tasks to APPs. “Some physicians are comfortable with giving APPs a certain amount of autonomy. However, there are a few who will micromanage, which can defeat the purpose of working with an APP,” said Dr. Kulkarni. “When you are first working with an APP, you may be more involved in every decision of the clinical care because you are unsure of the APP's abilities or experience. However, once you get to know the person with whom you are working, you feel more comfortable at delegating tasks.”

Physicians can also increase the efficiency of APP services by avoiding redundancy. “Don't double the work. Confirm aspects of the history and physical, for example, but don't redo it in its entirety,” Dr. Kulkarni cautioned.

Finding the right APP for a hospitalist program can be challenging, said Dr. Kulkarni. “It's different than working with residents. Physicians are very aware of the background and training of residents because we have all been there and are aware of the requirements. With APPs, many physicians don't know what the training and experience has been.”

It's important to make sure that an APP's experience and interest focus on hospital medicine, recommended Robert Donaldson, MS, NP-C, FNP-BC, clinical director of emergency medicine and president of medical staff at Ellenville Regional Hospital in Ellenville, N.Y.

“So many believe that nurse practitioners are fancy nurses who can work anywhere and do anything, but you can't just hire one and say it's going to work. It's not one size fits all,” he said. “Look at the structure of your organization, the people who are in the organization, and what tools they need.”

Orientation is also important to success, Dr. Brown said. “What often happens is that APPs get added out of desperation, and then the program is destined to fail because the physicians are already overburdened and don't have the time to show them the ropes. They just tell [the APPs] to go see patients.”

Although training an APP will naturally vary based on the clinician's experience, it does take some time, Dr. Mann noted. “We invest at least four months in orientation and training. We'll adjust from there based on the needs of the individual,” he said.

Dr. Dutta agrees that training should be tailored to the individual. “Everyone starts at a different point, and it's often not an investment that you get a fast return on. No one hits the ground running. But unlike residents, who come and go, with APPs over time you develop tighter relationships. You come to know what each other is good at, and build a lot of trust.”

Physicians also need to be oriented for optimal collaboration. “Many physicians starting out as hospitalists have never worked with APPs before and may not know what they can and can't do,” said Dr. Kulkarni.

“Each discipline needs to have clear expectations of the roles and services of each hospitalist provider and understand that roles and expertise overlap,” said Dr. Cooke. “Willingness to have challenging discussions if or when problems arise can address evolving relationships.”

At Northwestern, hospitalist group leaders orient new physician hires to the role of the APP as well as discuss with them how to work efficiently with APPs. The APPs themselves have given presentations to the physician group about their background, education, training, and responsibilities.

But once APPs and hospitalists are working well together, physicians shouldn't be afraid to think creatively when tapping into their colleagues' skills, according to Dawn Morton-Rias, EdD, PA-C, president and CEO of the National Commission on Certification of Physician Assistants.

“As the profession grows, and there are new and revised ways to bill for services, physician assistants may branch out into telemedicine, home visits as part of postdischarge follow-up care, and other ways of making care more accessible. That's what we were created for: to fill gaps. It's part of our profession to be nimble,” she said.

Dr. Choi, who was an NP before she became a physician, said that the best working relationships between physicians and APPs are those that are founded on collegiality and collaboration. “The organization has to respect the APPs like team members and not look at them as subservient or subordinate. That's why we don't use the word ‘midlevel.’ No one goes to school and spends that much time and effort on training, saying they want to be a ‘midlevel.’”