Definitions. Using Physician Extenders on Inpatient Resident Teams to help meet. Kathleen Finn, MD. ACGME Requirements. Physician Extenders

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1 Using Physician Extenders on Inpatient Resident Teams to help meet ACGME Requirements Kathleen Finn, MD John Moriarty, MD Definitions ACGME Requirements Physician Extenders Clerical Assistants Nurse Practitioners Physician Assistants Nurses Hospitalists

2 Outline Background Our experience Small group problem solving Large group sharing of ideas and practices Questions Do you have physician extenders at your hospital? Do they directly work with residents? Why did you choose to attend this workshop?

3 Nurse Practitioners 1965 University of Colorado RN plus Masters degree (2 year) Medical/Nursing Model: Bio-psychosocial Specialty track: (acute or adult) Certification Exam Board of Nursing/Board of Medicine Regulations vary by State Nurse Practitioners ,348 NPs Evaluate, diagnose, treat and manage care, promote health, educate, collaborate MD Supervision varies Bill 85% of MD fee Salary $66,000 - $90,000 American Academy of Nurse Practitioners,

4 Physician Assistants 1965 Duke University Medical Model BA-PA or MA-PA degree Obtain histories, perform exams, diagnose, prescribe, order and interpret tests, treat, perform procedures, assist surgeries MD supervision required Certification exam Physician Assistants 142 accredited programs 68,124 PA in 2008 Salary $63,000-$98,000 Bill at 85% physician rate Can bill for 100% of E and M services as long as physician has some face to face time with patient American Academy of Physician Assistants:

5 Embedding Clerical Support Services- The Yale MTA experience Analysis of Intern Work What are they doing? Self-recording Retrospective Questionnaires Work Sampling Time Motion Study Role of the MTA Work with 2 medical teams Geographically localized Perform clerical tasks Calling physician offices and pharmacies Appointment scheduling for follow up Obtaining outside records Scheduling inpatient studies and tests

6 Role of the MTA Clerical Position Salary $43,000 Hours 7:30 AM to 4:00 PM Some prior medical administrative experience MTA Time Motion Results Intern Activities Without MTA 7% 7% Intern Activities with MTA 9% 8% 16% 51% Indirect Patient Care Educational Activities Work Rounds 15% 43% Direct Patient Care Other 19% 25%

7 MTA Time Motion Results Intern Activities with and wihtout MTA Time(minute No MTA MTA Indirect Patient Care Educational Activities Work Rounds Direct Patient Care Other Activity Type MTA Time Motion Results Indirect Patient Care Activities Time (minute Phone Computer Notes Prescriptions Activity Type Discussing Patients Time with MSA No MTA MTA

8 MTA Survey Results is absolutely amazing. She is able to help in whatever way is needed to support the residents and interns this has allowed me to spend more time with my pts and teaching the students and interns. I also think that the pts are receiving improved care because Justine gets outside records in a timely fashion and schedules appropriate f/u appts w/ OP PMDs quickly which are things that often get lost in a busy day. I strongly feel that both the housestaff and pts are well served by having medical team assistant and I hope that it can continue and be expanded to other services as well. It is just wonderful! MTA Survey Results MTA has allowed me to spend more time with patients Interns Number of SA A N D SD Responses

9 Lessons Learned Effective Medical Team Assistant Program Integrate into the teams Proactive Accessible and visible Interact with EMR Frequent recalibration and adjustment of activities Embedding a Nurse Practitioner MGH Experience Discharge and Patient Safety Shorten LOS and quicker and sicker Residents are busy ACGME cap on admissions only

10 Embedding a Nurse Practitioner MGH Experience Grant: Study Improvement of Discharge Process Embedded NP on one resident team Resident Team = 1 resident, 4 interns,1 Attending 5 month trial Intervention Team (n=440) vs. Control Team (n=432) Characteristics similar: 50% Medicare 25% discharge to facilities Co-morbidity 2.3 Funded by Partners Physician Education/Care Delivery Reengineering Innovation Grant NP Role Work and Interdisciplinary Rounds Follow-up appointments and planning Discharge Orders and Summaries Prescriptions Communicated with PCPs and Nurses Met patients and provided phone number Called high-risk patients at home Followed-up pending lab tests

11 Outcomes Primary Outcomes Time to completion of discharge summaries Percentage completed Length of stay 30 day ED visits/readmissions Secondary Outcomes Number of follow-up appointments Time to patient follow-up Time saved for residents Results and Lessons Learned Discharge summaries completed More and earlier follow-up appointments No difference in LOS or 30 day ED and Readmission Rates Attending Rounds finished on-time Residents sign-out rounds earlier Residents felt it incredibly helpful Not cost neutral $$$$

12 Scenarios Break into groups of 7-8 Pick a reporter 20 minutes to solve the issue Large Group Discussion What s happening at your hospital?

13 ???? Conclusions Should we be using resident extenders? How best to include them in residency programs? How to further study this? Collaborative projects? How to share information among programs? Thank you Our Program Directors Dr. Andrew Yacht All of you for your participation

14 References 1. Physician assistants and nurse practitioners. American College of Physicians. Ann Intern Med. 1994;121(9): O'Connor AB, Lang VJ, Lurie SJ, et al. The effect of nonteaching services on the distribution of inpatient cases for internal medicine residents. Acad Med. 2009;84(2): Kleinpell RM, Ely EW, Grabenkort R. Nurse practitioners and physician assistants in the intensive care unit: an evidence- based review. Crit Care Med. 2008;36(10): Finn K, Carty M, Laing M, Harris L, Rachelefsky L, Katz J. A Program for Reducing Noneducational Resident Activities at an Academic Medical Center. Journal of Clinical Outcomes. 2008;15(1):1-6. References 5. Kirton OC, Folcik MA, Ivy ME, et al. Midlevel practitioner workforce analysis at a university-affiliated teaching hospital. Arch Surg. 2007;142(4): Pioro MH, Landefeld CS, Brennan PF, et al. Outcomes-based trial of an inpatient nurse practitioner service for general medical patients. J Eval Clin Pract. 2001;7(1): Abrass CK, Ballweg R, Gilshannon M, Coombs JB. A process for reducing workload and enhancing residents' education at an academic medical center. Acad Med. 2001;76(8): Knickman JR, Lipkin M, Jr., Finkler SA, Thompson WG, Kiel J. The potential for using non-physicians to compensate for the reduced availability of residents. Acad Med. 1992;67(7):