Expansion of Neurological Services through Partnership with Physician Assistants and
Nurse Practitioners
Carmel Armon, MD, MSc, MHS, FAAN, CPE.
Baystate Medical Center /Tufts University School of Medicine, Springfield, MA, United States
Introduction
Figure 1. The Baystate Neurology Team, 2011
There are approximately 84,000 certified physician assistants and
(PAs) [1] and 148,000 nurse practitioners (NPs) [2] practicing in
the United States. Many are in primary care specialties, but they
may be found in most practice settings.
The training of PAs provides them with a broad foundation with a
primary care focuses. PAs typically graduate a two-year postbaccalaureate program. Most PAs do not graduate with clinical
experience beyond their rotations as students. In contrast, NP
training requires an RN credential. Initially NP training was
undertaken by RNs after several years of independent hands-on
patient care experience. However, there are post-graduate
programs leading to an RN and then NP qualification without
intervening independent RN hands-on work. Different NP training
tracks have emerged, including Pediatric, Family, Adult, Geriatric,
Women's health, Neonatal, Acute, Occupational health [3], and
graduates tend to practice in the track in which they have trained.
While in general the training varies for PAs and for NPs, there is
overlap in the material covered. One program offer shared courses
to PAs and Family Nurse Practitioners [4]. PA or NP Graduates
need to pass national certifying examinations in order to be
licensed to practice. The laws in different states differ in regards to
permitted practice settings and specific physician oversight
requirements for PAs and NPs, and some insurance carriers also
differentiate between PAs and NPs.
An important consideration for a prospective employer of new PA
or NP graduates is that their clinical readiness varies based on their
pre-training career, the training track in which they were enrolled,
their specific rotations during training, and individual factors.
Neurologists are in severe shortage in Massachusetts [5], and
recruitment of neurologists to western Massachusetts is
particularly challenging.
In 2003 I was recruited to expand the neurological services in
Baystate Medical Center, the flagship hospital of Baystate Health,
a 650-bed tertiary referral hospital in western Massachusetts, and a
teaching hospital for Tufts University School of Medicine.
Between 2003 and 2011, Baystate Neurology quadrupled the
neurological services it provides to Baystate Medical Center and
the residents of Springfield and western Massachusetts. The
number of neurologist FTEs only doubled. This preferential
growth in volume, in excess of increase in physician FTEs, was
achieved through integration of physician assistants and nurse
practitioners into the inpatient and outpatients neurology practices
attaining a 1:1 MD to PA/NP ratio (Figures 1-2).
This presentation will review the lessons learned from this
experience, discuss the temporal trends over the past 8 years of
integrating PAs and NPs into a neurology practice, and examine
economic implications in fee-for-service settings and alternative
models of care, such as accountable care organizations.
Figure 2. Growth in Baystate Neurology Provider
Numbers, Charges and RVUs: 2003-2011
Recruitment and Retention (cont’d)
Seated L to R: Edith Zive; Lacy Florentino, Practice Manager; Kate Kogut NP; Molly Cahill-Kert NP Standing middle row, L to R: Philip Hsu MD; John Wojcik
PA; Carol Zimmermann NP; Kayla Martin MA; Carmel Armon MD, Chief; Leigh Felton; Gladys Davis; Chandranni Quinones PA; May Yang MA; Maria Ferreira
Standing back row, L to R: George Baquis MD; Elaine Reich RN; David Runge NP; Karen Lawson; Jeanne Smigiel; Jennifer Reardon; Ann Powers RN; Anant
Shenoy MD; Ela Zlobicka DNP; William House MD; Sandra Godin [6]
Recruitment and Retention
Baystate Neurology recruits NPs and PAs fresh out of training,
and individuals with previous work experience. We assume a
minimal fund of neurological knowledge and no neurology
experience. Our orientation program is summarized in the Table.
Table. Orientation of New Baystate NPs and PAs
1. Pre-hire: Verbal overview of the scope of activities of the Neurology
Division; shadowing in the relevant work settings (inpatient, outpatient);
meeting with colleagues; and setting of expectations.
2. Immediately post-hire: The general Baystate orientation for all new
employees.
3. On-the-job ramp-up, starting on the neurology inpatient consulting
service. This is the principal neurology inpatient service at Baystate
Medical Center. The inpatient setting lends itself to immediate neurologist
oversight and feedback for all new patient evaluations and subsequent daily
care decisions by the PAs and NPs. The ramp-up has quantitative and
qualitative aspects. Initially, the workload is reduced to make sure that
performance is safe and accurate. Once accuracy is established the
workload is ramped up gradually till the work is shared equally among new
and established PAs and NPs. Qualitatively, the most challenging task on
the inpatient service is carrying the service beeper, triaging incoming calls.
Assumption of this task is delayed till the team feels the new member is
ready. Often, it is assigned first for half a day, with an established NP/PA
available close by to support.
4. Lectures, some standard (such as the neurological exam), some given on
a rotating basis to the medical students, and some ad-hoc, case-related.
5. For individuals who will have outpatient roles: their on-the-job
orientation is facilitated in new patient intake clinics staffed jointly with
neurologists and by an initially reduced follow-up work load, permitting
greater opportunity to learn and ask about patients being seen.
6. There is an explicit expectation for ongoing independent learning, more
so during the ramp-up phase, both as a time-of-care /point of care “look-itup” and as an after hours effort to read-up on at least one patient scenario
daily. The neurologists model this behavior.
7. Participation in divisional didactic and administrative activities.
Recognizing that different individuals have different learning
styles, it is important for them to have a range of options, and for
us to set the expectation that this is a joint responsibility.
We have found that different individuals are inclined to be most
comfortable in different aspects of neurological practice. We have
permitted specialization, based on individual practitioner strengths
and preferences and divisional needs, in inpatient care, outpatient
care, and sleep medicine.
Support in adjustment
I discuss the challenges of adjustment explicitly with all new hires.
I meet with them monthly, and work with them on a regular basis
on the inpatient consulting service. I discuss that neurology
inpatient work can be stressful in general, because we are
inundated by never-ending waves of acute human suffering. This is
harder for the novice to handle because of the mismatch between
expectations and capabilities, and for most, the absence of training
in how to cope with these circumstances. The milestones I put
forth, in terms of attainment of levels of comfort, are 6 months, 12
months and 24 months. There is a clear expectation that the first 6
months will be challenging. The new hire can look for support
from colleagues, and is expected to seek it. The more senior NPs
and PAs keep their eyes open, as do I. “On-the-spot” interventions
can be used to help individuals decompress.
Temporal and Economic Trends
Temporal trends in PA/NP acceptance
When we expanded the use of PAs and NPs in our practice – they
were not accepted universally by many of our stakeholders,
including referring physicians and physician leaders. Many of the
concerns were valid, including the objective fact that an NP or PA
cannot fill in for a neurologist in terms of diagnosis of challenging
cases and the range of capabilities of NPs and PAs ramping up.
However, the benefits, in terms of expanding the reach of
neurological services and provision of continuity care, outweighed
the limitations. As NPs and PAs established themselves, their
competency became recognized, and they were positioned to
develop direct professional relationships with referring sources.
However, as more MDs now want to work with PAs and NPs, the
competition has become tougher to recruit PAs/NPs to neurology.
Economic and non-economic implications – fee-for-service
The chief economic implication of the team approach in the feefor-service setting is that it permits providing specialty cognitive
services even as the reimbursement for them has been shrinking.
The team approach permits neurologists and their PA/NP partners
to concentrate their work in the upper range of their skill set.The
PA or NP is shielded in part from the need to multitask among
different constituencies, and may focus on one service area. This
enhances provider engagement and patient satisfaction.
Future models of care: Accountable Care Organizations
Primary care physicians are increasing their reliance on PA and NP
partners, who have little neurology focus in their training. This
reliance is expected to grow as the shortage in primary care
physicians continues and the eligibility to receive care grows.
Where the goal is avoidance of hospitalization – access to
outpatient specialty care will continue to be valued. The aging of
the population and the increase in treatment options for most
neurological diseases suggest that the need for readily available,
affordable neurology care will increase. As long as PAs and NPs
can contribute to patient care at a fraction of the hourly cost of a
specialty MD -- models of neurological care incorporating PAs and
NPs will continue to remain attractive.
References
Retention
Our experience with retention has been mixed. While some
individuals have joined us with a clear goal of making neurology
their career, others have joined us with a more tentative agenda. By
virtue of their training before joining us -- PAs and NPs have
invested less in neurology than neurologists, and more options are
available to them if they choose to leave. The statistic that 50% of
physicians do not stay with their first job more than three years
approximates the retention rate of our PA/NP population.
We attempt to maximize our retention through attention to the
ramp-up, which reflects our care for our co-worker, support of
specialization, and fostering of team spirit. We are fortunate to have
an excellent team of neurologists, NPs and PAs.
1.
2.
3.
4.
5.
6.
National Commission on Certification of Physician Assistants.
http://www.nccpa.net/Public.aspx. Accessed 3-18-2012.
American Academy of Nurse Practitioners.
http://www.aanp.org/AANPCMS2/AboutAANP
Accessed 3-18-2012.
Education Portal. Com. http://educationportal.com/nurse_practitioner_education_requirements.html
Accessed 3-18-2012.
UC Davis School of Medicine. Family Nurse Practitioner and Physician
Assistant Program.
Physician Workforce Study. Massachusetts Medical Society. October 2010.
http://www.massmed.org/AM/Template.cfm?Section=Research_Reports_and_Stu
dies2&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=36166. Accessed
3-18-2012.
http://baystatehealth.com/Baystate/Main+Nav/About+Us/Locations/Baystate+Med
ical+Practices/Specialty+Care/Neurology. Accessed 3-25-2012.
www.postersession.com