Over the past 20 years, legislative changes in many states have enabled healthcare organizations to leverage the experience and know-how of licensed Physician Assistants (PAs) and Nurse Practitioners (NPs).
To differentiate these two types of providers, collectively, from physicians, the term Advanced Practice Provider, or “APP” is often used.
The Case for Optimizing the Use of APPs
The American Academy of Nurse Practitioners (AANP) and American Academy of Physician Assistants (AAPA) have studied this shift and also noted the challenges that legislative restrictions can place on healthcare organizations.
One example of these challenges, according to the AAPA, is in a rural setting where “mandating physicians to be constantly on site limits the team’s ability to expand access to care.”
Conversely, a state that allows healthcare organizations to determine the best method of patient care – including the ability to enable APPs to treat patients on their own in a carefully defined scope of practice – can provide twice the opportunity for patient care and access, especially in a rural community where distance can limit the capacity of practicing physicians.
While the education requirements and scope of practice for APPs vary by state, those that place fewer restrictions on their license and allow healthcare organizations to define their own staffing models have an advantage in delivering patient care.
Phoenix Children’s: A Model for the Future
Phoenix Children’s Hospital is fortunate to operate in the state of Arizona, where favorable legislation has enabled a significant transformation in healthcare practice.
Nurse Practitioners have full practice authority, allowing them to evaluate, diagnose, order and interpret diagnostic tests; as well as initiate and manage treatment plans, including the ability to prescribe medications and narcotics. This is the model recommended by the Institute of Medicine and National Council of State Boards of Nursing. At Phoenix Children’s, APPs operate at the top of their license, which has improved access to care and enhanced operational efficiency of the hospital and related medical group – a win for both patients and health system.
Of course, this shift didn’t happen overnight. In fact, over the past 18 months, Phoenix Children’s has taken deliberate steps to refine the delivery process to fully leverage the skills and expertise of the existing (and growing) team of APPs.
Like many healthcare organizations, Phoenix Children’s physicians were long-accustomed to working with APPs in the same way they worked with medical residents or fellows – but this limited the value of employing these professionals. Phoenix Children’s carefully, and thoughtfully, designed a more optimal approach to fully leverage our advanced practice providers. Now, APPs see their own patients, make diagnoses, and create and manage care plans within the area covered by their training and legal scope of practice.
In certain cases, patients are treated by NPs or PAs from beginning to end. Outcomes are overwhelmingly positive and patients report high satisfaction. In cases where the patient’s needs are highly complex, or will likely require surgical intervention, physicians do the initial consult and use their specialized knowledge to determine the ideal plan of care. From there, an NP or PA often assumes a supporting role that may include managing post-operative care, following through on the physician-ordered care plan, monitoring the patient’s condition, and consulting with the physician if the patient’s condition changes.
This division of labor between physicians and APPs has enabled Phoenix Children’s to care for more patients, and more complex patients, because the physician is free to stay focused on the areas where his or her expertise is needed. This is a critically important benefit within divisions in the hospital where patient acuity and demand for services is very high. Notably, this approach has improved overall quality of care and raised patient satisfaction scores.
Roles and Division of Labor in the Future
The Association of American Medical Colleges (AAMC) predicts the U.S. will be short between 46,000 and 90,000 physicians by the year 2025.
About a third of the shortfall will consist of primary care physicians, and APPs will be critical in filling the gap. Depending on market conditions and other factors, APPs could eventually serve as primary care providers, with physicians focusing on specialty areas and complex disease management.
There’s no time to waste – patients are counting on healthcare organizations to deliver the best care in the shortest amount of time, and organizational leadership is looking for efficiency now. By using models that enable APPs to work independently at the top of their license, patients are afforded increased access while healthcare administrators achieve a higher level of efficiency – truly a win-win combination.
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