Incorporating Advanced Practice Providers into GI Practice

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Nurse practitioners (NPs) and physician assistants (PAs), collectively known as advanced practice providers (APPs), can improve patients' access to care and advance an institution's research and quality improvement initiatives. In Gastroenterology, Andrea H. Thurler, DNP, FNP-BC, director of Ambulatory Advanced Practice Providers and Nursing in the Massachusetts General Hospital Division of Gastroenterology, Kyle Staller, MD, MPH, director of the Gastrointestinal Motility Laboratory in the Division of Gastroenterology, Priyanca Waghmarae, PA, physician's assistant in the Division of Gastroenterology, and Kristin E. Burke, MD, MPH, inflammatory bowel disease physician in the Crohn's and Colitis Center, recently gave pointers on how to integrate APPs into a gastroenterology practice.

Advantages of Working with APPs

There are multiple inherent benefits of collaborating with APPs. Their training emphasizes spending enough time with patients to understand the psychosocial influences on their illness and counsel/screen them carefully, which can enhance patient care and outcomes when physicians aren't able to spend as much time with them. This also means that APPs can provide better access to care for patients who have urgent concerns and continuity of care for outpatients who need long-term management of chronic conditions. And because they can help with research both directly (screening patients for trials, conducting study visits) and indirectly (identifying potential candidates), they can play an important role in research teams.

Potential Limitations of Working with APPs

It's important to recognize that while there are many benefits of working with APPs, there are certain limitations that must be mitigated through a collaborative team comprising various experts. APPs bring a strong complementary skill set to physicians, but they cannot replace physicians. Their broad training does not give them the same knowledge base or clinical experience as gastroenterologists. It's critical that an APP–physician team be structured to incorporate regular check-ins and ongoing training. When physicians view their collaboration with an APP as an opportunity for mentorship, not just increased patient throughput, teams can thrive.

Sometimes, patients may feel abandoned or confused when scheduled with an APP instead of their gastroenterologist. Gastroenterologists should formally introduce their APP to patients during a physician visit; for the best results, subsequent appointments should either be shared between the two or scheduled to alternate between the APP and the physician.

Collaborating physicians may need to serve as advocates for their APPs with administrators because much APP revenue is not directly captured in billable charges. Reimbursement varies by payer and state.

Finding APPs to Complement Your Practice

Nurse Practitioners begin their careers as registered nurses, usually also with a BSN degree, and as such are trained to care for the whole person. They go on to complete two or three years of a master's program and earn a national certification in a specialty (Family, Adult–Gerontology, Neonatal, Pediatrics, Women's Health or Psychiatric–Mental Health). Some NPs add a doctoral degree with a clinical (DNP) or research (PhD) focus, which requires another two to five years of training.

NPs earn an independent license, but their scope of practice varies by state. Currently, 25 states allow NPs to open their own practice and prescribe medications independently of a collaborating physician.

Physician Assistant training is a master's degree and is disease-centered. Generally, the two classroom years of medical school are encompassed in one or two years of PA school, followed by a year that combines classroom and clinical experience.

PAs receive a generalized, national certificate. They can be incorporated into any specialty with training provided by the collaborating physician. They cannot practice independently.

Integrating APPs into a Practice

Before hiring an APP, carefully consider the practice's reasons for wanting to work with one. The recruitment team should write a job description and evaluate how candidates match the practice's needs and goals. APPs will want to discuss expectations for patient volume, clinic initiatives, continuing education and opportunities for leadership, research and growth.

Training

The collaborating physician might choose to create an intensive content orientation followed by a series of weekly readings covering "bread and butter" cases. The American Gastroenterological Association publishes on-demand webinars for APPs and hosts an annual conference for them. A period of observation in the clinic with dedicated time to discuss management decisions can also be very helpful.

Competency Evaluation

In 2008, the Joint Commission extended the Ongoing Professional Practice Evaluation to APPs who hold credentials and privileges at an accredited hospital. This assessment is to be conducted at least semiannually. There are standardized criteria, but the qualitative and quantitative measures included are determined by the individual practice or institution.

Retention of APPs depends on maintaining a vested interest in their training and growth. The APP and collaborating physician should meet regularly to see patients and discuss clinically relevant topics. Potential areas of growth include participating in or leading departmental quality improvement and research initiatives, developing administrative leadership skills or participating in APP society and legislative initiatives.

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