Improved utilization of advanced practice providers



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IMPROVED UTILIZATION OF ADVANCED PRACTICE PROVIDERS

by

Megan Suter

BS Health Management Systems, Duquesne University, 2013

Submitted to the Graduate Faculty of

the Department of Health Policy and Management

the Graduate School of Public Health in partial fulfillment

of the requirements for the degree of

Master of Health Administration

University of Pittsburgh

2015



UNIVERSITY OF PITTSBURGH

GRADUATE SCHOOL OF PUBLIC HEALTH

This essay is submitted

by

Megan Suter



on

April 10th, 2015

and approved by

Essay Advisor:

Julia Driessen, PhD ____________________________________

Assistant Professor

Department of Health Policy and Management

Graduate School of Public Health

University of Pittsburgh

Essay Reader:

Joel Stevans, PhD ____________________________________

Senior Implementation Scientist

Health Policy Institute

University of Pittsburgh

Essay Reader:

Ben Reynolds, PA-C ____________________________________

Director of the Office of Advanced Practice Providers

University of Pittsburgh Medical Center





Copyright © by Megan Suter

2015




Julia Driessen, PhD

IMPROVED UTILIZATION OF ADVANCED PRACTICE PROVIDERS

Megan Suter, MHA

University of Pittsburgh, 2015


ABSTRACT

The passage and subsequent implementation of the Patient Protection and Affordable Care Act of 2010 has brought a wave of health reform to America. This exploratory case study is intended to focus on how using Advanced Practice Providers (APPs) can better serve the newly insured population and meet the population health goals set forth by the Triple Aim. There are new and emerging roles throughout healthcare where these providers could be utilized more expansively both in the inpatient and outpatient settings. The evolution and development of these roles will help offset the impact of the expected increase in demand for care for these newly insured patients against the looming predicted physician shortage, as well as improve the health of the population, which is a main component of the goal of public health. Allowing advanced practice providers to practice and work to their fullest capabilities and scope of practice is a low cost, high quality solution that many will employ.



TABLE OF CONTENTS

Introduction………………………………………………………………………………………1

APPs at UPMC…………………………………………………………………………………...3

Methods…………………………………………………………………………………………...4

Results…………………………………………………………………………………………….4

Emerging Roles…………………………………………………………………………………..7

Barriers………………………………………………………………………………………….13

Conclusion………………………………………………………………………………………17

Bibliography…………………………………………………………………………………….19

LIST OF TABLES

Table 1: Most Common Roles of PAs/NPs……………………………………………………..8

LIST OF FIGURES

Figure 1. Sentinel Finding: Scribing……………………………………………………………6

Figure 2. Team-Based Models…………………………………………………………………10

Figure 3. Nurse Practitioner Scope of Practice Authority…………………………………….14

Figure 4. Physician Assistant Dispensing Authority…………………………………………..15

INTRODUCTION

Currently, the United States finds itself in the midst of health reform due to the Patient Protection and Affordable Care Act of 2010. The principle function of the reform is to provide more Americans access to health insurance coverage, as well as to establish exchanges where consumers can shop independently for their insurance through a streamlined process (Centers for Medicare & Medicaid Services, 2014). In addition, Medicaid qualifications were expanded to include a wider range of participants, and employers are being financially incentivized to provide health coverage to their employees. As a result of the reform and what it aims to improve, which is achieving the three parts of the Triple Aim (improving cost, population health, and the patient’s overall satisfaction and experience of care), a change must take place in the current structure of the healthcare system. Not only is the current rate of spending on healthcare unsustainable, with close to 18% of our nation’s GDP being spent on health care services, but the traditional volume driven fee-for-service approach to care used for decades can no longer remain the precedent for care. Providers and hospitals alike had monetary incentives to ramp up the volumes of the services they provided and the number of patients they saw, however the results did not lead to better health outcomes, and oftentimes had negative results (NRHI, 2008). With such a large percentage of the GDP spent on health care, one would expect that the United States would rank among the top in health outcomes, however that is far from being true (Calsyn & Lee, 2012). As a result the emphasis of care should be modified to focus on specific needs of each patient, with the intent to deliver accurate and quality care, rather than on simply pushing as many patients and services through the system as time will allow. Thankfully, we are beginning to see the shift from ‘volume to value’, with less emphasis on the amount of patients seen and more emphasis on the quality of care being delivered and the outcomes achieved (Calsyn & Lee, 2012).

In addition, with the influx of American consumers now covered by insurance, there will undoubtedly be a shortage of healthcare providers, most notably in primary care (HealthCare Recruiters International Staff, 2014). This shortage is present due to several factors, the first being the aging population. Not only is the baby boomer generation reaching the stage where more care is required, but physicians are aging as well. According to the American Association of Retired Persons (AARP), of the 830,000 physicians in America, almost half are over the age of 50 and seeing fewer patients than they did four years prior due to the extensive attention that the baby boomer generation requires (Mercer, 2013). Along with the challenge of the aging population comes the nearly 30 million previously uninsured individuals who will be seeking care due to the implementation of the Affordable Care Act and its mandate to become enrolled in an insurance plan (Mercer, 2013). Due to this issue, innovative models of care will be needed to meet the future demand for healthcare. This exploratory case study is intended to address one approach on how to better use Advanced Practice Providers (APPs) with the intentions of pursuing the guidelines of the Triple Aim: improving cost, population health, and the patient’s overall satisfaction and experience of care.

For the purpose of this exploratory case study, the term APPs includes both nurse practitioners and physician assistants. Nurse Practitioners, as defined by the American Association of Nurse Practitioners (AANP), are health care providers who can work both autonomously as well as in collaboration with other health care professionals. They have “an emphasis on the health and well-being of the whole person”, and can provide “a full range of primary, acute and specialty health care services, including: ordering, diagnosing, prescribing, managing a patient’s overall care, counseling, and educating” (AANP, 2014). Physician Assistants, as defined by the American Academy of Physician Assistants (AAPA), are health care providers who work on teams with other providers to practice medicine. A physician assistant can prescribe medications in any state, as well as “take medical histories, diagnose and treat illnesses, order tests, counsel, assist in surgery, and round in hospitals or nursing homes” (AAPA, 2014).

Historically, the United States healthcare system has been set up to favor the fee-for-service payment system which incentivizes physicians to produce quantity over quality, particularly for the expensive, highly specialized services (Calsyn & Lee, 2012). Under fee-for-service, insurers pay the service provider separately for each service provided. This type of system has not only been responsible for skyrocketing health care costs, but also encouraged unnecessary medical services leading to waste, and produced fragmented communication between providers, which led to a culture of providers remaining in their own silos of care (Calsyn & Lee, 2012). This type of culture, along with the traditional hierarchy that takes place within healthcare that places the physician at the top results in diminished collaboration and communication, and finds other health professionals such as APPs feeling underutilized and underappreciated (O’Daniel & Rosenstein, 2008).

APPs AT UPMC

The University of Pittsburgh Medical Center (UPMC) is an integrated finance and delivery system located in Pittsburgh, Pennsylvania. It is made up of more than 20 hospitals, over 500 doctors’ offices and outpatient facilities, and consists of four major operating units: Provider Services, Insurance Services, UPMC International Services, and UPMC Enterprises (UPMC, 2015). Within Provider Services exists the Office of Advanced Practice Providers (OAPP), which oversees the training, deployment, and utilization of over 1,300 physician assistants and nurse practitioners. In addition, the office provides support for various operational issues and any scope of practice questions involving the APPs.



METHODS

In order to fulfill my summer administrative residency requirements, I worked at UPMC in the Physician Services Division, where I was fortunate to work on a project that examined how APPs within the UPMC system are utilized, and if they are happy with how they are currently being used within their scope of practice. To do this, an electronic survey was dispersed through email with a link to the web based Survey Monkey tool to all physician assistants and nurse practitioners in the system. The survey asked various questions to help better understand where the gaps were in how APPs were being utilized, the amount of time they spent on tasks, as well as their satisfaction with their current roles. The respondents were given three weeks to complete the survey, and given weekly reminders to do so. Example questions were chosen at the request of the Director of the Office of Advanced Practice Providers at UPMC and included: how well they were being utilized to their best potential, how satisfied they were in their current position, how much of their time was spent on tasks that could otherwise be performed by a clinical secretary or nurse, and how often they interacted with or duplicated the work of the attending physician.



RESULTS

Upon collection of the survey results, it was found that the APPs employed by UPMC who provide inpatient services spend portions of their time completing a wide range of activities, such as: conducting patient rounds, discussion with other providers on the care team, recording progress notes and entering orders, writing prescriptions, performing the patient admission exam and interview, and chart review and documenting the history and physical exam of each patient they see. By analyzing the results of the survey, of which there was a 37% response rate out of a total of 1,306 nurse practitioners and physician assistants combined, the results were analyzed and recorded into a master spreadsheet that allowed viewers to easily look at the outcomes broken down by each specific department. There was a total of 28 departments, both inpatient and outpatient that participated. The survey prompted the APPs to report on various questions in order to gauge their utilization. After analyzing the results, it was determined that the top three complaints from the APPs were: too much time spent entering notes or scribing for the physician, very little autonomy and boredom in their role, and redundancy of rounding, with the physician repeating the work completed by the APP. When asked the question “how strongly would you agree with the following statement: I believe that I am being utilized to my fullest extent as a physician assistant or nurse practitioner”, 15% strongly disagreed and reported that they felt dissatisfied with their jobs and how they were being utilized. As the graph below shows, a total of 54% of all APPs reported that they spend time scribing, or entering physician notes, and that another 22% spend greater than 20% of their active work time performing tasks that fall below their optimal scope of practice, such as scribing for the physician, which entails making entries into the patient’s electronic health record for the physician. In total, APPs reported that 39% of their overall time is spent in the electronic medical record (UPMC survey, Reynolds 2014).




Of the following in your role at UPMC, rate how much time you spend on the following duty: Scribing.

List what sorts of traditional nursing tasks, if any you perform.




Figure 1: Sentinel Finding Scribing

Additionally, upon reading the comments section that was included in the survey, there were frequent complaints from APPs stating that physicians do not use them correctly within their scope of practice, or in some cases at all, and at times even medical residents were treated with more respect than the APPs (UPMC survey, Reynolds 2014). Comments taken directly from the survey include:



  • “I am not in a role that needs me to maximize all the previous skills developed as an APP”

  • “I spend time doing nursing/MA work that could instead be spent on patient care”

  • “Seems we are more used for nursing education, nursing councils, other things related to nursing. This should not be the role of a physician extender.”

It is clear from the responses by the APPs, as well as the national push for change due to unsustainable costs and physician shortages, that APPs are not being used to their fullest potential and that it is time for new models of healthcare delivery to emerge, specifically with the use of APPs in mind. I will now move into examples of possible models and the outcomes they could potentially produce if APPs were to be integrated and used in these models.

EMERGING ROLES

While many potential changes are possible in order to stop the ever-increasing cost of healthcare, as well as the response to the shift from ‘volume to value’ and physician shortages, the focus here will be on placing APPs into emerging roles that will allow them to practice within their intended scope of practice and act as either a beneficial complement to, or substitute for, physicians. Research has shown that APPs have the ability to provide care for multiple health diagnoses and that patients are satisfied with their care as illustrated by one study showing that 80% of patients felt that the APP “always listened carefully” and showed respect toward patients (Furlow, 2011). In another publication, care given by APPs has been linked to greater patient education, which resulted in longer periods of time spent with patients, which increased satisfaction (ACP, 2009). These are important results to note when looking at what the guidelines of the Triple Aim are aiming to improve upon, which includes patient satisfaction with the care they have received. It is for this reason that placing APPs into these emerging roles should be given strong consideration.



The first example of this change is to incorporate APPs into the role of a hospitalist or one who will practice inpatient medicine. Generally, hospitalists have the responsibility to coordinate the daily medical care needed by patients admitted to the hospital. Traditionally this position was carried out by medical residents or specialists, but in recent years the responsibility has been gradually shifting to APPs due to several advances in technology helping to standardize processes (Timmermans, Jah Van Vught, Wensing, & Laurant, 2014). An example of this is the addition of computerized patient handoffs that allow for the “social interaction and information exchange that occurs when responsibility for a patient’s care transfers from one clinician to another” (Vawdrey, et al., 2013). Additionally, in 2004 the Society of Hospital Medicine (SHM) published a policy that outlined several conditions in which APPs could be incorporated into the practice of hospital medicine and supported the idea of using these professionals in this new role (Society of Hospital Medicine, 2014). In a survey composed and distributed by The Society of Hospital Medicine in 2006, group leaders who employed APPs as hospitalists answered with the following top six activities their APPs were performing, not all of which would be considered top of license practice, and are shown below. (Feinbloom & Wah Li, 2006).

Table 1. Most Common Roles of PAs/NPs

Activity

% of Programs Whose APPs Perform Each Task

Perform Patient Rounds

83%

Write Prescriptions

82%

Perform History and Physicals

77%

Communicate with Primary Care Physicians

72%

Act as an Initial Responder

66%

Participate in Discharge Planning

66%

*(Feinbloom & Wah Li, 2006). Sample size = 1,551 groups surveyed
Integrating APPs correctly into the hospitalist role will allow these individuals to feel as though they are being used at the top of their scope of practice, and change the current outlook seen in the survey results from UPMC where APPs feel as though they are not used to the best of their ability, and often feel a sense of redundancy in the activities that they complete. According to the UPMC survey APP’s perceive that there is frequent duplication in the practice of rounding for patients with the attending physician. This is viewed as an inefficient use of time for both the APP and the physician and is not ideal for the patient and their ideal experience of care (UPMC survey, Reynolds 2014). This type of practice model relies too heavily on the attending physician’s participation, when the APP is capable of providing autonomous care to a number of low risk patients, and eventually leads to a slowed progression of the patient’s care (UPMC survey, Reynolds 2014). In order to successfully integrate APPs into the hospitalist role and assure that they are being used to the highest scope of their practice, an organized plan must be prepared. According to the Society of Hospital Medicine, the APPs in their initial months of employment should be matched with a mentor in order to develop a trusting working relationship as well as to gauge one another’s clinical ability (Society of Hospital Medicine, 2014). There should be a reserved timeslot in each clinical day where the APP is able to review certain issues revolving around patient care with the attending physician, as well as a culture in which the APPs feel that their opinions, thoughts, and concerns are valid and are being heard. Additionally, the plan should include options for supplementary educational seminars as well as an assessment of how well the APPs are communicating with patients and families (Society of Hospital Medicine, 2014). The Advisory Board, in their figure below, shows that the ideal model for implementing APPs successfully into the hospitalist role is that of a parallel model, where only the patients that require physician attention are seen by both the APP and physician, compared to the often current model where both the APP and physician provide care to every patient (The Advisory Board, 2013).



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