Moving the conversation forward on scope of practice

As healthcare shifts toward value-based platforms, many primary care practices are adding advanced practitioners such as nurse practitioners (NPs) and physician assistants (PAs) to their rosters. As a result, medical practice collaboration is taking on growing importance.

A recent survey from search firm Merritt Hawkins provides evidence of this trend, revealing that NPs and PAs, collectively, were the firm’s fourth-most requested recruiting assignment of the past year, up one spot from the 2014 survey. Just four years ago, neither PAs nor NPs were among Merritt Hawkins’ top 20 assignments, individually or collectively, according to the report.

Nonetheless, the proper scope of practice for advanced practitioners remains a hot-button issue, with regulations and supervision requirements varying by state.

At the heart of this debate, for many, is the length of training physicians receive compared with advanced practitioners, according to Jeffrey Gold, MD, a family physician and owner of Gold Direct Care, PC, in Marblehead, Massachusetts. “I definitely think there’s a place for [advanced practitioners] in the system, and in the direct primary care model that I’m doing; but there’s a very big difference between a two-year program and four years of medical school with a minimum of three years of residency where you’re on call pretty much every fourth night,” Gold says. “It’s not to say it in any deleterious way to [advanced practitioners], but there is a difference in the time that is spend on education, training, and building a knowledge base.”

Physicians’ training helps them develop a mindset that considers more serious medical “zebras” that can masquerade as horses, Gold explains. Especially when care is fragmented, such as with care provided at walk-in clinics, the risk is greater that a cough an NP treats with a Z-pack, for example, might turn out to be a tumor, Gold says.

Gold acknowledges that most NPs and PAs are very good at what they do and have helped fill a void created by a shortage of primary care physicians. Nevertheless, he would personally rather be treated by a doctor. “I hate to say it, but when I go to the doctor, I want a physician-and that’s what I want for my family,” Gold says. “It doesn’t mean that I don’t trust NPs, but especially if it’s something that I’m really worried about and I think is complicated, I want a doctor.”

Next: Achieving the aims

Achieving the aims

Gold is not alone in pointing out key distinctions between physicians and advanced practitioners. The American College of Physicians (ACP) recommends that licensing bodies “recognize that the skills, training, clinical experience, and demonstrated competencies of physicians, nurses, physician assistants, and other health professionals are not equal and not interchangeable,” according to a 2013 position paper.

Reid Blackwelder, MD, board chair of the American Academy of Family Physicians (AAFP), agrees that while every member of a care team is important, they are not interchangeable. State regulations governing use of advanced practitioners vary widely, he says, making a resolution to the scope-of-practice debate difficult because each state presents its own “particular situation.”

The ACP does not support the idea of one-size-fits-all licensure either, stating that “state legislatures should conduct an evidence-based review of their licensure laws to ensure that they are consistent with ACP policies.”

With these caveats, both physician groups support the use of clinical teams in primary care. “To be frank, many of the discussions that are happening right now are asking the wrong questions,” Blackwelder says. And the right questions aren’t necessarily about what advanced practitioners should or shouldn’t be doing, he says, but what happens to patient outcomes, satisfaction, and costs under various models.

“In the places there are good team-based care approaches, we are starting to see an impact on the Triple Aim,” says Blackwelder. “It’s time to look at this issue through a different set of lenses to move things forward, rather than draw lines in the sand.”

Edward Bujold, MD, FAAFP, who leads Family Medical Care Center, a small family practice in western North Carolina, has first-hand experience with the evolution of team-based care. He has employed advanced practitioners for 25 years, and they have been an indispensable part of his practice’s patient-centered medical home.

Next: Assigning patients

In a recent commentary in Annals of Family Medicine, Bujold wrote that the past five years of having all members of the clinic working to the highest levels of their job descriptions have helped the practice achieve increased efficiency, better patient access, higher gross and net revenue, and improved population health, all of which have helped the practice contribute to reaching the goals of the triple and quadruple aims.

“Each member of the staff now feels his or her contributions to the team make a difference in our patients’ health care,” he wrote. “The health of our population has improved and, by focusing on patient needs, our hospitalization rates are down 80% over the last five years.”

None of these are overnight changes, however. To make the most of team-based care, practices must consider licensure limitations, supervision and collaboration requirements, reimbursement issues, patient needs, and more when developing a workflow that achieves desired results.

Assigning patients

For many practices, the first step is determining which patients advanced practitioners should see. The Institute for Healthcare Improvement and other thought leaders in team-based care agree that all providers in a practice-including physicians, NPs, and PAs-should have his or her own panel of patients, says Debra P. McGrath, MSN, CRNP, president of DPM Healthcare Consulting in Pennsylvania.

“It’s certainly up to the practice how they slice and dice their panel, but what’s really important is that they understand what their population of patients looks like and how that’s broken down across things like diagnoses, socioeconomic status, high utilization, high risk, etc. Then they can distribute that panel across their providers in a way that makes sense and is reasonable based on at least some measure of acuity,” McGrath says.

On the other hand, assigning patients to NPs or PAs based on their reason for a specific visit has pitfalls, according to Gold. “Sending an NP just to see 40 sinusitis and urinary tract infections a day is going to end up with somebody having a back tumor or something else that’s going to get missed,” he says. “In the current system (which I’m not part of,) the patient has to be the focus, with the NP not just being dumbed down with sick visits but able to work collaboratively with the provider that’s there.”

Next: Assigning responsibility

Patients new to Bujold’s practice generally are assigned to one of his two NPs, both of whom have worked in intensive care units and are capable of treating a wide variety of problems in primary care. “I typically end up seeing the sicker patients they just don’t feel comfortable managing,” he says. “Or they may have established patients that get more chronic diseases or have an acute heart attack with issues related to that, and those patients may end up in my panel over time.”

This fluidity is consistent with the ACP’s stance that teams must have the flexibility “to determine the roles and responsibilities expected of them based on shared goals and needs of the patient.” For the most part, Bujold says, patients have welcomed the opportunity to work with his NPs.

“We’ve had a couple of patients that wanted to see me all of the time, but we haven’t had that much pushback,” he says.

Assigning responsibility

In many cases, NPs and PAs aren’t just assigned patient panels, but also teamed with a medical assistant (MA) and other allied health professionals. McGrath refers to these groups as provider-medical assistant “teamlets,” noting that such teams should be stable and complementary.

“You don’t want to put your two most disorganized people who have wonderful people skills in the same teamlet,” she says. “You want to have adequate people skills and good organizational skills.”

Next: Making the right hiring decisions is key

The teamlets are then surrounded with additional support people. In a practice with six clinical teamlets, for example, the same nutritionist, behavioral health specialist, and registered nurse might support three of the teamlets, while a second group of supporters works with the other three, McGrath says.

“The concept is that the team consists of more than just the provider than the MA, but that those two people are absolutely stable, that they are always working together, they complete each other’s sentences, and the provider is able to assign responsibility at the highest capability of that MA,” she says.

Practices can use any variation of this model that suits their needs, but a key to success is assigning responsibility-versus delegating tasks-to team members, according to McGrath. “You need to teach PAs, NPs, and physicians how to be the CEO of their teams, so they’re not yelling or demanding or being authoritarian, but they’re being authoritative in a way that inspires good work and the ability to assign responsibility to the rest of the team,” she says.

Examples of this distinction are abundant in the arena of population health management. Using a tool built into its electronic health record or separate software, a practice might, for example, identify patients with diabetes who are overdue for having their A1C levels checked. In a well-functioning team, the provider would assign to his or her MA the ongoing responsibility of reminding these patients to make an appointment. “It’s not, ‘Hey, Suzie, would you call Mrs. Smith to come in for a hemoglobin A1C?’” McGrath explains. “It would happen automatically without having to ask.”

But assigning roles and responsibilities will only work if practices make the right hiring decisions in the first place, notes Bujold. “You have to hire a certain type of employee from top to bottom of your organization, and they all have buy into the vision, they all have to be capable of functioning in a team, and they have to like each other and want to work with each other.”

Because he believes so strongly in the value of team chemistry, all the hiring decisions at Bujold’s practice are made by committee. “If there are one or two team members that say, ‘I don’t feel good about this person,’ then we don’t hire them-because these are the people who are going to be working with this employee and if it doesn’t work out it’s very divisive and disruptive to the whole team,” he says.

Next: Making collaborating work

Making collaboration work

State laws vary as to the level of physician supervision required for NPs or PAs working in a practice, and billing rules are very specific for Medicare and other payers. Regardless of these regulatory parameters, however, good communication is critical to teamwork.

In most cases, a physician must be available at least by phone, if not on the premises, to consult with advanced practitioners about patients when needed. Practices should agree on the day-to-day circumstances in which such consultations must occur, McGrath says. A physician might advise other providers to pick up the phone, for example, any time he or she may be feeling shaky or have nagging questions in their minds about patient care.

“We’re right there next to each other so we communicate pretty much every day if there are issues to talk about. They may ask me to see a patient when I’m there and I’m just a phone call away when I’m not,” he says.

Sometimes Bujold disagrees with an NP’s proposed course of action. “As good as these people are with their ICU background, I can tell that there are some situations they’re not trained to handle because they don’t have the MD,” he says. “I think NPs and PAs can handle 85% to 90% of what comes through the office, with the caveat that there’s always a physician to touch base with.”

That said, it isn’t necessary or feasible for physicians and their team members to discuss every patient encounter, but systems can and should be put in place to keep care from falling through the cracks.

At Bujold’s practice, the team huddles daily to review reports showing any gaps in care, such as mammograms, colonoscopies, or vaccinations patients may need. “So those things are flagged before the patient comes in for what he thinks is just a sinus infection, but we can talk about getting these things done,” he says. “A lot of times the nurses will go out to the front and get a colonoscopy scheduled before I even get to the door.” With the rest of the team on top of these matters, Bujold’s time is freed up to spend talking with patients about other issues, he says.

Next: Measuring success

Along with the daily huddle, Bujold and his team members meet quarterly and pick a patient or two to discuss in greater depth. McGrath says such collaboration should take place at least monthly, especially to talk about high-utilization patients. “That’s an opportunity to make sure we’re all talking and that we’re thinking about the possibilities for this patient,” she says.

In the era of EHRs, collaboration can take place asynchronously, using the software’s internal messaging system, or simultaneously, even if some team members are looking at charts remotely. “Think of those collaborating sessions as a consultation,” McGrath says. “It’s not, ‘You should do this or that’ or directing the NP to do something. It’s more, ‘I’m concerned about this. Here are all of the things that I’m thinking about. Am I missing anything? Do you have a different perspective on this?’ It’s really giving the patient another set of eyes on the issue.”

Measuring success

For team-based care to succeed, all members have to accept the vision and be willing at least to try new workflows, experts agree. Other common mistakes include not planning how to create transformation or measure success in a meaningful way.

McGrath recommends that practices study a provider’s patient panel in terms of quality-improvement metrics. “There can be a number of metrics you’re looking at, which can also be around provider satisfaction and staff satisfaction,” she says.

Practices should revisit those metrics a month or so later to determine whether they’ve improved. Signs of success could be as simple as noting that two out of three days the staff got out on time-or as dramatic as Bujold’s 80% reduction in hospitalizations.

The first step in realizing such benefits, however, is trusting that team-based care is worth a serious try.