How to start an NP/PA program

There's not much uncertainty anymore about whether nurse practitioners (NPs) and physician assistants (PAs) can add value to hospitalist programs, said Christopher Frost, MD.

“The focus of the question as it relates to NP/PA integration has pivoted from ‘Should we consider this?’ to ‘How do we do this?’” said Dr. Frost, national medical director of LifePoint Health, based in Nashville, Tenn.

The 2014 State of Hospital Medicine report from the Society of Hospital Medicine found that 75% of hospital medicine groups include NPs or PAs. But that doesn't mean they've all made the best use of advanced practice providers (APPs), according to Dr. Frost, who along with Tracy Cardin, ACNP, and Leah Schmitz, PA-C, spoke about optimal NP/PA integration during Hospital Medicine 2019, held in National Harbor, Md., in March.

Common pitfalls include insufficient consideration of the goals of integration and ineffective utilization of APPs' skills. “When the day is done, they say, ‘You know what, we probably could have gotten that done with RNs. Or we could have accomplished that with scribes.’ That can be incredibly frustrating,” said Dr. Frost.

Clarifying the goals behind hiring NPs and PAs will also help program leaders choose the most suitable model for integrated care. The speakers reviewed a variety of these models, ranging from “tried and true” to “evolutionary or revolutionary” concepts.

The rounder model falls into the former category, explained Ms. Schmitz, APRN/PA manager for hospital medicine at Cleveland Clinic's Avon Hospital in Ohio. “Essentially, take care of everything from admission to discharge—I think that is what most people think about when they think about how an NP/PA would practice in a hospitalist setting,” she said.

A challenge with this common model is the high level of communication and division of responsibility required between specialties, the panelists said. “There needs to really be a lot of clarity around when an NP or PA rounder is collaborating with their physician colleague,” said Ms. Cardin, vice president for advanced practice providers at Sound Physicians, a national health care practice based in Tacoma, Wash.

The admitter model also requires a lot of communication, given its inherent quantity of handoffs. Another risk is that NPs/PAs may burn out faster handling only admissions, but this model can increase a hospitalist service's efficiency. “This also is a good place to start when you have a new program or a new NP or PA, just to get their feet wet doing this admission process,” Ms. Schmitz said.

Then there's the self-explanatory nocturnist model, which some rural hospitals are using as their sole on-site night coverage and some high-volume hospitals use in addition to physicians, Dr. Frost said. “If you have people that love to work nights, this is beautiful,” Ms. Schmitz said. If not, “You just have to be a little bit careful about how you're dividing up the equity of these tasks.”

Having APPs who are service-specific is another increasingly popular model, the experts said. Appropriate services might include stepdown, neurology, or perioperative care. An upside is that APPs can get very proficient at the specialized care, while the downside is that it could get monotonous for them.

Another possible area for an NP or PA to specialize is observation care. “It's the sweet spot where you're taking the lower-acuity patient and utilizing an APP at the maximum scope of practice,” said Ms. Cardin. “It's a good match for the skill set.” Once again, the lack of variety in practice is a potential issue, along with the rapid patient turnover and high documentation burden.

The final tried-and-true model is to focus on complex patients, especially those at risk of readmission. “You're appointing an advanced practice provider who gets to know that patient population really well, refines those care plans. You could have a huge impact on the care of these people,” said Ms. Cardin. Burnout is a risk, however.

On the more experimental side, the experts proposed having APPs use telehealth to partner with remote physicians. “In a hospital that requires physician visits every day, could telemedicine take the place of those daily physician visits? Could a teledoc perform the initial admission visit with the APP?” asked Ms. Cardin. She noted that the answers to these questions depend on local rules and regulations.

Population health is another area where APPs might increasingly be employed. These jobs could involve following patients in the hospital and outside it, including to skilled nursing facilities, said Dr. Frost. “Imagine a population health NP who is responsible for preventing admissions in a population of patients. I think it's a great role,” said Ms. Cardin.

The final model they offered is team-based care, in which one physician collaborates with a team of NPs or PAs. “You may have three APPs, you may have four or five APPs, nobody really knows the maximum or the appropriate number,” Ms. Cardin said. In this model, she explained, the APPs drive the care and consult with the physician as needed. “It may free up some of the physician's time to use in some committee work, [quality improvement] work, and other activities,” she said.

That's a lot of models to choose from, obviously, and another challenge will be the number of people who need to be consulted in the decision. “You do want to get a broad swath of potential stakeholders to hear what the potential hiccups will be, what the naysayers have concerns about, so wherever possible those concerns can be addressed,” said Dr. Frost.

Don't let the naysayers ruin the whole concept, though. “If you have a negative Nelly or negative Neil that's not engaged or involved with this process, this is going to sound very counterintuitive, but it may be OK during the onboarding period to isolate them a little bit from the process because they can sour the proverbial well,” said Dr. Frost.

On the other hand, it's important to involve cooperative physicians in the process of launching an APP service and help them figure out how best to collaborate with the new clinicians. “Don't forget that we have to have physician competencies about successful NP/PA integration. Physicians are not taught in school how to do that,” said Ms. Cardin.

Make sure the APPs also learn everything they need to practice successfully, too. A good onboarding process for a new APP includes didactics and shadowing of other clinicians, the experts said. It can last for months or up to a year, Dr. Frost noted, but definitely more than a few minutes. “‘Hey, here's your list of 20 [patients], and good luck. I'll see you at intake tomorrow.’ That does not qualify as onboarding,” he said.

Provide clear structure and guidance on scope of practice and collaboration with physicians, both hospitalists and subspecialists, the experts advised. “Regardless of the experience of your APP, I think there needs to be a very specific and structured format for having review of your patient rounding lists,” said Ms. Cardin. “Have a guardrail that says that if your patient goes on BiPAP unexpectedly, your physician partner should probably know. If you turf somebody to the ICU, you probably should have a physician partner be aware.”

Once an integrated model is up and running, there should be a system for determining whether it's working. Performance measurement options include quality and safety metrics, length of stay, readmissions, and patient and clinician satisfaction, the experts said.

Quantifying these effects will make it easier to deal with the inevitable growing pains of a new program. “Some consultant is going to call you up and say your NP/PA didn't know anything about whatever they were being consulted about. Take that, listen to it, respond to it, but don't throw the baby out with the bathwater,” said Ms. Cardin.