Advanced Practitioners: The World As We Know it

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Presentations text content in Advanced Practitioners: The World As We Know it

Slide1

Advanced Practitioners:The World As We Know it

May 5, 2016

Slide2
Session Objectives

Education on national and regional trends as they relate to Advanced PracticeDiscuss scope of practice in several licensure categories

Discuss role optimization in the ambulatory setting

Discuss Advanced Practice structure and compensation models

2

Slide3
Introductions

Survey

Slide4

Change is Hard

4

Slide5

Jennifer DerKazarian

DNP, RN, ANP-BC

is the former Director of Advanced Practice at Lahey

Hospital & Medical Center (LHMC) in Burlington Massachusetts where she oversaw the practice of the Nurse Practitioners, Physician Assistants, Nurse Anesthetists, and Clinical Nurse Specialists. She is also an acute care cardiac electrophysiology nurse practitioner.  Her doctoral work focused on an organizational assessment of LHMC and the interface between NPs and PAs and team building. Dr.

Derkazarian

is currently in a position of multi-site nursing leadership with

Atrius

Health where she works in a triad of regional leadership including a Senior Vice President and Medical Director. She is also involved in the development and implementation of an advanced practice fellowship accreditation pathway with the American Nurses Credentialing Center (ANCC). Dr.

DerKazarian

is a member of the American Academy of Nurse Practitioners (AANP) Region 1 Leadership Group and of the Board of Advisors for the

APPex

Advanced Practice Provider Executives Inc., as well as advises nationally on topics particular to NP and PA leadership.

Lisa O’Connor

is a Senior Managing Director at FTI Consulting and is based in Boston, MA. She in the Health Solutions segment in the Clinical Solutions service line. Ms. O’Connor has more than twenty years of experience in the healthcare industry. Most recently, Ms. O’Connor was the Senior Vice President of Clinical Operations and Chief Nursing Officer at Boston Medical Center where she was responsible for both the day-to-day operations and strategic planning for the clinical delivery systems. Ms. O’Connor’s experience includes labor productivity management within a unionized environment, clinical quality improvement, operations, disaster preparedness and management, supply chain, physician relationships, negotiation, regulatory compliance and other key leadership responsibilities.

Ms. O’Connor has a green belt in Lean Six Sigma from GE and was a 2009 Robert Wood Johnson Executive Nurse Fellow. Ms. O’Connor holds an MS in Management from Lesley University, and a BS in Nursing from Salem State College.

Introductions

5

Slide6
Audience Survey

Are the AP’s in your organization being fully leveraged? (scale of 1-5)

What are your top three concerns regarding Advanced Practice in your organization?

a) retention

b) the practice environment

c) compensation

6

Slide7
Industry Trends

Slide8

Utilization of Advanced Practitioners

Market Overview

The healthcare industry is currently facing internal and external forces that are making traditional clinical staffing models unsustainable; leading organizations are recognizing the downstream impact of these forces and better aligning resources in an effort to improve patient access, efficiency and quality of care.

The implementation of Advanced Practitioner (AP) models has proven to be an effective solution to overcoming market pressures and meeting the needs of a growing patient population.

Physician Demand Outpacing Supply

Declining Reimbursement

Heightened Patient Expectations

Need for Enhanced Care Coordination

Pressure to Improve Patient Access

Restructured Care Delivery Model

Forces Driving Change

8

Slide9

Utilization of Advanced PractitionersPhysician Supply and Demand

Demand for physicians has already exceeded the number of physicians graduating from medical school; therefore, APs are becoming critical to supplement patient demand.

Source

“The Complexities of Physician Supply and Demand: Projections from 2013 to 2025“: IHS, Inc. March 2015

Primary Care

Medical Specialties

Surgical Specialties

Other Specialties

Supply

Demand

9

Slide10

Utilization of Advanced PractitionersProvider Growth

Without proper governance and structure for APs, hospitals and medical groups will not be able to deploy AP workforce effectively

Source

“Bureau of Labor Statistics. Occupational Employment Statistics, May 2015/

Health systems have been hiring more APs to offset physician shortages

As the employed AP workforce grows, health systems must be able to evaluate the efficiency of their Nurse Practitioners and Physician Assistants

Variations in physician practice and state scope of license can limit the utilization of APs to the top of their license

10

Slide11
Ambulatory Skill Mix Management

Slide12

Ambulatory Skill Mix Management

What does “top of license” mean?

Leading Advanced Practitioner programs enhance efficiency and quality of care in the following ways:

1. APs and MDs operate at or above national, peer group productivity benchmarks

2. APs function at the top of their state licensure

3. APs and MDs have clear roles and deliver care in a coordinated, structured model

4. APs have independent schedules and carry patient panels as appropriate

5. APs have assigned clinical coverage/on-call responsibilities

6. AP compensation models are aligned with physician counterparts

12

7. AP's drive clinical quality and are key to organizational performance improvement efforts

Slide13

Ambulatory Skill Mix Management Roles and Responsibilities

Clinical skill mix is reviewed to ensure:

Roles are being fully leveraged to operate at top of license

Appropriate mix of roles develop effective

team for care delivery

Optimal skill mix to deliver quality care and responsible financial outflow

Role responsibilities are defined based on best practice

Clerical

MAs

LPNs

APs

MDs

RN

13

Slide14

Who is a Provider? Scope of Practice Limitations

Advanced Practitioners can be utilized to

increase and expand access to care

for organizations

National accreditation and certification examinations define the level of practice and establishes the competency levels of APs

Limitations on scope of practice varies from state to state for Nurse Practitioners (NP) and Physician Assistants (PA)

Congress is deliberating on expanding the scope of practice for NPs within Veteran’s Administration to allow them to provide care independently regardless of state.

14

Slide15

Who is a Provider?Scope of Practice – New England

State

CRNA

CNM

CNS

CNP

PA

Practice Independently?

Prescribe Independently?

Practice Independently?

Prescribe Independently?

Practice Independently?

Prescribe Independently?

Practice Independently?

Prescribe Independently?

Practice Independently?

Prescribe Independently?

Maine

No

No Prescribing Authority

No

No

Yes

No Prescribing Authority

Yes

Yes

No

No Prescribing Authority

Massachusetts

No

No

No

No

No

No

Yes

No

No

No

New

Hampshire

Yes

Yes

Yes

Yes

Not an APRN

Not an

APRN

Yes

Yes

No

No

Rhode

Island

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

No

No

Vermont

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

Independent

– no requirement for a written collaborative agreement, no supervision, no conditions for practice

Not Independent

- a written agreement exists that specifies scope of practice and medical acts allowed with or without a general supervision requirement by a MD, DO, DDS or podiatrist; or direct supervision required in the presence of a licensed, MD, DO, DDS or podiatrist with or without a written practice agreement.

Prescriptive Authority -

an APRN is authorized to prescribe pharmacologic and non-pharmacologic therapies beyond the perioperative and

periprocedural

periods.

Note:

PAs by definition practice dependently, and Prescribe dependently. Their license for both clinical and prescriptive practice from a regulatory standpoint is directly linked to their supervising MD.

Source

: National Council of State Boards of Nursing, Updated 05/2014

.;

Physician Assistants http://www.bartonassociates.com/nurse-practitioners/physician-assistant-scope-of-practice-laws/

15

Slide16

Who is a Provider?Registered Nurse (RN): Scope of Practice – New England

Duties and responsibilities

Assessment of health status for individuals and groups and recording related health data

Establishing nursing diagnoses

Planning, implementation and evaluation of outcomes of nursing intervention including all elements of nursing care, prescribed medical or therapeutic regimens mandated for the situation, recent advancements and current knowledge of the field

Collaboration, communication and cooperation as appropriate with other health care providers to ensure quality and continuity of care

Proper teaching, directing and supervising delegates and the outcomes of delegation

Delivery and coordination of health teaching required by individuals, families, and groups to maintain optimal health

Sources: Massachusetts Board of Registration in Nursing, New Hampshire Board of Nursing, State of Rhode Island Department of Health, Vermont State Board of Nursing, Maine State Board of Nursing

16

Slide17

Who is a Provider?Licensed Practical Nurse (LPN):

Scope of Practice – New England

Duties and responsibilities (typically under the supervision of MD, AP, or RN)

Assessment of basic health status for individuals and groups and recording related health data

Participate in planning, implementation and evaluation of outcomes of nursing intervention including particular elements of nursing care, prescribed medical or therapeutic regimens mandated for the situation, recent advancements and current knowledge of the field

Proper teaching, directing and supervising delegates and the outcomes of delegation

Delivery and coordination of health teaching required by individuals, families, and groups to maintain optimal health

LPN can fulfill almost any function as that of the R.N. The initial patient assessment must be performed by the R.N. but the L.P.N. will implement a patient assessment as ordered per the Physician as a part of the daily ritual as well. She also can take verbal and written orders from the Physician and can perform wound care, assist with procedures, start I.V.s, perform blood draws and provide essential patient care.

They may not give I.V. push meds or start PICC lines

Sources: Massachusetts Board of Registration in Nursing, New Hampshire Board of Nursing, State of Rhode Island Department of Health, Vermont State Board of Nursing, Maine State Board of Nursing

17

Slide18
Scope of Practice

Overlap and Impact on Operations

X - Level can perform task

P - Level is the primary person to perform task

18

Clinical Duties

PA / NP

RN

LPN

MA

Triage

 

P

X

X

Escort patient to exam room

 

X

X

P

Provide Acute and Chronic Care Management

P

X

X

 

Medication Refill Request

X

P

X

 

Prescribe and Manage Medication

P

 

 

 

Diagnose and And Treat acute and Chronic Illnesses

P

 

 

 

Perform Patient Assessments

X

P

 

 

Perform Triage

X

P

 

 

Administer Medications/Immunizations

X

P

X

 

Perform intake of medical data (patient history interviews including medication and problem lists)

 

X

X

P

Provide patient information/instructions

X

P

P

X

Assist with medical examinations/surgical procedures

 

 

X

P

Prepare patient for examination

 

X

X

P

Remove sutures

X

P

P

X

Change dressings

X

P

P

X

Wound Vac / Complex Wound Care

X

P

 

 

Call Reports

X

P

 

 

Notify patients of laboratory results

 

P

P

X

Instruct patients about medications or special diets

X

P

P

X

Perform basic laboratory tests

 

X

X

P

Perform ECGs

 

X

X

P

Slide19

Who is a Provider?

Medical Assistant:

Scope of Practice – New England

Duties

MA

ME*

NH

VT

RI

Clinical procedures

, such as injections, calling in prescriptions or drawing blood

YES

YES

YES

YES

YES

Telephone health

screenings for patients

YES

N/A

NO

N/A

YES

Recording

patient data

YES

YES

YES

YES

YES

Checking patient vital signs

YES

YES

YES

YES

YES

Scheduling patients and other administrative duties

YES

YES

YES

YES

YES

Change dressings

YES

YES

YES

YES

YES

*Duties vary depending on hospital, clinic, or other health care setting

Sources: Medical Assistant Certification website, New Hampshire MA Task Force, Vermont State Board of Nursing, State of Rhode Island Department of Health

Rhode Island- Additional Duties

Reconcile medication

Perform ear lavage, Electrocardiography, spirometry

Assist an authorized practitioner, under direct supervision, to carry out a specific task, as a “second set of hands

19

Slide20

Who is a Provider?Pharmacy Technician:

Scope of Practice – New England

Duties

MA

ME

NH

VT

RI

Pharm

Tech

Cert

Pharm Tech

Pharm

Tech

RegPharm TechCert Pharm TechPharm TechCert Pharm TechPharm Tech IPharm Tech IIRequest and accept NEW prescriptionNOUnder SupvUnder SupvNOYESNO

Under Supv

NO

YES

Request and accept

REFILL authorization

Under

Supv

YES

Under

Supv

YES

YES

YES

YES

YES

YESEnter prescription

data into a data processing systemYES

YES

N/A

YES

YES

N/A

N/A

N/A

N/A

Drug utilization

review

NO

NO

N/A

N/A

N/A

NO

NO

NO

NO

Patient

Counseling

NO

NO

NO

N/A

N/A

NO

NO

NO

NO

Sources: MA Board of Registration in Pharmacy

, Maine Department of Professional and Financial Regulation, Office of Professional and Occupational Regulation – Board of Pharmacy, New Hampshire Board of Pharmacy, Vermont Board of Pharmacy, Rhode Island Board of Pharmacy

20

Slide21
AP Reimbursement and Compensation

Slide22

Advanced Practitioner BillingReimbursement Structure

Reimbursement for Advanced Practitioner Services is foundationally based on if the state and/or organization recognizes APs as independent providers

22

Slide23

Advanced Practitioner Billing “Rules of the Road” - Medicare

* High-level directional estimate using Medicare reimbursement rates

Provider Type

Hospital OP Setting

Hospital

I

P Setting

Private Physician Owned Ambulatory Site

Physician

Assistant

Can Bill

under own provider ID with general physician supervision. Payment rate is 85%. (Physician does not have to see the patient )

Same as OP

Same as OP

Nurse PractitionerCan Bill under own provider ID – Does not need general physician supervision depending on state regulations (see Grid regarding scope of practice). Payment at 85% of physician fee scheduleSame as OPSame as OPPhysicianCan bill at 100% of physician fee schedule. Must either complete entire visit OR repeat key components of visit completed by other provider. ONLY 1 BILL PER ENCOUNTER MAY BE SUBMITTEDSame as OPCan bill for services directly provided OR may bill for services provided by midlevel provider if strict incident-to requirements are followed. ONLY 1 BILL PER ENCOUNTER MAY BE SUBMITTED23

Slide24

Advanced Practitioner BillingCMS Guidelines for AP Billing Under “Incident to Provision”

Ambulatory AP services can also be billed as "incident-to” physician services; however, this requires the physician is present within the office/clinic

24

APs must have sufficient training to provide the service and when appropriate, licensed under state law to perform without supervision

Individual rendering service and individual supervising service must be employed by the same entity (i.e., employee, leased employee, independent contractor)

Professional

Designation

Description

Requirements

Auxiliary

Staff

Medical

Assistant

LPN

RN, etc.

Services can be billed by physician or AP,

but must be connected to a service performed by physician or AP

Medical services usually performed by office staff

Administration of therapeutic or chemotherapy

medications

AP

Nurse Practitioner

Clinical

Nurse Specialist

Physician Assistant

Certified Nurse Midwife

Preceded by a related physician service

Related to an initial covered service performed

by a physician

Connected to the physician delivery of care

related to the initial service

Provided during the course of treatment of the illness or injury

Furnished under direct supervision

Source: Health Care Compliance Association

Slide25

Advanced Practitioner Billing“CMS Guidelines for AP Billing Under “Incident to Provision”

(cont’d)

25

Must be in an office/clinic setting and perform service commonly performed in a physician office/clinic

Established patient

Established diagnosis

Integral, incidental, physician’s

personal professional services

Furnished under direct supervision

Billing physician must be in office/clinic

Immediately available

Does not have to be in the same room

Additional AP Specific AP Rules

Source: Health Care Compliance Association

Slide26

Advanced Practitioner Billing“Incident To” Rules – Anthem BlueCross

26

APs provide services under direct supervision by the supervising provider, that are integral to the care of a patient

AP services are eligible for separate reimbursement, if separately reported, as if the supervising provider had personally provided the service

Services performed and billed under the supervising provider must meet the Anthem BCBS definition of medically necessary and be otherwise covered services

Anthem requires that the supervising provider must:

Be physically present in the office suite and immediately available when necessary to provide assistance and direction throughout the evaluation and management visit and/or rendered service

Stay involved and have an active part in the ongoing care of the patient

If the AP has an Anthem PIN (or has applied for one), they are required to bill under their own NPI and cannot bill incident to a physicians services.

Source: Anthem BlueCross BlueShield

Anthem does not follow CMS “Incident to” reimbursement rules for any M.D. or non-physician practitioner (“NPP”) who has been assigned his/her own Anthem provider identification number

Slide27

Compensation of Advanced Practitioners

Median Compensation Comparison

Note: Primary Care NP and PA MGMA Specialty as compared to Physician Internal Medicine: General MGMA Specialty

Source: MGMA Provider Compensation, 2014

Recruitment of APs has been steadily increasing over the past several years to offset physician shortages and open up access. Organizations must continue to offer competitive salaries to retain and attract talent

27

Slide28
Advanced Practitioner Care Models

Ways to Reward Care Team Productivity

Per-RVU

Fee

Supervision Stipend

Cost Defrayment

Profit

Sharing

wRVU

Credit

Description

PCP paid

fee for each RVU generated by AP

PCP

paid set annual amount to supervise AP

AP covers PCP practice costs in proportion to revenuePortion of revenue generated by AP paid out to PCPMD and/or AP receives additional $ /wRVU if achieve wRVU targetAdvantagesLucrative for PCPRewards PCP for AP productivityExplicitly rewards supervisionLower cost to groupMotivates AP to raise productivityLower cost to groupCan share profit among AP, PCP, groupRewards PCP for AP productivityRewards practice (not just individual) success

Tiered productivity goals for providers

Incentivizes

all providers to raise productivity

Drawbacks

May be expensive for medical group

Perceived

by APs as unfair

Reward not linked to AP productivity

performance

Often lower compensation potential for PCP

Requires accurate assessment of AP-generated revenue

Limited incentive if PCP not fully

exposed to costs

Requires

accurate assessment of AP-generated revenue

Requires

monthly reconciliation of performance

Common Models for Incentivizing PCPs on AP Utilization

Some organizations choose to align under group productivity models that employ aspects of the incentives mentioned above

28

Slide29
Case Study

Slide30

Advanced Practitioner Care Models

Common Health System Challenges

Insufficient Clinical,

Financial Contribution

APs restricted to ancillary clinical roles

AP productivity not justifying investment in compensation, added practice expense

Weak Management

Infrastructure

Groups lack structure, expertise, clear vision for managing AP workforce

AP oversight may be fragmented across group

Dissatisfaction, Lack

of Engagement

APs fell underutilized, disenfranchised within medical group

AP turnover close to double that of physician staff (11.5% to 6.8%)

Groups Facing Multiple Challenges to AP Utilization

Common Problems with Medical Group AP Workforce

30

Slide31

Phase 1 –Care Team Model

Define and expand the AP role

Recalibrate physician role

II- Promote Alignment

Formalize internal AP training

Educate MDs regarding appropriate AP utilization

Introduce performance incentives into care team compensation

III- Realign Governance

Restructure AP hiring and management to mirror provider infrastructure

Define AP leadership roles and structures

Incorporate APs into group governance

Care Team Model

Deployment

Governance

EducationCompensationManagementAdvanced Practitioner Care ModelsRecalibrate Expectations Across the Care TeamNotes: Adapted from Advisory Board and FTI experience31

Slide32
Advanced Practitioner Care Models

Realizing Full Value of the Care Team

Strengthen

AP-Physician

Collaboration

Systemize evaluation of AP deployment

Support physicians in becoming effective AP partners

Ensure AP clinical preparedness

Incorporate performance incentives into AP compensation

Structure physician incentives to align with AP productivity

Align AP

Management to

Provider Status

Standardize clinician-driven performance evaluation

Develop dedicated AP oversightIncorporate APs into group governance

Expand ClinicianRoles Across theCare TeamEnable autonomous AP visits to maximize physician efficiencyGive AP hospitalists full responsibility for appropriate patientsStrategically Deploying Advanced Practitioners to Expand Access and Coordinate Care

1

2

3

32

Slide33
Advanced Practitioner Care Models

Multiple Stakeholders Affected by AP Compensation Model

Rewards AP PerformanceIntroduces performance accountability

Recognizes APs for higher-quality work

Promotes Group Goals

Rewards AP performance on strategic goals set by medical group leadership, such as quality, panel size

Supports Physician Success

Motivates AP to support physician in achieving productivity, quality goals

Aligns incentives for AP, physician

AP Compensation Should Reflect Medical Group, Physician Goals

Attributes of Ideal AP Compensation Model

33

Slide34

Ambulatory Skill Mix Management Organizational Culture Change: Key Initiatives

III - Promote Alignment

Create education plan to communicate standards to APs and MDs

Develop AP and MD training program

Design updated credentialing mechanisms

I – Planning

Establish AP Working Committee

Review current AP policies, roles & responsibilities

Prioritize opportunities

Determine Key Performance Indicators and targets to track progress

II - Care Team Model

Determine productivity and model of care expectations for each specialty area

Draft roles and responsibilities for redesigned care model

IV - Realign Governance

Design and implement hiring mechanism to target desired APsAlign AP with MD compensation model

Overlapping roles (MD/AP)

APs operating below licensure

AP role varies based on specialty

APs and MDs competing for clinical functions and productivity

Strategic division of care

APs operating at top of licensure

Standardized AP role

High productivity of entire team/ department

34

Slide35

Organizational Culture ChangeAP Governance Council

Co-Chairs

Surgery

Medicine

Primary Care

Community Group Practices

Sub-Specialty

ED, Psych, Radiology

Intensivist

CRNA

Pediatrics

Maternal-Child

At Large

At Large

35

Slide36

Advanced Practitioner Care ModelProductivity Impacted by Clinic Workflow

On-site observations and interviews help organizations assess clinical workflow and provides recommendations for developing best practice processes to assure that the right provider is treating the right patient at the right time

Insurance Authorization

Triage

36

Slide37
Organizational Culture

Aligned Care Team Model

Advanced Practitioners can be an integral part of the care team model, effectively increasing access and extending continuity of high quality, low cost care

Identifying clear roles and responsibilities for each member will lead to increased efficiencies and a fully leveraged care team model

Shared incentives amongst care team model , such as care team model productivity targets and bonus payments for quality metrics, can help shift culture and perceptions

Provider

(MD/DO/

PhD/NP/PA)

Provider

(MD/DO/

PhD/NP/PA)

MA/

Nurse Aide

Nurse (LPN/RN)

Scheduler/Registrar

Care Navigator

Patient Panel

Care Team

37

Slide38

Resource Alignment initiatives in large organizations are typically performed in phases over a 2-3 year period with the first phases focused on medical specialties with the most projected opportunity based upon current cost or opportunity to create coordinated systems of care

Advanced Practitioner Care Model

Typical Provider Resource Alignment and Optimization

Cost Calculation

Productivity Assessment

Peer Benchmark Analysis

Gap Analysis and Opportunity Identification

Financial & Resource Optimization

9-12 Month Process per Phase

The resulting model provides a framework to ensure both current and future clinical resources transactions are performed at fair market value and in line with peer benchmarks for similar organizations and that client is cost competitive in the evolving world of quality and value care

Hospital – Physician Group Collaboration

38

Role definition

Slide39

Survey Results and Group Discussion

Review of Survey Findings

Group Discussion

Word Cloud

39

Slide40
Questions?

Slide41
Appendix

Slide42

Advanced Practitioners

Definitions

Advanced Practice Registered Nurse (APRN)

is a nurse who has a master’s, post-masters, or doctoral degree in a nursing specialty and can generally practice medicine without the supervision of a physician The four types of APRNs are nurse practitioners, clinical nurse specialists, nurse-midwives, and nurse anesthetists.

Physician Assistant (PA)

is able to practice medicine under the auspices of a licensed physician. Although the physician need not be present during the time the PA performs his or her duties, there must be a method of contact between the supervising physician and the PA at all times. The PA must be competent in the duties he or she is performing and the physician for whom the PA is working must also be licensed and trained to perform the relevant duties.

Other Advanced Practitioners include:

Pharmacists (

PharmD

)

Licensed Social Workers

Clinical Nutritionists

Rehabilitation Therapists (Physical Therapy, Occupational Therapy, Speech Therapy)

42

Slide43

Slide44


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