APs Take the Lead in Achieving Programmatic Goals: Part One

Sandy Kurtin, PhD, ANP-C, AOCN
Hematology/Oncology Nurse Practitioner at the University of Arizona Cancer Center and an Assistant Professor of Clinical Medicine and Adjunct Clinical Assistant Professor of Nursing at the University of Arizona
Jason Astrin, DMSc, MBA, PA-C, DFAAPA
Director of advanced practice provider services for the US Oncology Network, supported by McKesson, an affiliation of privately held community-oncology practices
Gabrielle Zecha, PA-C, MHA
Director of advanced practice providers at Seattle Cancer Care Alliance
Mailey Wilks, DNP, APRN
Outpatient nurse practitioner and physician assistant manager at Cleveland Clinic

Advanced practitioners (APs) are uniquely positioned within their practices to implement change, and make sure that the changes stick. ASH Clinical News’ Associate Editor Sandy Kurtin, ANP-C, PhD, invited three AP leaders to speak about their experiences. Jason Astrin, DMSc, MBA, PA-C, DFAAPA, is the director of advanced practice provider services for the US Oncology Network, supported by McKesson, an affiliation of privately held community-oncology practices around the country. Gabrielle Zecha, PA-C, MHA, is the director of advanced practice providers at Seattle Cancer Care Alliance. Mailey Wilks, DNP, APRN, is an outpatient nurse practitioner and physician assistant manager at Cleveland Clinic.

In part one of this conversation, the participants discuss how they achieve quality, fiscal, and accreditation outcomes within their institutions. Look for part two in our November issue.


Dr. Kurtin: This is a great opportunity to share ideas as we all represent different practice types. Our aim is to talk about how APs are involved in achieving quality metrics and clinical outcomes across key programs in our institutions. To start, can you each talk about your roles in your institutions, and how you have helped to achieve quality, fiscal, or accreditation outcomes?

Dr. Astrin: Because The US Oncology Network isn’t an academic institution or tied to a hospital, we do not have the associated regulatory issues. Our standards around quality and accreditation are all payer-based, such as the Oncology Care Model, the Radiation Oncology Alternative Payment Model, and commercial value-based care programs. My role is twofold: ensuring that our APs understand what those quality programs involve and what role they play in them.

Ms. Zecha: We have a much different approach, as I work in a large academic center affiliated with the University of Washington. From a quality perspective, we have APs embedded in many of our quality and safety committees. I am chair for the Patient Safety Council, which is a multidisciplinary team of operational clinical and provider leaders, and I serve on our organizational quality committee, which will allow us to provide better support and oversight for our entire oncology program.

Dr. Wilks: At Cleveland Clinic, I mainly oversee the outpatient main campus. We also have several regional sites in Northeastern Ohio, so I work closely with our AP director to maintain the quality of the projects on a broader scope. Between our regional and main campus and our inpatient teams, we have more than 100 APs.

Dr. Astrin: In our experience, many of the metrics that we measure, particularly in the outpatient setting, can be AP-led. Several years ago, we recognized that we needed to do a better job of defining these models – why were these programs created, what is the value to the patient, and what is the value to the payer? Then, we went to each independent practice and helped with the transformation from a traditional fee-for-service model to quality-based models, bundled payments, and shared savings. The transformation required workflow modifications around delivering value-added services such as distress screening, pain management, emergency department (ED)/hospitalization avoidance, and advance care planning/hospice utilization.

Ms. Zecha: From a fiscal standpoint, we’ve been able to work with our organizational leaders to do things like make sure that APs are working at the top of their scope of practice. Our organization set a goal that no more than 15% of visits would be shared visits for return patients. That has been a gamechanger for us, and the benefit is evident in our financials. By using people appropriately, we have improved our access to care.

We work closely with our regulatory team to maintain accreditation. As we all know, there are many hoops to jump through – making sure that we’re prepared for Joint Commission, Department of Health visits, for example. We have a PA who chairs our medical emergency response committee to meet the new Joint Commission accreditation requirements around rapid response teams.

Dr. Wilks: We work on regulatory and fiscal outcomes as well. On the regulatory side, like Gabrielle’s team, we are also trying to keep our APs updated on their continuing education credits and all the new regulations and policies.

The rapid access clinic is one of our biggest priorities. Like Gabrielle’s center, we are focused on having APs working to their full scope of practice. None of our APs see patients in shared visits. In the past two years, we have focused on having our APs help during new consults for certain diseases and independently facilitate survivorship visits.

Regarding quality, my AP director and I are part of our quality steering committee, which meets frequently. Recently, our focus has been on decreasing ED utilization. We developed an outpatient rapid access clinic at the main campus to focus on decreasing utilization, particularly during normal business hours, and managing the overflow of patients who require urgent, same-day care. With this effort, we are growing our resources and trying to avoid hospitalizing patients. It is being led entirely by the APs.

Non-billable productivity is another issue we have been addressing. All four of us have had conversations about this topic and how to capture the productivity of an AP and the support they provide an oncology practice from a billing standpoint.

Dr. Kurtin: Whom do you interact with in achieving these outcomes?

Dr. Astrin: Within The Network, from the corporate perspective, our value-based care team takes the lead on practice transformation–type initiatives. Each independent practice then has a quality program lead and a physician champion. These teams are in frequent contact, with multiple calls throughout the month. In my role, I participate on those task forces and committees to make sure that new programs are being discussed, including how they will look in practice.

I offer my expertise around areas that would impact the APs in those practices, which often allows us to expand their roles and be more visible in that quality process. We also have data platforms updated daily that give us live quality scores for individual providers and practices, as well as provide insight on any potential areas for improvement. We share that information among our practices to create benchmarks across our network.

As Mailey mentioned, how we value APs from a fiscal perspective is a passion project of mine. I have worked with everyone from the clinical leadership of our practices to the president of our network and our CFO on ways to demonstrate our APs’ value, which is different than how we value physicians. I’ve also created a framework used within our practices that incentivize APs to achieve certain quality scores. We allow practices to pick the metrics most relevant and valuable to them.

Ms. Zecha: It’s incredibly important for APs and AP leaders to know the key players who are driving their organization. I have a longstanding relationship with our quality team, and that relationship is very important.

Our medical director has been extraordinarily supportive of our APs. Our current high-priority initiative involves improving the coordination of care. Part of that is, obviously, to meet the needs of our patients, but we also want to make sure that patients receive the care they want and need, as opposed to what the provider thinks they should receive. It requires a group effort among our teams, of course, but our palliative care NP has been vital to rolling out that work. Often, APs are the providers who know patients best, so they should be the ones having those conversations and they are embedded in all these groups.

We established what we call the “undiagnosed masses clinic.” In an academic setting, doctors typically do not want to see a patient who does not have a pathologic diagnosis, so we set up a completely independent, AP-run clinic that sees patients who are referred from our general medicine clinics. The AP initiates the workup, and then assigns them into the right disease group if a cancer diagnosis is confirmed.

Our acute care evaluation, or ACE, clinic is another big initiative aimed at keeping patients out of the ED, which is similar to the clinic that Mailey described. For example, the ACE clinic takes patients who may have a neutropenic fever and, instead of sending them to the ER, APs treat them in the clinic if appropriate. The implementation of this clinic has substantially reduced our ED visits. Also, although it is a completely AP-run clinic, we incorporate the multidisciplinary team when needed, including our nursing professionals, pharmacy staff, and medical directors, to make it run smoothly and consistently.

Dr. Kurtin: Mailey, you mentioned working with your AP directors and other colleagues. Are there key alliances or connections within your institution or system that are critical to achieving these outcomes?

Dr. Wilks: Yes, we do work very closely with our leadership – physician chairs, department chairs, nursing directors, and anyone who might be involved in the quality or fiscal projects. In the example of our rapid access clinic, we’ve been working closely with leadership across our different teams to find solutions to take care of patients, especially when the physicians’ schedules are full. That was one of the reasons that we consider the quality, fiscal, and regulatory aspects of having our APs practice more independently and help with consults for undiagnosed cancers, or anemia, or lymphadenopathy, or monoclonal gammopathy.

We’ve become more creative within our project management team to find other ways that our APs can practice independently, as well as collaboratively, to support our patients. As one example, we launched a new initiative to allow our APs to prescribe chemotherapy, which is not allowed within our institute, but is allowed in our state. Our quality director, pharmacy team, nursing team, and physician chairs are working together to develop a policy allowing our APs to independently prescribe chemotherapy so we can treat patients quickly and safely.

Of course, we also have several standing meetings with our executive AP leaders across the Cleveland Clinic enterprise, and with our quality director to review all ongoing projects.

Dr. Kurtin: These are all areas where people may not understand the full integration of APs in practice and their roles in achieving overall programmatic outcomes and goals. In the next discussion, we will talk more about how AP efforts to effect change impact the patient experience and how APs stay informed about new accreditation, quality, and fiscal policies.

Literature Scan: Advanced Practice Edition

To say that this has been the most difficult 20 months for health-care professionals in our lifetime is an understatement. Just when we thought there was a light at the end of the COVID-19 tunnel, enter the Delta variant, vaccine hesitancy, and vaccine and COVID-19 misinformation. Resilience and burnout are in a fine balance among health-care professionals, and resilience and quality of life are at the core of patients’ cancer journeys. Here, I’ve highlighted three recent publications from advanced practitioner (AP) authors that focus on factors important to resilience, communication, and patient-reported outcomes and quality of life.

—Sandy Kurtin, PhD, ANP-C, AOCN, Associate Editor, ASH Clinical News

Klein CJ, Weinzimmer LG, Dalstrom M, et al. Investigating practice-level and individual factors of advanced practice registered nurses and physician assistants and their relationship to resilience [published online ahead of print, 2021 Jul 29]. J Am Assoc Nurse Pract. doi: 10.1097/JXX.0000000000000639.

Researchers used an online survey to investigate factors associated with resilience among 1,138 APs actively engaged in a clinical role, representing a diverse cross-section of practice settings. Factors positively associated with resilience included older age, autonomy, a collegial relationship with collaborating physicians, working full time, and availability of collaborating physicians. Except for age, these factors are amenable to institutional and professional intervention. Intentional onboarding and mentorship programs, role delineation to support APs practicing to the full scope of their licenses, and programs to cultivate a workplace culture of community, accessibility, and collaboration will likely create a more resilient and satisfied AP workforce. This study was conducted in 2017, before the COVID-19 pandemic.

Mohanraj L, Sargent L, Elswick RK, Jr., et al. Factors affecting quality of life in patients receiving autologous hematopoietic stem cell transplantation [published online ahead of print, 2021 Jul 24]. Cancer Nurs. doi: 10.1097/NCC.0000000000000990.

In this longitudinal study, adults with hematologic malignancies undergoing autologous hematopoietic cell transplant (AHCT) were asked to complete validated questionnaires to measure frailty, fatigue, quality of life, and cognition before and after transplant. Fatigue and quality of life improved post-AHCT in this sample (mean age = 58.9 years). Although frailty worsened after AHCT, most patients were found to have frailty before AHCT. The authors found that patients reporting fatigue were more likely to report inferior quality of life, perceived well-being, and functional well-being after transplant. Surprisingly, increased fatigue correlated with improved cognition. Systematic frailty assessment and programs to improve pre- and post-AHCT functional and emotional status are critical to improving patient-reported outcomes.

Stephens JM, Thorne S. When cancer is the self: an interpretive description of the experience of identity by hematology cancer patients [published online ahead of print, 2021 Aug 4]. Cancer Nurs. doi: 10.1097/NCC.0000000000000984.

Reseachers conducted face-to-face interviews with 14 adults with hematologic malignancies to describe how their identity is affected by their diagnoses. Three major themes emerged: the unique cancer-self, the invasion of cancer opposed to self, and the personification of the cancer within self. Interestingly, few of the patients ever used the term “cancer” when describing their experience, rather named their individual disease. Finding support groups of patients with the same disease proved to be difficult for patients, most of whom had a type of acute or chronic leukemia. Eliciting the patient perspective and continuing to capture patient-reported outcomes using validated tools will improve our ability as clinicians to develop programs and processes to meet the needs of patients living with hematologic malignancies.