Engaging advanced practice providers and redefining care models in a way that supports their ability to expand access and generate additional revenue drives operational performance and supports future sustainability.
The healthcare industry is in the midst of unprecedented change as hospitals and health systems nationwide balance managing the immediate implications of the COVID-19 pandemic with planning for what lies ahead. To meet evolving patient needs, address emerging operational challenges, and maintain financial sustainability, organizations must clarify the “who” and “how” of care delivery in the future.
The focus on team-based care will require organizations to optimize the performance of all members of the care team. With the ability to direct patient care and generate revenue, advanced practice providers (APPs) – including nurse practitioners (NPs) and physician assistants (PAs) – are critical members of this team and can play an important role in the transformation of care delivery and the achievement of key quality, access, service, and financial goals.1,2 During this time of unparalleled disruption, there is an opportunity for healthcare organizations to renew their focus on using APPs to assist with ongoing COVID-19 related operations and planning for the future.
In response to COVID-19, 78.6 percent of organizations redeployed or planned to redeploy APPs into other specialties because of clinical staffing shortages in critical departments.3 Given APPs’ extensive training, specialty skill sets, and ability to adapt to different settings, these strategies often include redeploying APPs to provide support for COVID-19 surge-related activities in the intensive care unit, testing sites, and employee health clinics, highlighting the versatile role this workforce plays in meeting patient needs and organizational goals.
As the industry plans for what lies ahead, physician leaders will be called upon to extract the lessons learned regarding care team optimization to help improve patient access, experience, and safety. Additionally, they will be expected to continue to maintain a flexible workforce to prepare for potential surges, mitigate certain financial risks, and increase revenue.
As physician leaders take stock of the lessons learned during COVID-19, it will be imperative that they launch intentional discussions and processes aimed at permanently enhancing their care delivery teams. APPs can be an important resource for physician leaders looking for both immediate and long-standing improvements.
OPTIMIZING A GROWING APP WORKFORCE
As one of the top healthcare systems and academic medical centers in the country (see Figure 1), Stanford Health Care recognized the need to optimize its care delivery teams through more effective utilization of APPs.
As in many large healthcare organizations, the number of employed APPs at Stanford had seen double-digit annual increases during the past decade, presenting a unique set of challenges and opportunities. With a workforce of more than 500 APPs in the competitive northern California labor market, this represented a significant payroll expense. However, with the lack of role clarity and no intentional strategy for deployment of the APPs, Stanford was not experiencing the expected gains in patient volume, access, or revenue related to incremental organizational spend on APPs.
IDENTIFYING KEY OPPORTUNITIES FOR IMPROVEMENT
A 2017 organizational wellness survey conducted by Stanford showed growing APP dissatisfaction and turnover due to their perceived underutilization and lack of role clarity. Executive leadership partnered with SullivanCotter, a national healthcare workforce consulting firm with experience in optimizing APPs, to assess the utilization of the current APP workforce and develop an intentional, data-driven approach to improve their optimization, engagement, and integration into the care team. This project became known to all as the APP SHINE Project (Strategies to Heighten INtegration and Engagement of APPs).
First, Stanford’s key policies, practices, and structures were reviewed and compared to federal and state regulations, national workforce trends, and other leading practices. In addition, all of Stanford’s physicians and APPs were surveyed in an effort to understand their perception of current APP utilization as well as the culture and infrastructure necessary to support this growing workforce. The data were compared with SullivanCotter’s proprietary market data and other national APP benchmarks.
Key findings from Stanford’s wellness survey and SullivanCotter’s assessment of the perception of APPs revealed:
- 51 percent of the APP workforce had considered leaving the organization in the previous 12 months. Of those who had considered leaving, 84 percent perceived they were underutilized.4
- 35 percent of APPs identified as professionally fulfilled with only 12 percent showing high professional fulfillment.5
- 36 percent of APPs were experiencing burnout.5
- APP turnover within the organization was 17.5 percent, which was 7.5 percent higher than the national average for APPs.
- 21 percent of APPs perceived themselves to be utilized to their maximum potential.4
- APPs reported being involved in multiple other activities, many of which could be completed by other team members. Some reported being utilized primarily as scribes or MAs.
- Redundant work between physicians and APPs was commonly reported. For example, in the ambulatory setting, 59 percent of APPs reported that physicians must see all or most of their patients during the visit (see Figure 2).4
Focus groups consisting of physicians, APPs, patients, and other operational and nursing leaders were then assembled to validate survey findings and assess readiness for potential care model redesign. During studies by these focus groups, patients reported feeling comfortable seeing an APP when introduced by the physician and presented as part of the care team. It also became clear that physicians believed APPs could have a greater impact on patient and organizational outcomes. Physicians were generally supportive of the APP SHINE Project and its focus on role clarity, utilization, and engagement (see Figure 3)6.
REDESIGNING CARE MODELS TO SUPPORT APP OPTIMIZATION
A steering committee that included Stanford’s chief operating officer, chief medical officer, chief nursing officer, chief human resources officer, and key leadership advisors from the Center for Advanced Practice was formed to identify the clinical departments with the greatest opportunity for enhancement. In SullivanCotter’s experience, the most success is achieved in departments with a quantifiable opportunity to increase revenue and/or access and cultural readiness for change.
The departments selected for the first two phases of the redesign work included Primary Care, Urologic Surgical Oncology, Neurosurgery, Oncology Infusion Center, Interventional Radiology, Endocrine Surgery, Gastroenterology Oncology, and Orthopedic Surgery – Spine. The steering committee chose the departments based on careful analysis of the current state assessment, focus groups, degree of opportunity, and interest from physician leaders. Stanford identified strong support from physician leadership as a critical key to success.
Utilizing SullivanCotter’s proprietary care model redesign process, consultants facilitated workgroups from each division in partnership with an identified physician and APP leader. These workgroups included the physician, APP and operational/ nursing leader, one to two additional practicing physicians and APPs, and an RN and an MA.
During these sessions, participants discussed the current state of the care model while also developing their ideal vision for redefining it. This included an evaluation of the following:
- The roles and responsibilities of APPs and other members of the care team (e.g., RN, MA, care manager) in clinical specialties or practice settings.
- Types of patients APPs can see in parallel or in collaboration with a physician.
- Clinical and non-clinical work effort expectations for APPs.
- APP staffing plans and practices.
- Changes to infrastructure necessary to support enhanced care models (e.g., scheduling templates, documentation processes, leadership roles).
- Action plans and metrics/scorecards to monitor immediate and long-term impact.
As the final step in the redesign phase, physician and APP leaders together presented the workgroups’ care model redesign recommendations to the steering committee and outlined the support each department needed to help ensure success. Examples of some key recommended changes included:
- Oncology Infusion Center: Developed protocols for MAs and RNs to triage all phone and in-basket messages before sending them to the APPs. This allowed APPs to open up their schedules to see acute, same-day patients rather than having them go to the Emergency Room, where they could wait for hours or be admitted for something that could be managed by an outpatient provider.
- Urologic Surgical Oncology: Shifted from purely independent visits, in which APPs saw all types of patients from all of the surgeons, to a sub-team model in which the physicians and APPs were paired together, enabling the APPs to build expertise on a sub-population and understand the management style of one or two surgeons. Creating this sub-team model allowed teams to address patient care issues more efficiently. Parallel clinics were also incorporated to allow for a more collaborative approach in which APPs were seeing their own patients with physicians available for consultation as necessary.
- Orthopedic Surgery – Spine: Initiated APP clinics to improve patient access.
- Neurosurgery: Created a standardized list of competencies to train APPs to be able to see an appropriate subset of patients independently. This ultimately freed up physician time to see new and more complex patients.
- Interventional Radiology: Defined and expanded the types of procedures APPs could perform as well as the type of patients that were appropriate for the APP to see independently in the clinic.
In addition to department-specific modifications, a variety of organizational processes were identified in all specialties as needing improvement to support the enhanced models of care. These included:
- Structured escalation and communication processes for RNs and MAs to use rather than having all questions referred immediately to the APP — most of which did not require medical intervention.
- Templates, training, and ongoing feedback to streamline and simplify documentation, which was frequently identified as adding to clinician burnout.
- Transition of patient education responsibilities from the APPs to the RNs.
- Specialist outreach to referring physicians to introduce them to the APPs to build ongoing relationships and support for referrals.
- Scripts for schedulers to use to introduce the role of the APP to patients calling in to schedule appointments, offering them the option of seeing the APP sooner.
- Structured opportunities for team members to meet to discuss operational improvement efforts and feedback.
MAXIMIZING APP UTILIZATION AND ENGAGEMENT
Guided by physician leadership, the organization developed a comprehensive process and strategy for optimizing its APP workforce. Over time and through a series of surveys, interdepartmental collaboration, and facilitated workgroups to understand necessary care model changes, Stanford was able to:
- Redesign or enhance care models across multiple departments to help maximize APP utilization and engagement.
- Achieve an incremental increase in APP visits by 17 percent with no additional APP positions.
- Reduce overall APP turnover by 22 percent from 2017 to 2019.
- Increase visit slots by 47 percent in the infusion treatment area by creating same-day oncology patient visits.
Additionally, the organization has been able to demonstrate greater APP satisfaction and engagement as a result of SHINE. A post-project survey of APPs involved in the work shows that:
- 78 percent believe their physicians and staff better understand the role of the APP.
- 89 percent believe the APPs and physicians will practice more as a collaborative team.
- 78 percent believe they will be able to conduct more in- dependent visits and be utilized more effectively within the organization.
Recognizing the value of APPs and the critical role they play in transforming care delivery has helped the organization implement specific practices, policies, and procedures designed to enhance their role within the care team. Putting physician, APP, and executive colleagues together in a room to discuss pain points and develop solutions collaboratively has accelerated successful APP integration and optimization and engaged them as impactful and highly valued members of the care delivery team.
KEY FACTORS FOR SUCCESS AND THE CRITICAL ROLE OF THE PHYSICIAN LEADER
Although this work was done prior to the onset of COVID-19, having this framework already in place helped Stanford to develop its response to the pandemic and meet patient needs in a time of crisis. Stanford’s model is transferable to any organization looking to develop a more comprehensive APP workforce strategy and starting to plan for what lies ahead in an increasingly uncertain environment.
A number of key lessons were learned during this strategic process. When setting out to do this type of work, organizations must ensure they:
- Quantify the opportunity and assess readiness for change.
- Secure executive sponsorship and commitment.
- Identify physician champions in each specialty.
- Define goals and timelines.
- Dedicate project resources including a project manager and administrative support.
- Commit to ongoing monitoring of process and progress with revision as needed.
- Promote transparency and frequency of communication to all key stakeholders.
Additionally, physician leadership and accountability were critical. From the outset and throughout, physician leaders representing each of the care model redesign workgroups helped to support the success of this project by:
- Acknowledging the value of APPs to their departments and the need to clarify their role and optimize their expertise.
- Listening to all workgroup members to better understand current state and opportunities for improvement.
- Actively participating in meetings and encouraging the same of their physician colleagues.
- Supporting the creation of new and better care models in which APPs were utilized more effectively.
- Agreeing to own and oversee the implementation action plans.
- Presenting workgroup recommendations to executive steering committee initially and ongoing.
- Socializing suggested care model enhancements with other physicians and faculty.
As hospitals and health systems start on the road to financial recovery from COVID-19, Stanford’s experience can help to serve as a roadmap for successful integration, utilization, and optimization of the APP workforce. Engaging APPs and redefining care models in a way that supports their ability to help expand access and generate additional revenue plays an important role in driving operational performance and sup- porting sustainability.
Megan R. Mahoney, MD, is chief of staff for Stanford Health Care and clinical professor, medicine – primary care and population health, Palo Alto, California.
Dale Beatty, DNP, RN, NEA-BC, is vice president and chief nursing officer, Patient Care Services, Stanford Health Care, Stanford, California.
Clair Kuriakose, MBA, PA-C, is executive director of advanced practice, Center for Advanced Practice, Stanford Health Care, Stanford, California.
Trish Anen, MBA, RN, NEA-BC, is principal at SullivanCotter, Chicago, Illinois.
Zachary Hartsell, DHA, PA-C, is principal at SullivanCotter, Chicago, Illinois.
- Hartsell Z, Ficco D, English L. Optimal Use of APPs Can Enhance a Health System’s Post-COVID-19 Financial Recovery. hfm Magazine. July 30, 2020. www.hfma.org/topics/hfm/2020/august/optimal-use-of-apps-can-enhance-a-health-system-s-post-covid-19-.html.
- Comunale MJ, Lerch W, Reynolds B. Integrating Advanced Practice Providers into Value-based Care Strategies: One Organization’s Journey to Achieve Success Through Interprofessional Collaboration. J Interprofess Ed Pract. 2021; 22:1-4. https://doi.org/10.1016/j.xjep.2020.100384
- SullivanCotter. Market Response to COVID-19: Physician and Advanced Practice Provider Compensation Practices Survey Report II. May 27, 2020. https://sullivancotter.com/wp-content/uploads/2020/05/2020-COVID-19-Physician-and-APP-Compensation-Practices-Survey-Report-II_May.pdf.
- 2018 Advanced Practice Provider Workforce Individual APP Survey.
- Stanford Healthcare. 2017 Advanced Practice Provider Wellness Survey.
- SullivanCotter. 2018-2020 Physician Perception of APPs Survey.
This article was published in the March/April 2021 Physician Leadership Journal.