How to Incorporate Advanced Practice Providers Into GI Practice

Partnering with advanced practice providers (APPs) affords a unique opportunity to improve access high-quality patient care, while advancing the research and quality improvement initiatives of an institution. However, achieve these missions, careful integration through education, training, mentorship is critical. Here, we describe advantages considerations before hiring APPs, differences between nurse practitioners (NPs) physician assistants (PAs), keys successful integration. Before integrating APPs into practice, it essential understand benefits vulnerabilities such collaborations. Although formal studies investigating role in gastroenterology are limited, there inherent collaborating providers. Perhaps most important, can enhance care situations where time limited.1Wagner E.H. The teams chronic disease management.BMJ. 2000; 320: 569-572Crossref PubMed Scopus (721) Google Scholar APP training model generally emphasizes greater patients, clear application understanding biopsychosocial disease. An patient’s psychosocial milieu increased for counseling directly benefit patients all facets GI particularly when establishing supportive relationship disorders brain–gut interaction, explaining medication side effects, facilitating screening.2Dorn S.D. Mid-level gastroenterology.Am J Gastroenterol. 2010; 105: 246-251Crossref (11) A recent retrospective analysis commercial claims database cirrhosis showed that APP–physician collaboration resulted improved screening hepatocellular carcinoma lower 30-day readmission rates overall mortality.3Tapper E.B. Hao S. Lin M. et al.The outcomes provided by providers.Hepatology. 2019; 71: 225-234Crossref (14) In complex high risk morbidity mortality as cirrhosis, involvement may stave off admissions ensure adherence protocolized treatment protocols. Working allows many physicians increase their efficiency, complementing activities academic practices. facilitate urgent or follow-up allowing investigators uninterrupted conduct research. addition, often serve important members either (by clinical trials performing study visits) indirectly identifying inclusion protocols biorepositories). We should acknowledge several potential limitations best met upfront active mitigation strategies. Most trained broadly less likely have same specialty exposures, knowledge base gastroenterologists. large demonstrated survival physician–APP received cirrhotic alone (without gastroenterologist involvement) was inferior APP).3Tapper It must be understood not attempting replace physicians, but rather bring strong complementary skillset professional clinicians provide optimal care. Successful partnerships among require engagement, structured check-ins, ongoing whereby competency reflection committed mentorship. Furthermore, despite increasing acceptance skepticism some limited exposure. pairings formed sees working education mentorship, than solely throughput. Collaborating advocates on administrative well, because much revenue captured billable charges,4Nandwani M.C.R. Clarke J.O. Incorporating practice.Clin Gastroenterol Hepatol. 17: 365-369Abstract Full Text PDF (3) which obstacle negotiations hospital administrators. Some practices created incentives collaboration, allocating portion salaried APP’s relative value units physician. Understanding individual streams effective billing methods difference enthusiastic support mounting deficit. Finally, although receive better practices, patients’ preconceived perceptions color interactions. Patients feel “abandoned” following up instead usual gastroenterologist. establish early therapeutic relationship. Shared consultations allow see interaction physician, promote sharing ideas (best if shared company patient), education. offer continuity busy continue semiregular basis, visits APP, trust Both NPs PAs play key providing highest both inpatient outpatient improving healthcare patients.5American Academy PasHistory PA profession. Volume 2019.www.aapa.org/about/history/Google Scholar,6Allen J.I. Aldrich L. Moote Building team-based providers.Gastroenterol Hepatol (N Y). 15: 213-220PubMed setting, new consults, schedule procedures, after procedures care.7Timmermans M.J.C. van Vught A. Peters Y.A.S. impact implementation care: multicenter matched-controlled study.PLoS One. 2017; 12e0178212Crossref (17) clinic, long-term management conditions evaluation concerns.6Allen Despite filling similar roles, do significant models licensing (Figure 1). NP holistic primary based patient-centered philosophy caring whole person (as opposed disease-centered model). earn national certification one given area (ie, acute adult, adult–gerontology, family) completing 2–3 years master’s program. further doctoral degree (eg, PhD) focus, adds another 2–5 training. grow expertise seeing within practice. who achieved level field been found good, better, satisfaction colleagues, making them ideal partner.8Newhouse RP, Stanik-Hutt J, White KM, al. Advanced 1990-2008: systematic review. Nurs Econ 2011;29:230-250; quiz 251.Google analogous constructed essentially masters-level version medical school. Generally, first 2 didactic school encompassed 1–2 school,9Baklid-Kunz E. Medicare’s split/shared visit policy. 2019. Available: www.aapc.com/blog/23741-medicares-splitshared-visit-policy/. American Professional Coders; 2008.Google followed additional year combining classroom experience.10Physician assistant 2019.www.healthcaresystemcareersedu.org/physician-assistant-2/Google generalized, incorporated any physician.9Baklid-Kunz Like NPs, comparable colleagues flexibility more services circumstances.11Kurtzman E.T. Barnow B.S. comparison practitioners, assistants, physicians' patterns health centers.Med Care. 55: 615-622Crossref (67) critical scope Whereas independent license, varies across state lines, impacting opportunities. There currently 24 states full authority (meaning open own physician), 19 reduced 12 restricted practice.12ANNP (2019) map. 2019.https://campaignforaction.org/resource/state-practice-environment-nurse-practitioners/Google Contrarily, earned dictates they collaborate Overall, reimbursement does vary payer state. private payers accept billing, whereas Medicare offers standardized fee structure. 3 different involving APP: shared, incident to, independent.13Ladd Hoyt Shedding light practitioner prescribing.J Nurse Pract. 2016; 12: 166-173Abstract involves joint visit, billed at 85% schedule.9Baklid-Kunz occurs independently established problem original plan premises, 100% schedule. Independent occur completely States restrictive regulations experience decreased unable extent license training.14Poghosyan Timmons E.J. Abraham C.M. economic expansion oractice Medicaid.J Regul. 10: 15-20Abstract (5) Scholar,15Safriet B.J. Federal options maximizing nurses quality, cost-effective careThe future nursing: leader change health. National Academies Press, Washington, DC2011: 443-476Google With authority, economically viable option reducing costs. 2009 Rand Report, examined spending Massachusetts, estimated that, 2010 2020, Massachusetts could saved from $4.2 $8.4 billion reform reliance delivery care.16Eibner C, Hussey PS, Ridgely S, Controlling massachusetts: options. www.rand.org/pubs/technical_reports/TR733.html. RAND Corporation, 2009.Google Because enter workforce very little gastroenterology-specific success hinges thoughtful development realistic job description, comprehensive orientation plan, objective criteria will measured. This planning complete hired optimize start 2). step result retention consideration needs defined goals APP. recruitment team then evaluate how candidates match goals. Discussions volume expectations, clinic initiatives, continuing opportunities leadership, research, growth just areas seek part development. Given variability settings, no one-size-fits-all APPs. One choose create intensive content series weekly lectures readings covering “bread butter” cases subspecialty. incorporating Gastroenterological Association publishes on-demand webcasts (www.gastro.org/aga-leadership/initiatives-and-programs/nurse-practitioner-and-physician-assistant-resource-center). also hosts annual conference late summer, dedicated focus (https://nppa.gastro.org/). advocate period observation discuss decisions salient issues. reality, combination techniques well-rounded introduction subspecialty lend insight style whom working. Accreditation Council Medical Education mandates regular assessment resident fellow 6 domains: knowledge, practice-based learning improvement, interpersonal communication skills, professionalism, systems-based practice.17Nasca T.J. Philibert I. Brigham T. next GME accreditation system--rationale benefits.N Engl Med. 2012; 366: 1051-1056Crossref (983) system adapted Joint Commission extended hold credentials privileges accredited 2008.18Holley S.L. Ketel C. Ongoing focused evaluation: overview clinicians.J Midwifery Womens Health. 2014; 59: 452-459Crossref assessment, termed “Ongoing Practice Evaluation,” combines qualitative quantitative data measure least twice per year. criteria, included specific determined define front transparent expectations metrics serially. Once starts work rests features: (1) execution thoughtfully designed (2) establishment creation sense community. Similar survey, identified career parts retention.19Burke K.E. Thurler A.H. Teamwork makes dream – providers.GI & Hepatology News. 26Google what ensuring has likelihood retention. meet regularly clinically relevant topics. Engagement ensures strong, patient-focused affiliation ultimately positive outcomes. Regular meetings mentors only solidify concepts case discussion informal feedback, Potential include leading participating departmental leadership skillsets, other specialties society legislative initiatives. addition building community presenting integral member satisfaction. recommend formally introducing during visit. Practices structure (multiple nurses, staff) consider face sheets appreciation team. alternating investment strengthen advance vigorous, yet practical set throughout Retention heavily depends motivation continually foster maintain vested interest Establishing respect, trust, valuable institution benefit.