APs Take the Lead in Achieving Programmatic Goals: Part Two

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.

Part one of this conversation, published in the October issue of ASH Clinical News, covered how and with whom AP leaders work to effect change in their institutions. In part two, the participants discuss the role of APs in patient experience and ensuring continuity of care.


Dr. Kurtin: In our institution, one of our key service line initiatives is the patient experience. Knowing the patient, to me, is 99% of the work. So, let’s talk about the critical role of the AP in putting the patient at the center and elevating a program’s patient-reported experience measures (PREMs). How does the unique relationship APs have with their patients help to achieve these outcomes?

Dr. Astrin: One of our goals at The US Oncology Network is for APs to be recognized as active participants on the care team. A physician’s role on the care team is different from that of the AP, as the role of the social worker and financial counselor and the other care team members all differ. APs are well-positioned to create positive patient outcomes. From the continuity of care perspective, we strive to involve our APs early in a patient’s care, often on the first visit. Even if a patient is seeing the physician for a consult that the AP is not participating in, we try to introduce the AP to the patient and caregivers to lay the foundation of that relationship. The early meetings between APs and patients are often for things like chemotherapy education or advance care planning.

These in-depth meetings also define the AP as part of the care team – the patient knows they are going to start seeing this AP throughout the trajectory of whatever care they’ll receive. The AP will see the patient as they progress through therapies to help manage toxicities, offer supportive care, review survivorship plans, or discuss the possibilities of clinical trial participation. Those interactions lead to incredible continuity of care, so much so that many of our patients prefer to see the AP for routine follow-up or an acute issue. They enjoy that relationship.

APs have always cultivated relationships with patients that differ from those between physicians and patients. Even in my own career, I have been able to relate to patients differently, which is a particular benefit in our specialty. This is a driving force behind centering APs in continuity of care and quality initiatives. From an experiential perspective, the patient recognizes that they received best-in-class care, got everything that they felt that they needed, and that there’s more than just a physician managing their care.

Ms. Zecha: Building on those points, I’ll mention that our system has APs who are embedded in every single disease group. Nearly every physician is working with an AP, which means nearly every patient is also working with an AP. By virtue of having a little bit more time with them, APs get to know patients better. The APs are usually the first line of defense: When the nurses get calls from the patients about an acute issue, they are, for the most part, going to APs, not the physicians. So, naturally, if APs are most often managing the medical or psychosocial issue, patients have more trust and better rapport with them. This absolutely helps establish continuity of care.

We also have an AP-run inpatient oncology service with a small group of APs who care for our inpatients and facilitate their discharges, which has a positive effect on the patient experience because patients know that their cancers can be managed well. Our excellent nurse navigator team and social workers help with that too. Ensuring continuity of care is a huge group effort.

Dr. Wilks: In the past, an AP would see the patient every other cycle of chemotherapy or every other visit. But, over the past several years, as the volume of patients has increased, APs are now the ones who are routinely seeing the patients. APs are introduced to patients at the initial consult with the hematologist/oncologist, but it may be another four or five visits before they see the physician again. That is the perfect opportunity for APs to serve as a support system for patients.

Frequently, patients just want to see their oncologist. APs must work hard to prove to patients that we are well educated, we know our regimens of chemotherapy, and we are here to help them and support them. We want them to see us as an extension of the physician and part of their care team. Over the years, we’ve seen patients become more accepting of that idea, and they rely heavily on their communication with APs.

Like Gabrielle was saying, our nursing care coordinators come to the APs with questions and help manage phone calls, messages, and electronic medical records. APs pride ourselves on our communication skills and comfort level with patients. Our CEO gave us a motto to work by: “At Cleveland Clinic, we treat every patient like our family member.” When our oncology APs see patients, they take the time to talk with and support them, not just from the medical standpoint but also from the psychosocial perspective.

Dr. Kurtin: How do you, as AP leaders, educate yourselves and others about quality and fiscal outcomes? How do you stay abreast of new changes?

Dr. Astrin: We have engaged in grassroots education, particularly around value-based care, that has benefited our APs as well as our physicians. With value-based care, we want to explain to providers why we have it and what led up to it. That means explaining spending versus outcomes and the other factors that prompted payers to rethink reining in health-care costs. Then, we talk about how that affects the patients – its importance to them, not just payers. This type of somewhat basic review and education has helped our providers quite a bit, because, as you can imagine, most programs, whether fiscal or quality initiatives, often require more work. These efforts don’t necessarily make our lives easier – they often mean more clicks in the electronic medical record (EMR), which is always met with some pushback and hesitation.

So, we spend a lot of time educating APs in our practices about the premises behind value-based care initiatives. Then, we get into details about each of our payers. Because we are a national group, our markets and the commercial payers differ in what they want to see from the quality perspective. I stay in close contact with our value-based care team and our large government relations teams, particularly when the Centers for Medicare and Medicaid Services releases proposed changes to rules that may impact how APs practice. The government relations team engages me to help draft language that we can provide during any comment period, whether in support of or against a proposed change. I enjoy this working relationship because it keeps me ahead of the curve; I can gain some insight into how policies may change. We can start operationalizing early to reduce some of the anxiety around implementing new programs. Staying involved with the players who know more about these issues than I do is important to continuing our collaboration across the teams.

Ms. Zecha: This is inspiring me to figure out how I can better do that for our team. In terms of our practice, you can know all the accreditation requirements and all the rules that are coming down the pike, but implementing change is a huge endeavor. I’m salivating about working with a government relations team to get information ahead of time, as Jason mentioned. I would love the chance to be proactive, rather than reactive.

Networking and relationship-building like that are huge components of staying informed about changing quality, accreditation, or fiscal initiatives. Recently, the COVID-19 pandemic has majorly limited our ability to do that. There’s no watercooler where we can gather and say, “Oh, by the way, did you hear about such and such initiative?”

One thing that I love about my team is that we empower our APs to use their voices and to speak up when they see something that could be improved upon. They are even encouraged to speak up when they see an innovative change that could positively impact the operational bottom line or improve access to care. For example, our practice went live with the Epic EMR system a couple of months ago, which we are still stumbling through. In Basket, the system’s communications hub, has been the bane of our existence. We requested some specific changes to prevent us all from burning out, but those were denied. Our university counterparts paid attention to our requests, even though they did not necessarily understand how our teams functioned, and once our practice made the argument that we needed these changes, some of them were actually implemented. Empowering people to speak up is how you make those incremental changes stick.

Dr. Wilks: To add to the networking aspect, working with Jason and Gabrielle and other AP leaders from oncology centers around the U.S. has been incredibly helpful. We share our perspectives, what’s working at our centers, and get inspiration for how we can implement changes into our own practices. From the institutional perspective, it’s so important for everyone to have a seat at the table for a lot of these initiatives and projects. We strive to have an AP representative on every committee, in every type of project management, performance improvement, or quality project. That AP is there to lend his or her voice and insight to the discussion, and then to bring back that information to the rest of the team.

Dr. Kurtin: That’s vital. As director of advanced practice and clinical integration at my clinic, the “clinical integration” piece is where I am called to engage in practice transformation. You can make all the rules you want, but creating workflows to put those rules in place requires knowledge about how all these pieces work together.