APP- Advanced Practice Providers: Nurse Practitioner and Physician Assistant Structures Melnic Consulting group
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Nurse Practitioner and Physician Assistants thrive when Advanced Practice Provider (APP) models include a leadership structure. Doctors, nurses, nurse practitioners, and physician assistants are working collaboratively all over the United States to improve three critical needs in healthcare delivery. These needs are to increase access to care, improve the quality of care, and to reduce in the overall cost of care to the system. It has been a gift to observe the innovation and evolution of the nurse practitioner and physician assistant roles. A few of the healthcare settings that have reaped the benefit of adding the role of the nurse practitioner and physician assistant to the patient care team are hospital acute and critical care units as well as outpatient clinics. Healthcare is not an inherently nimble industry, especially in the hospital setting. However, through the efforts, hard work, and initiative of doctors, nurse practitioners, and physician assistants we are seeing a positive impact for the patient. The additional of leadership and a structure to recruit, retain, and optimize a sustainable environment is the key to success. Happy to discuss, Jill Gilliland, www.melnic.com
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APP- Advanced Practice Providers: Nurse Practitioner and Physician Assistant Structures Melnic Consulting group
- 1. www.melnic.com Melnic Consulting Group Jill Gilliland, President & CEO (800) 886-7906 Jill@melnic.com
- 2. www.melnic.com Table of Contents 1. Overview 2. Structures within an Organization 3. Billing 4. Conclusion & Recommendation Confidential 2 Melnic Consulting Group Summary- Advanced Practice Structures
- 4. www.melnic.com • Acute Care – Cardiology – GI – Hem Onc – Nephrology – Immunology – Pulmonary – Hospitalist – ED • Intensive Care – PICU/CICU • Surgery – Thoracic – Bariatric – Surg Onc – Vascular – Solid Organ transplantation – ENT – Orthopedic – Neurosurgery – Cardiac Surgery Carmel McComiskey, Director Advanced Practice UMMC Unit-based Services Provided
- 5. www.melnic.com Basis for the Model • Fragmented reporting Structures • Lack of standardized process for hiring, credentialing and orientation • Multiple entry points into practice within the campus • Variable scope of practice among NP • Inefficiencies in addressing NP professional issues • Difficulty with recruitment and retention • Lack of centralized budgeting and resource utilization creating duplication and waste • Lack of a Professional ladder • Role confusion Basis For Model Carmel McComiskey, Director Advanced Practice UMMC
- 6. www.melnic.com Blending of the NP/PA role into the Academic Teaching Model • Great challenges versus Great Variability • How NP/PAs entered the system, through different doors with different paths • ‘Intern’ role that morphs into ‘fellow role’ as NP/PA gains expertise • Resident replacement role • Lack of awareness of AC scope of practice • NP/PAs practicing differently in different places • Establishing financially independent NP/PA practices within critical care areas Blending of the NP/PA role into the Academic Teaching Model Carmel McComiskey, Director Advanced Practice UMMC
- 7. www.melnic.com Role of the Director of Advanced Practice• Recruitment and Retention • Professional support • Mentoring Novice • Clarification of the NP/PA Role • System Wide NP/PA Team Building • Communication and planning for NP/PA resources • Managing Performance/Expectations • Implement Billing • Professional Development-Program Development Role of the Director of Advanced Practice Carmel McComiskey, Director Advanced Practice UMMC
- 8. www.melnic.com Case Study: Children’s Medical Center Dallas Confidential 8
- 9. www.melnic.com Scope of Problem at CMC in 2003 • Disconnected group • Disparity (Pay, Travel/Ed support) • Lack of APN/PA practice understanding by nursing managers • Increased complexity of practice (scope of practice as well as BON rules & regs) • Growing numbers of APNs/PAs – Increasing cost without associated revenue generation Scope of Problem at CMC in 2003 Joe Don Cavender, ACNO Children’s Medical Center Dallas
- 10. www.melnic.com Plan • Create a ‘service line’ for all APNs and PAs • Director, APN Managers – Director, Managers are all practicing APNs/PAs • Budgeting all within a single cost center • Standardization of support/compensation • Creation of a “Sense of Community” • Quantification of productivity • Begin to explore opportunities for reimbursement Plan-Children’s Medical Center Dallas Joe Don Cavender, ACNO Children’s Medical Center Dallas
- 11. www.melnic.com Joe Don Cavender, ACNO Children’s Medical Center Dallas
- 12. www.melnic.com Overview: Impact of Advanced Practice Providers Confidential 12
- 13. www.melnic.com Adding NPs to Inpatient Practices Source Findings Burns, et al., 2002 Per pt. savings $16,293. Burns, et al., 2003 Over $3,000,000 in cost savings. Butler et al., 2011 Increase in charge capture by 48%. Chen et al., 2009 Total drug costs per patient for $208 Cowan, et al., 2006 Increased hospital profit by $952 per pt. Ettner, et al., 2006 Net cost savings of $978 per patient. Meyer, et al., 2005 Total cost decreased by $5039 per pt. Russell, et al., 2002 Total cost savings of $2,467,328. Sise et al., 2011 Decreased complications by 28.4%, LOS by 36.2%, costs of care by 30.4% April Kapu, Chief Advanced Practice Vanderbilt Adding NPs to Inpatient Practices
- 14. www.melnic.com April Kapu, Chief Advanced Practice Vanderbilt
- 15. www.melnic.com Length of Stay • Description of service – gap solution • Evidence supporting practice model in terms of cost savings associated with quality. • FTE requirement based on coverage, acuity and other providers. • Proforma of total expenses and gross collections. With ramp up • Estimated ROI related to specific quality measures and time frame • Potential challenges • Overall anticipated impact Vanderbilt-Business Case April Kapu, Chief Advanced Practice Vanderbilt
- 16. www.melnic.com NP Specific Dashboards Balanced Scorecard-NP Specific Dashboard April Kapu, Chief Advanced Practice Vanderbilt
- 17. www.melnic.com • National health initiatives have created the optimal setting for NPs to showcase their abilities and contributions. • Structural empowerment provides the environment and resources necessary for NPs practice at the top of their license. • NP associated outcomes quantified in terms of dollars can make a powerful statement in the valuation of NP practice. Impact on Practice April Kapu, Chief Advanced Practice Vanderbilt
- 18. www.melnic.com Overview: Heart Center APP Structure Integration Confidential 18
- 19. www.melnic.com Lindy Moake, Manager APP Children’s Medical Center Dallas
- 20. www.melnic.com Lindy Moake, Manager APP Children’s Medical Center Dallas
- 21. www.melnic.com Lindy Moake, Manager APP Children’s Medical Center Dallas
- 22. www.melnic.com Lindy Moake, Manager APP Children’s Medical Center Dallas
- 24. www.melnic.com Define the Roles APP Director Lead NP Strategic Planning Team Planning Organizational Representation of APP Providers Represents a team of NP/PAs who are responsible for a patient focused population Manager responsibility for hiring Lead NP/PAs, contributing to model development, Lead mentoring Manager responsibility for hiring, orientation, annual appraisal, corrective action, mentoring Fiscal direction and accountability for Salary, market analysis, salary equity, professional advancement, credentialing process, medical staff office and risk, quality and safety reporting Local team responsibility for managing moonlighting and allocation of manpower within the teams Utilization of the NP /PA Provider Role across departments Utilization of the NP/PA Provider Role within teams Carmel McComiskey, Director of Advanced Practice University of Maryland
- 25. www.melnic.com At the Table • CNO, CEO, CMO and APP Leadership – APP Council Leaders: APP Council or Advisory Group is step one to establishing an APP Structure • Discuss roles, expectations, initiatives – Billing – Credentialing – Recruitment and Retention – Physician/Nursing buy-in, relationships – Structure
- 26. www.melnic.com Essential Keys to Success • Buy-in From the Top Down – Agreement on resource support – Agreement regarding APP Structure • Role of Director of APPs – 95% Administrative • Structure of APPs – Leads/Managers (unit/service line bases) – NPs/PAs report to Leads/Managers – Leads/Managers report to Director APP • Seat at the table – C-suite meeting – Physician Executive Meetings • Resourced: budget, assistants, hiring authority APPs
- 27. www.melnic.com Links to Presentations and Resources • Advanced Practice (APN) Leadership Structure and Billing (Power Point Document) • Advanced Practice (APN) Leadership Structure and Billing (PDF) • Summary Creating an Advanced Practice Service Summary • Advanced Practice Business Case Template • Advanced Practice Value Proposition – Team Based Care- April N. Kapu, DNP, RN, ACNP-BC, FAANP • Clinical Standard Work Pathways and Tools • The Development of an APP Leadership Model in the Hospital Setting - Carmel A. McComiskey, DNP, CRNP • Evolving Roles of Advanced Practice Nurses and Structures that Work - Lindy Moake, RN, MSN, PCCNP • Advanced Practice Providers Leading Process Improvement - Shari Simone, DNP, CPNP-AC, FCCM Run presentation to activate links, or go to- to find all the resources http://melnic.com/advanced-practice-nursing-pediatric-jobs.php
- 28. www.melnic.com Thank you! Jill Gilliland President, Melnic Consulting Group jill@melnic.com www.melnic.com