The primary care physician (PCP) shortage is reaching crisis proportions — and is poised to continue being an industry-wide concern, as more than a third of currently active physicians are likely to retire within the next decade. With fewer new doctors entering the field and more experienced ones leaving, practices face growing challenges in maintaining timely access to high-quality care for their patients.
Advanced practice providers (APPs) such as physician assistants (PAs) and advanced practice registered nurses (APRNs) offer an opportunity to increase the number of clinicians who can support patient care by playing key roles in improving practice efficiencies and care quality. They can also be powerful “force multipliers.”
Since practices tend to build more flexibility into APPs’ schedules, they can efficiently expand patients’ access to care while allowing physicians to focus on more complex patients. It would not be surprising to find that APPs deliver a higher percentage of primary care within the next 10-20 years. Indeed, the next generation may receive the majority of their primary care from APPs.
Ideally, however, APPs should work in tight collaboration with the physicians in their practice. Practices must ensure that APPs receive adequate support and oversight to optimize each clinician’s training and keep everyone working at the top of their licenses.
Three key APP integration strategies
Determining the best role for APPs within a primary care practice requires recognizing and appreciating the different skill sets and training that various clinicians bring to the table. For instance, here are some examples of different types of post-graduate training:
- Physicians typically spend 4 years in medical school plus 3-4 years in residency
- ARNPs usually spend 2-4 years receiving a master’s degree or doctorate in nursing
- PAs often spend 2-3 years obtaining a PA master’s degree
While physicians on the whole undergo more post-graduate clinical education, APPs may have years of nursing or other patient care training. Practices should take all of these factors into consideration. To optimize each clinician’s strengths, practices should consider three APP integration strategies, starting with physician mentorship.
Strategy 1: Encourage physicians to mentor APPs
Learning and mentoring never cease for those who need to keep up with the lightning-fast pace of medicine. All clinicians are always students.
Although we tend to downplay the value of collective learning environments in medicine, practices must find healthy ways to encourage clinicians to learn from and challenge each other’s clinical thinking. Just as more experienced physicians often lift newer physicians by sharing their knowledge, opportunities for mentorship and development exist between physicians and APPs. Physicians who invest time in sharing their practical experience and insight with APPs can help grow their clinical knowledge and abilities over time. Likewise, APPs should share their expertise with their colleagues – both APPs and physicians.
Leaning into developing a truly collaborative learning environment tends to spill over into a healthier practice dynamic, as well as better patient relationships.
Strategy 2: Provide clinical guidance and decision support
The key to successful APP integration is to use their skills in a way that best supports the needs of the patient population, including increasing their access to care. While that will differ from practice to practice, many primary care practices achieve success by utilizing APPs for relatively straightforward patient concerns — which usually constitute a fairly large volume of patient visits. As APPs offer patients easier access to more routine care, physicians have time to spend on more complicated cases requiring their expertise.
Regardless of how efficiencies are created, practices should be sure that their APPs have access to all the same clinical guidance and decision support tools as their physician colleagues. Educational opportunities, too, should be consistent. For example, workshops to improve clinical documentation can be as beneficial for APPs as for physicians.
Strategy 3: Implement monitoring programs to ensure quality care
Ongoing guidance matters. It is crucial for physicians to perform a consistent sampling review of their APPs’ notes to ensure they agree with the clinical thinking of any APPs working under their licenses. It opens opportunities to offer clinical mentorship, as well as strengthen documentation — which impacts both patient care and practice reimbursement.
In addition, physicians should live by the mantra, “You cannot manage what you do not measure.” Some practices use reports to gauge how well their APPs meet specific performance metrics, such as HEDIS measures or medication adherence.
Admittedly, when APPs work under a physician’s license, metrics can be conflated because it is difficult to tell whether an APP or a physician delivered care. Still, some sophisticated practices are beginning to compile APP-specific performance reports that enable them to see which APPs are closing care quality gaps and which need additional training.
Such reports give practices the ability to identify high-performing APPs and give them the tools to become APP champions within the group. These champions can then use the reports to develop peer-to-peer mentoring and other continual performance improvement efforts — thus coming full circle to Strategy 1: Mentorship.
The future of primary care
Integrating APPs into primary care practices is essential to address the ongoing reality of physician shortages. Doing so successfully, however, requires offering APPs strategic support and oversight. Practices must understand all the strengths and limitations of their training and empower them through collaborative learning and development, clinical support, and quality improvement insights. Helping APPs work at the top of their licenses promises to not only enhance patient care and drive practice efficiencies, but to ensure a more sustainable health care future for all.
Photo: stockvisual, Getty Images
Joe Nicholson, DO, is the Chief Medical Officer at CareAllies, where he provides strategic direction, operational oversight, and thought leadership for all of the CareAllies clinical programs and initiatives. Additionally, he is the senior executive responsible for running operations and clinical oversight for the CareAllies Medicare Shared Savings Program ACO. He earned his Bachelor of Science in Nursing from Creighton University and his Doctor of Osteopathic Medicine from Oklahoma State University.
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