ACADEMIC GROUP PRACTICE AND THE LEADERSHIP OF APRN S Margaret Head, Chief Operating Officer/Chief Nursing Officer Susan Moseley Gent, Administrative Director Vanderbilt Medical Group March 10, 2012 With Special Acknowledgement to Clare Thomson-Smith, JD, MSN, RN, FAANP
National Trends Introduction to VUMC Advanced Practice Registered Nurse (APRN) Challenges Leadership & Governance Clinical & Business Model Development Ambulatory Model Case Studies Do I Need a Nurse Practitioner? Conclusion & Lessons Learned
Findings are based on a series of events likely to contribute to the shortage including: Increase in physician visits rates in those patients over 45 Decreased working hours due to gender and generational changes in the workforce. Moderate growth in graduate medical education Moderate increase in productivity (due to PAs and NPs) Impact of Health Care Reform on the Future Supply and Demand for Physicians Updated Projections through 2025 (Association of American Medical Colleges, 2010) Health care reform has prompted the Association of American Medical Colleges Center for Workforce Studies to update their 2008 report The Complexities of Physician Supply and Demand: Projections through 2025
Projected Supply and Demand, Full-time Equivalent Physicians Active in Patient Care, 2008-2025 Year Supply All Specialties Demand All Specialties Shortage All Specialties Shortage Primary Care2 Shortage Non-Primary Care3 2008 699,100 706,500 7,400 7,400 0 2010 709,700 723,400 13,700 9,000 4,700 2015 735,600 798,500 62,900 29,800 33,100 2020 759,800 851,300 91,500 45,400 46,100 2025 785,400 916,000 130,600 65,800 64,800 From: Impact of Health Care Reform on the Future Supply and Demand for Physicians Updated Projections Through 2025 (Association of American Medical Colleges, June 2010)
The 2008 National Sample Survey of RNs reports: Almost 2.6 million RNs employed in nursing RN median age is 46 years old About 8% of RNs (250,527) are prepared as Advanced Practice Nurses 50% of APRN s are > 50 years of age From 2004 to 2008 there was about 13% increase in Nurse Practitioners, 7.1% increase in Nurse Anesthetists More than 64% of NPs providing ambulatory or primary care Findings from 2008 National Sample Survey of RN s (US Department of Health & Human Resources & Services Administration)
Figure 3-3. Age distribution of the registered nurse population, 1980-2008
Over 148,000 APRN s are practicing in the US In 2010-2011, there were 9500 new NP graduates Distribution, Mean Years of Practice, Mean Age by Population Focus Percent of Years of Population NPs Practice Age Acute Care 5.6 7.0 45 Adult+ 19.3 10.9 50 Family + 48.3 9.5 48 Gerontological + 3.2 11.6 52 Neonatal 2.0 12.3 47 Oncology 1.0 8.3 47 Pediatric + 8.5 13.3 49 Psych/Mental Health 3.0 8.5 52 Women's Health + 9.0 14.7 49 Primary Care focus +
2700 applicants were turned away from APRN programs due to: Faculty shortages 60% of nursing faculty are > age 50 Inadequate supply of preceptors and clinical placements Limited funding for students
2010 Affordable Care Act providing $31M over 5 years to 26 nursing schools to increase full time enrollment of APRNS $15M to 10 APRN-led clinics to provide primary care in medically underserved communities Created incentives for graduate to become faculty
Primary Care physician shortage Nursing shortage Scope of practice for APRN s vary by state Health plan reimbursement Professional tension among RN s, APRN s, PA s and physicians Consumer expectations
Includes Vanderbilt Clinics, Monroe Carrell Jr. Children s Hospital at Vanderbilt, and Vanderbilt Psychiatric Hospital *Licensed Bed Capacity 916 Residents, Fellows, Interns 900 Full Time Equivalent Employees 10,150 Admissions 53,000 Average Length of Stay (in days) 5.3 Emergency Room Visits 109,500 Ambulatory Visits 1.58 million * Does not include 20 bassinets in normal newborn nursery
In the last six years, Vanderbilt University Medical Center (VUMC) has seen rapid growth in the utilization of the advanced practice nurse provider Currently VUMC has: - 400 + Nurse Practitioners (NP) - 120 + Certified Nurse Anesthetists (CRNA) - 24 Certified Nurse Midwives (CNM)
Origins in Vanderbilt University School of Nursing (VUSN) Faculty Practice - Community based primary care practice sites - VUSN contracts for employee health services - VUSN contracts with VUMC Challenges on the Horizon for VUMC - Decreased resident work hours - Strategic growth - Increased demands for coverage - VUMC needs for outreached capacity of VUSN to serve adequately
Decision Point - 2005 moved all VUMC APRN oversight to a centralized office of advanced practice within the medical center - Formation of the Center for Advanced Practice Nursing and Allied Health (CAPNAH) - Formal APRN leader appointed as director to provide professional practice oversight and serve as a resource to VUMC departments and leaders - Reports to the Executive Chief Nursing Officer for VUMC
Primarily Academic Medical Centers Oversight for utilization, quality, viability Provides infrastructure support Supports practice standardization Accountable for quality and financial reporting Multiple structural formats
Purpose to provide support for existing and emerging practices for advanced practice nurses and allied health professionals. The Center serves as a point of contact to provide expertise and support for: Practice Analysis Credentialing and Privileging Competency Evaluation Models of Care Legal and Regulatory Issues Billing and Reimbursement Hiring Decisions Orientation Support Scope of Practice Compliance Funding Faculty Appointments
Hiring Tool Box Credentialing Process Orientation & Onboarding Certification & Clinical Competencies Business Case Analysis Templates & Samples Protocol Management Mentoring Program OPPE / FPPE Competency Evaluation Physician Resources
Executive Chief Nursing Officer Administrative Director Director Administrative Officer Quality Value Analyst Director, Professional Development (new) Program Coordinator Program Coordinator
Nursing Executive Board Medical Center Medical Board APN Administrative Board VUMC Credentials Committee APN Leadership Board Joint Practice Committee APN Council Advanced Practice & Standards Committee Recruitment & Retention Quality/Safety & Research QSR Professional Development
Dedicated Business Officer (AO) Dedicated Quality Value Analyst Director, Professional Development Compliance Office Department of Finance Accreditation & Standards Provider Support Services (Medical Staff Office) CAPNAH Website
VMG CNO/COO Chief Medical Officer CAPNAH Physician Groups Practice Administrators Business Officers Provider Support Services 22
Board of Medical Examiners Board of Nursing Center for Medicare & Medicaid Services (CMS) The Joint Commission (TJC)
APRNs are credentialed and privileged as providers under the supervision, and in collaboration with, an attending member of the VMG Medical staff. They function across nearly all the departments, divisions and centers of the VUMC clinical enterprise In the same way as physicians, they are privileged for core and noncore privileges based on evidence of competency and medical executive approval Additionally, many APRNs are credentialed with insurance carriers to bill for their professional services.
APRN Core Privileges Perform admission / new patient H&P Daily rounding and progress or clinic notes Order and interpret diagnostic tests Prescribe pharmacological and non-pharmacological interventions Establish problem lists and diagnoses Establish and revise plan of care Ensure adherence to plan of care and throughput Serve as first responder Facilitate early discharge, discharge summaries
Based on additional education, training, and evidence of competency, a large number of APRNs are privileged to perform procedures. Procedures vary by specialty and may include such procedures as suturing, line placements, tube placement, and invasive diagnostics (ex. lumbar puncture, image guided liver and thyroid biopsies) www.capnah.com Advanced Procedure Master
APRNs are educated and trained to provide and manage patient care throughout the continuum NPs and PAs are required to have a designated supervising physician in the state of Tennessee, and utilize evidenced based practice protocols With reduction in resident staff, expansion of services, requirement for 24/7 coverage, increasing acuity, NPs and PAs are ideally situated to provide continuity of care, continuous physical presence, and adherence to practice guidelines to facilitate throughput
Traditional resident staffing models are no longer viable Must develop collaborative APRN:MD teams Three collaborative practice models: Intensivist (Critical Care) Hospitalist (Acute Care) 1) Service aligned, or 2) Unit/MD Aligned Ambulatory Care
PRIMARY CARE Community based Billing providers PCP model Walk in and primary care Business plan Patient panel-visit model INTENSIVIST Unit based 24/7 coverage Panel size 1:8 plus churn Proceduralists Billing Designated Medical Director Designated APN leader SPECIALTY CARE CLINICS Complex Multiple comorbidities Medicine Surgery Billing providers Business plan
Geographically restricted by unit Intensivist role Reports to medical director 24/7 coverage Billing critical care time Proceduralist Requires specialized education and training
Hospital-based employee Inpatient acute care step down; admission to discharge Non-billing if global/ salaried / cost report Dual reporting structure nurse administrator and supervising physician Separated by specialty and subspecialty practice Day to day inpatient management based on service panel size Trending increase in procedures performed. NOT a physician extender or resident substitute Primarily throughput; supports continuity
Community-based practice Predominantly primary care, some walk-in urgent care Billing providers (3 rd party payers and location of consequence to business model) Daily clinic visit panel size based on scheduled visits and walk-ins, 5 days per week Physical presence of physician not required Family, Women s, Adult, Geriatric, Psychiatric and Pediatric NP primary care specialties Referral base for hospitals
Aging patient population Management of chronic and multiple co-morbid disease states Subspecialty expertise Medical Home Model Incentivized to keep patients out of hospitals Prevention and wellness emphasis Affiliated with hospitals within ACOs Growth in APRN as collaborative provider
Improve access to care Add efficiency and improve physician productivity Provide continuity of care for a certain population Provide specialty expertise, resources, and increased visibility within the organization Add capacity and resources for provider group Bill for professional services
MD time for nonclinical duties Reduce LOS Improve continuity Physician productivity Patient throughput Other Primary Improve access ACGME limits 0% 20% 40% 60% 80% 100%
Primary utilization of the APRN in ambulatory care setting is as billing provider based on business case analysis. Expectation that revenue will meet expenses over time OR gap supported by increased physician productivity Driven by specialty specific volumes and strategic growth Breakeven business case based on 9 half day clinic sessions/week Built-in orientation time Administrative Director oversight in collaboration with nursing leadership Funding: 1) Department funded or 2) Start up gap funded 38
Pro Forma Memorandum of Understanding (MOU) Funding Models
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VMG cost centers dedicated to support time-limited gap funding of new and evolving ambulatory practices Gap funding designed to support difference between revenue and expenses, or funding may consist of one time start up funds Funding dependent on approved business case analysis, dedicated practice oversight and financial reporting Funding agreement memorialized in Memorandum of Understanding (MOU) Some internal taxes waived VMG financial oversight relative to correct revenue mapping and reporting Standardized financial reports and analysis based on term MOU Provider educated on business expectations
NP REQUEST A DIAGNOSTIC BREAST CENTER Serve as liaison with patients and referring physicians Contacts patients with biopsy results; orders additional diagnostic testing as indicated Coordinates care as needed; makes referrals Performs 4-6 needle aspirations per week (bills for this procedure) Pro forma reflects a salary gap @ 12 months but also shows an increase in MD procedure volumes
NP REQUEST B COSMETIC/PLASTIC SURGERY Removes sutures/staples Injects tissue expanders with saline Manages requests for prescription refills/renewals Triages phone and electronic messages from patients; can address many of the messages via established protocols Assists surgeons with minor office procedures Pro forma indicates NP would be a non-billing provider but assumes an increase in MD patient volumes
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Establishing credibility, subject matter expertise, and trustworthiness Thinking strategically in the midst of operations Formal versus informal authority to make change Understanding the corporate culture and identifying key stakeholders
Bylaws, policies, rules and regulations historically physician centric with inconsistencies created by ad hoc amendments Linking medicine and nursing to support consistency in APRN provider role Hiring, Privileging, Competencies Orientation Compensation Faculty Appointment
APRN reporting structure Articulating professional practice behaviors Accountability for evidenced based practice Dispute resolution Defining and capturing APRN outcome measures Professional development Support for new and evolving practices APN boards & councils
Establish relationships - medicine, nursing, and executive Establish boundaries and identify institutional resources Establish APRN leadership role definition Create entity specific APRN leader positions Develop APRN shared governance Give presence and voice within the institution through shared governance and central support Define required resources for centralized oversight Write, write and write it all down
Partnership: The relationship between the physician and the APRN is a key factor in ensuring collaborative, evidenced-based practice Integrated Practice Model: The relationships among the bedside/clinic nurse, physician, and APRN provider/first responder is vital to ensuring quality driven care and throughput Collaborative Nursing Practice: grows the body of knowledge to ensure the best possible care outcomes