Chances are, you have already incorporated Advanced Practice Providers (APPs) into your healthcare team or you soon will. The prevalence of APPs is growing as an already over-burdened and under-supplied healthcare system navigates a rapidly expanding Medicare-eligible baby boomer population and the impact of the Affordable Care Act (ACA). This increased demand for services, coupled with an aging physician workforce, has resulted in an additional strain on resources and in challenges getting access to care.
In order to improve accessibility to care, many medical practices, hospitals, clinics and surgery centers have hired APPs to close the gap between the demand for services and the availability of physicians to provide them. This initiative is often approached in a utilitarian manner, like installing a “pressure-release valve” to relieve caseload build up. However, such an approach fails to recognize the great value that APPs can bring to a practice and the benefits of purposefully integrating them in such a way that optimizes their value and enhances the quality and the continuum of patient care.
So what is an APP anyway? An Advanced Practice Provider (APP), often referred to as an Advanced Practice Professional, generally refers to a clinical provider who is not a physician but who has undergone specialized education, training, certification and licensure that allows her/him to provide some healthcare related services with varying degrees of independence and with different levels of “authority” to perform certain procedures and prescribe some medications. The APP scope of practice, level of independence and authority, varies by type of APP and by state.
While terminology related to APPs is somewhat inconsistent, the following is a generally accepted framework:
Advanced Practice Registered Nurse (APRN) is a registered nurse with advanced didactic and clinical education, knowledge, skills and scope of practice. The new Consensus Model defines four APRN roles*:
- Certified Registered Nurse Anesthetist (CRNA)
- Certified Nurse-Midwife (CNM)
- Certified Nurse Practitioner (CNP)
- Clinical Nurse Specialist (CNS): holds a master's or doctoral degree in a specialized area of nursing practice related either to:
- a population (e.g. pediatrics, geriatrics, women's health)
- a setting (e.g. critical care, emergency room)
Physician Assistant (PA) is a healthcare professional who provides healthcare within the medical model as part of a team with physicians and other providers. In the USA, Physician Assistants are nationally certified and state licensed to practice medicine under the supervision of a physician.
The simple secret to optimizing the value of your APPs is to focus on how you integrate and promote them as part of your team. Based on Studer Group’s extensive experience coaching medical practices across the country, here are some best practices that we have observed and some guidelines to consider:
- Words matter: How we (physicians) describe our APPs influences how others perceive them. Terms such as “mid-level provider,” “physician extender,” “non-physician provider” and similar designations have a negative connotation and tend to imply that the standard or quality of care that these professionals provide is inferior when compared to similar care provided by a physician. However, that is not the case. APPs practice within their defined scopes of practice, and they are trained and competent to provide specific services proficiently, at high standards and often at a greater frequency than their collaborating physicians. And, while it is true that not all APPs are created equal, the same applies to physicians.
- Terminology might need explanation: Don’t assume that all patients are familiar with terms such as APP, CRNA, Nurse Practitioner, PA, etc. If patients do not understand these words and roles, the intensity of their anxiety will be greater. We recommend using words that are easily understandable and that are reassuring to patients about the APPs’ training and competency.
- Managing up: If we want our patients to trust our APPs as valuable team-members, we must position them for success by managing them up. The best time to do this is early in the relationship with the patient, preferably at the initial encounter. Introducing your APP at that time solidifies his/her role as a valuable member of the team, especially when accompanied by expressions of confidence in their abilities. For example: “Sarah has been a Physician Assistant on my team for 4 years now, and she is awesome. The patients love her, and they tell me she is better at doing throat swabs than I am!” (or something similarly humble). When other team members (such as the Medical Assistant or receptionist) also endorse the APP, it positively reinforces the patient’s perception of the APP as a trusted and competent clinical provider and a valued member of the team. Similarly, the APP should manage up her/his collaborating physician and the practice, expressing pride in how they work together for the patient.
- Promoting the team: If patients feel that they have a “deep bench” that is taking care of them and cares about them, it enhances their sense of security that there is a team working in their best interests. Of course, this requires that the team actually acts as a team. That means communicating well with and watching out for each other; holding huddles to ensure that everyone is on the same page; referencing and emphasizing the benefit of the team approach in discussions with the patient; and more subtle messaging such as posters of the whole team, including the APPs, on the practice website. Furthermore, utilizing key words that confirm that you are communicating and partnering as a care-delivery team helps to build confidence in the team, reduces anxiety and reassures patients (and families) that things are not falling through the cracks. For example: “My Nurse Practitioner, Jim, let me know that you developed hives when you started the Zithromax antibiotic and so we have discussed alternative options ….” Note that a specific reference, not a generality, shows you really conferred on this issue with the Nurse Practitioner.
- Don’t surprise patients: Some patients may express concerns or demonstrate resistance to being cared for by an APP. This is most common when patients are blindsided and have been inadequately prepared to receive care from an APP instead of a physician. Consider the situation when a post-operative patient is seen by an APP alone, but her/his appointment was scheduled with the surgeon. The patient expected to see the surgeon and such a situation can make a patient feel abandoned and experience increased anxiety. This type of situation can usually be avoided by setting expectations early and by incorporating the best practices discussed above. Giving patients some ownership in their shared-care plan with key words and some sense of control will usually result in their agreement and allay their fears. For example: “John, my wonderful Physician Assistant, whom you met on your first visit will see you to check your wound and take your sutures out when you come in. He will let me know how you are doing and then I will see you the following week at your next visit.”
- Invest in your APPs: Hiring an APP should be taken as seriously as bringing a physician into your practice. A solid recruitment and selection process, including behavioral-based interviewing, will ensure that the APP you hire is a good fit for your practice, the other team members and the patient population that you serve. A potential new APP’s commitment to your practice mission, culture and standards should be a requirement before an offer is extended. An effective orientation process, assigning a buddy/mentor to the APP and a probation period with 30-day and 90-day performance reviews should be routine, together with on-going feedback about their performance after they are hired. When feasible, include your APP in incentive compensation programs related to quality and patient experience in the practice and always continue to invest in your APP by offering continuing education opportunities related to both professional and personal development.
In summary, APPs are invaluable members of the healthcare delivery team in medical practices, retail clinics, hospitals and surgery centers across the country. Using key words to manage up and promote the experience and skills of APPs is critical to maximizing their benefit in your practice. If you see APPs merely as a “pressure-release valve” for your workload overflow, that is how they will be perceived by your patients and by others in the practice. If you truly believe in them as valuable and valued members of your healthcare team, they will be appreciated and respected by both patients and staff alike. This will greatly enhance the quality, the consistency and the patient’s perception of the care they receive–a very worthwhile investment.
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