The critical role of advanced practice clinicians

In a high-level interactive discussion, five healthcare leaders met recently to examine the impact of APCs on access, patient satisfaction, quality and physician burnout. The Q&A participants were:

• Cindy Borum, MSN, APRN, FNP-C, Assistant Vice President for Advanced Practice Nursing, HCA Healthcare
• Andy Cohen, MD, Medical Director, Virtua Physician Partners Virtua Health Systems
• Jamie El Harit, DNP, RN, FNP-BC, Hospital Medicine, Franciscan Physician Network, Visiting Assistant Professor of Nursing, Valparaiso University
• Donna Forrest, NP-C, APRN-BC, Nurse Practitioner, Sentara Medical Group
• Michelle Hirschman, MBA, Program Manager, Strategy, Northwestern Medicine

The following are highlights from that discussion.

What is an APC?
APC stands for advanced practice clinician. This includes advanced practice registered nurses as well as physician assistants (PAs), although it generally refers to nurse practitioners (NPs) and PAs. In some health systems and practices, APP — advanced practice provider — is used in place of APC.

In your experience, what are the benefits of APC practice?
The benefits come in three main categories. By utilizing APCs, practices can consistently improve access to care, particularly for disadvantaged populations. This in turn improves medical outcomes, as more people can receive the treatment they need when they need it. Unlocking access to care in a timelier way is key since studies show no significant difference in patient outcomes or patient satisfaction when treated by APCs versus physicians. That assumes clinical competency, experience, and scope of license, of course.

Are patients usually accepting of APCs?
Patients have accepted the idea of being cared for by APCs, especially when it helps them get seen sooner. They also say APCs take more time educating them and answering their questions.

Why do the regulations for APCs seem so volatile?
Regulations for the APC scope of practice have changed a lot in the last few years, but the trend is headed overwhelmingly in the direction of increasing their scope of practice. A primary driver of this is the current, and likely continuing, physician shortage. Many states are increasing the scope of practice for APCs to ensure patients get necessary care. That said, we’d be remiss not to acknowledge that this is a topic with many passionate opinions. One area of evidence for that is the inverse relationship we see between PA and NP scope of practice across the states. One could interpret that around the strength of the lobbying party promoting their profession beyond the other. Similarly, physician advocacy groups and others, like the American Medical Association, also hold strong and well voiced opinions about risks and benefits. All of this contributes to both the movement forward and, at times, the confusion, about what the right approach is for scoping the regulations and delivering high-quality, accessible patient care.

What should you do if you have APCs, but schedulers don’t offer them to patients calling for appointments?
This needs to be addressed immediately, as you can often get patients in much earlier by using APCs. As a relatively unknown service, their capacity is generally underutilized. Realizing this opportunity can have a significant downstream impact on visit lag, patient retention and outcomes. We provide scripting and education to the front desk team regularly, so they understand what they can offer patients to get them seen ASAP while also helping to educate the patient about the APC role and competency. There are also technology and services available in the market to help both educate and navigate the most appropriate patients to your APC services.

Is there a tug-of-war between APCs and physicians?
There is, but there shouldn’t be. APCs and physicians should work more collaboratively to better manage populations. In our system, we find we need to make an upfront investment in educating physicians about the clinical, financial and quality of life benefits that they can realize when adding APCs. In addition, we agree on the clinical protocols for care along with the APC responsibilities to help promote trust and alignment. Ultimately, our physicians wouldn’t let their APCs go after about six months of working together.

What do you see as the future of APCs?
Moving toward the “care team” approach of one physician with one, two or three APCs working in conjunction with a lead medical assistant, nurse and office manager will be the most successful in managing all patient populations.

What is the business case for APCs?
The business benefits of APCs can be shown in two categories: hard ROI and soft ROI. The hard ROI of APCs features attractive financials and improved access to bolster your top line. The soft ROI from using APCs comes with clinical and operational improvements in patient satisfaction and retention, increased capacity and quality of care, decreased visit lag, reduced ED visits and reduced physician burnout.

Any other advice for developing a business case for APCs?
It is important to speak to the three elements of practice management: clinical, operational and financial. You need to make sure you engage key stakeholders — the CEO, COO, CFO and CNO — and explain how APCs can help improve operational outcomes with hard ROI from increasing access and timeliness of care, contribute to PQRI/PQRS measures/goals and make sense as a financial investment.  Downstream there are also measurable impacts in provider retention and patient loyalty.

What are the considerations for fee-for-service vs. value-based care?
You need to figure out how to balance volume and value. The trends today are moving from fee-for-service to value-based care, and APCs help with that transition. As a lower-cost resource, they can often meet the unique needs of your patients in a chronic care model across social determinants, behavioral health and lifestyle modifications that center around education and reinforcement. Creating this service line to meet these patient needs can prevent unnecessary ED visits and hospital admissions.

When assessing your APC program what are the appropriate evaluation approaches?
You can evaluate APC impacts operationally on quality, access, safety and coordination. You can also examine ROI impacts and margins, and contributions to value measures. Another area to consider is provider and patient satisfaction surveys.

What role does soft ROI play in APC strategy?
In today’s healthcare environment, physicians are really being stretched to the limit. When you realize the physician cannot do it all, you should start to look to APCs to grow and improve your practice. They are a key tool to increase access, streamline appointments and expand patient panels. In addition, you may find they are interested in unique work schedules that accommodate demand without obligating your staff to work schedules that burn them out.

What are the most common soft ROI benefits of APCs you have experienced?
In my experience, the reduction of physician burnout has been a marked benefit to our increased utilization of APCs. Also, patient satisfaction increases with team-based care (patients still feel connected to their physician but also have easy access to care from an APC), as does workforce satisfaction. I have also seen how patient outcomes and practice reputation improve from increased access.

How do you set up APCs for success?
Collaboration is really the secret sauce to being successful. It has to be very much a partnership between the physician and the APC. Putting the APC in a position where they can practice with some autonomy (where appropriate, based on competency and scope of practice) is key to realizing their potential.

What models of care do you recommend; team-based, APC panels, blended model?
The best approach is to ask the clinicians how they would prefer to utilize APCs. You will garner a greater buy in then when the clinician themselves have a hand in designing the solution. That collaborative team effort really sets the organization up for success.

All of you have a very positive culture. How do you develop that?
For our practice we had to hit the pause button to look at where we were and where we needed to be. Look at the efficiencies and inefficiencies of your practices and set expectations. How can you improve? So, leadership needs to get together and come up with the right solutions and executives need to come up with a plan to follow through.

What are some common barriers to optimal utilization of APCs?
Some barriers come from a lack of understanding of the APC’s role. Patients, physicians and staff can be unaccepting or unsupportive when they haven’t worked with APCs before or their role is unclear.  Subsequently, we have also seen challenges with APCs lacking confidence if the team wasn’t properly oriented to or bought in to having them. Other issues are the use of APCs for below-license tasks like scribing, calling patients for recall visits or even rooming patients. We have also seen challenges or issues with billing and credentialing from insurance companies when we don’t appropriately research and set that up properly before hiring. And, of course, as with any hire, making sure you find the right profile and experience necessary to be successful in the role.

What foundational culture changes need to happen?
First, it is important to identify an influential physician champion. You also must establish APC title consistency and recognition as provider in your organization; typically in partnership with human resources. Of course, there should be clear quality and RVU metrics in keeping with physician performance metrics. APCs should be incorporated into your governance and leadership structure and invited to practice and provider meetings. Additionally, inclusion in marketing and education materials is useful.

What are the various models to incorporate APCs?
I have seen three main models of APC use in our market: APCs as primary care providers; APC-physician patient care teams (Specialties); and All-APC urgent care.

What might onboarding look like for APCs?
I’ve seen it work best when we do onboarding together with physicians. You could have an additional separate evening orientation for APCs only, such as “Being an APC in the Medical Group.” The two-day provider orientation should include the culture and history of organization, quality metrics, EMR training and tips, finance, provider resources and system strategy.

What are the best practices for incorporating APCs?

• Some best practices that we use include:
• A standardized collaborative agreement
• Accurate job descriptions
• Performance evaluation process tool
• Title distinction
• Comprehensive marketing plan
• Incorporation of APCs into governance structure
• Development of an APC leadership program analogous to physician program and new APC practice models

Learn more 

Get more details on how to develop or optimize an APC strategy by attending MGMA 18 | The Annual Conference in Boston. Dr. Cohen's session, "Advanced Practice Clinicians in Ambulatory Care: Outcomes and Costs," will take place on Tuesday, Oct. 2 at 8:30 a.m.