Transcript Disclosures for - The American Society of Hematology

APP Lunch: Best Practices for Incorporation
of Nurse Practitioners, Physician Assistants,
and Clinical Nurse Specialists into
Hematology Care
ASH Annual Meeting
San Diego, CA
4 December 2016
Disclosures for:
Joseph Alvarnas, MD
In compliance with ACCME policy, ASH requires the following disclosures to the session
audience:
• Honoraria: American Journal of Managed Care/Evidence-Based Oncology,
National Comprehensive Cancer Networks, Ultimate Med Learning Company
• Membership on an entity’s Board of Directors or advisory committees:
Juno Therapeutics
• Consultancy:
• Discussion of off‐label drug use:
Disclosures for:
Marc Zumberg, MD
In compliance with ACCME policy, ASH requires the following disclosures to the session
audience:
• Honoraria: MD Anderson Board Review Course, Oncology Nursing Society, PeerVIEw
• Consultancy: Law Firms, NCF Diagnostics, NCF Diagnostics and DNA Technology
• Membership on an entity’s Board of Directors or advisory committees:
• Discussion of off‐label drug use:
Disclosures for:
H. Jean Khoury, MD
In compliance with ACCME policy, ASH requires the following disclosures to the session
audience:
• Nothing to Disclose
Disclosures for:
Clayton Hunter, MSPAS, PA-C
In compliance with ACCME policy, ASH requires the following disclosures to the session
audience:
• Consultancy:
• Honoraria: Oncology Nursing Society
• Membership on an entity’s Board of Directors or advisory committees:
• Discussion of off‐label drug use:
Disclosures for:
Brittany Hill, PA-C
In compliance with ACCME policy, ASH requires the following disclosures to the session
audience:
• Nothing to Disclose
Integration of Advanced
Practitioners into a
Hematology/Oncology Practice
Marc Zumberg MD and Clayton Hunter PA-C
December 2016 ASH Annual meeting
Department of Medicine
Division of Hematology/Oncology
University of Florida
Physician Assistant (PA) Training
• PA training
 Require Bachelor Degree with ~3-4 years of biological
science pre-requisite courses prior to entry
 Many programs require health care experience prior to
entry
 Program average length is 27 months (didactic &
clinical)
 Typically > 2000 clinical hours
 Most awarded a Masters Degree
 Required to pass NCCPA certification exam (PA-C)
 100 CME hours every 2 years, Board recertification.
Advanced Registered Nurse Practitioner
(ARNP) training
• ARNP requirement
 Earn a bachelor of science nursing degree (BSN)
 Pass NCLEX exam to become an RN
 Complete a graduate degree in the field of nursing
• Master’s of science nursing (MSN)
• Doctor of nursing practice (DNP)
 Pass AACN exam to be an Advanced Registered Nurse
Practitioner (ARNP-BC)
 Specialty certification
• Ex. Adult, family, adult-gerontology, emergency
• > 500 faculty-supervised hours
For this talk: PAs and ARNPs considered one
and the same
Advanced Practitioner
Why Advanced Practitioners?
• Expand patient access
• Expand patient satisfaction
• Improve work-life balance
• Improve quality of life at work
• ? Improve finances
Duties
• Physicians may delegate PAs/ARNPs medical duties
that are within the scope of the physicians practice,
the PAs/ARNPs training and experience, and
allowed by law
 In all states and District of Columbia and most US
territories
 Patient visits and procedures
 Prescribing privileges
• Narcotic prescriptions in some states
Advanced Practitioners
Kosty. ASCO Educ Book. 2015. e622-7
Models
• Independent visit model
 Advancer practitioner sees patients independently, but under the collaborative
practice agreement with their physician/practice
• Shared visit model
 Patients are seen by the advanced practitioner as well as the physician during
each encounter
• Mixed-visit model
 Independent and shared visits used
Kosty. ASCO Educational Book. 2015: e622-7
Some More Data
• Demand for visits to oncologists is expected to increase by 48% by
2020
 Supply of oncologists will only rise by 14%
 Doubling of Americans 65 years and older
 81% increase in people living with or surviving cancer
• Increasing the use of advanced practitioners can help expand services
Towle. J of Oncol Practice. 2011. 7(5) 278-282
Survey
• Identified Hematology/Oncology practices that have
integrated advanced practitioners
 Sites chosen based on diversity of practices
 Surveys to physicians, advanced practitioners, patients
• 84% physician owned
• 16% private owned
• Academic excluded after initial survey (8%)
Services Provided by Advanced
Practitioners
Satisfaction
• 98% of patients were aware they were seeing an advanced practitioner
 92.5% were extremely satisfied with the service
• Average overall physician satisfaction score was 80%
• Average overall advanced practitioner satisfaction score was 78%
Advanced practitioner works with
single vs. multiple MDs in practice
Reimbursement:
Medicare coverage
• “Incident to” provision billing
 Payment at 100% fee schedule if:
• Physician is physically on site when the advanced practitioner provides care
• MD treats and provides care on the initial visit for a particular problem
• New medical problems are personally treated and diagnosed by MD
 Payment at 85% of fee schedule if
• MD not present or directly participating during the visit
• Payments provided for medical and surgical services to the advanced
practitioner’s employer
• Includes inpatient, outpatient, OR, home, etc
• Include extenders NPI number which alerts medicare to bill at proper rate
Reimbursement:
Medicaid coverage
• ALL 50 states and the District of Columbia cover medical services
provided by advanced practitioners under Medicaid fee-for-service or
Medicaid managed care programs
 Rate of reimbursement is either the same as or slightly lower than that paid to
physicians
Reimbursement:
TRICARE coverage
• Covers all medically necessary services provided by an advanced
practitioner if the physician is an authorized TRICARE provider
 Fee for service program is 85% of MD fee
 Assisting at surgery is billed at 65% of MD fee
Reimbursement:
Private Payer coverage
• Nearly all private payers cover medical and surgical
services provided by advanced practitioner
 Some will separately credential and/or enroll advanced
practitioners
 Others will be billed under the physician NPI number
 May not follow Medicare rules
 Variability between insurance companies
Advanced Practitioner:
Measuring Productivity
• May be difficult to capture
 Claims may be under the physician NPI, especially with incident to billing
 Work may be captured under capitated care reimbursement (esp in surgery)
• Allows physician to see more new revenue generating encounters
 Improved work-life balance is difficult to quantify and capture
Alan O’Rourke
UF Hematology/Oncology Team
20.5 total advanced practitioners currently employed in UF Health
Hematology/Oncology Division
• Non-malignant Hematology team
 Inpatient 1 PA-C
 Outpatient 1.5 ARNP
• Malignant Hematology /Bone Marrow Transplant Unit
 14 (12 PA-C & 2 ARNP) 3 part-time & 11 full time
 Inpatient/Outpatient/Nocturnist
• Medical Oncology
 4 PA-C outpatient
Advance Practitioners in UF
Hematology/Oncology Practice
• Non-malignant hematology
 Inpatient
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Primary provider for sickle cell patients
Primary provider for patients undergoing therapeutic apheresis
Round on routine follow-up patients with the attending
See new consults when fellow is in clinic or service is extremely busy
Help train new fellows on daily activities of consult service
 Outpatient
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•
•
•
•
•
Schedules and sees return patients
Schedules and sees add on patients
Liason to the infusion center
Liason to the hematology laboratory
Handles electronic medical record quierries sent by LPNs
Performs bone marrow biopsies
Advance Practitioners in UF
Hematology/Oncology Practice
• Medical Oncology
 Primarily outpatient in our division
•
•
•
•
•
•
•
•
Assigned to individual physicians
Patient follow up visits (10-12 per day)
Pre chemotherapy visits (early morning)
Laboratory ordering and follow up (later afternoon)
Urgent add on visits
Coordination of patient care between specialties
Infusion center acute care issues
Bone marrow biopsies, IT chemotherapy
Advance Practitioners in UF
Hematology/Oncology Practice
• Malignant Hematology/BMTU
 Inpatient (24 Beds covered daily by 3 PAs)
• Round, write notes, and place orders on the majority of patients
• Perform bone marrow biopsies, skin biopsies, and IT chemotherapy
• Prepare and transition patients for discharge
 Outpatient (50-60 patients seen daily by 5 PAs, weekend clinic 5-8
patients by a PA)
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Patient follow up visits
Post- BMTU follow up visits
Coordination of care between specialties
Follow up of laboratory and bone marrow results
Perform bone marrow and skin biopsies, vascular catheter removal
Perform bone marrow harvests, and IT chemotherapy
Prepare patients for admission for transplant
Train new fellows to proficiently perform bone marrow biopsies
 Increasing autonomy with experience and time on the job
Conclusions:
Advanced Practitioner:
Benefit to Patients
• Improve access to care
• Improve continuity of care
• More holistic approach to patient care as compared
to MD
Advanced Practitioner:
Benefit to Physicians
• Improve ability to see new patients and highly complex or acute return
patients
 More time with patients
• Improve Quality of life

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Inpatient/outpatient coverage
Clinic add on patients
Vacation coverage
? Financial
• Comradery
Coordinated Team
Approach in Hematology
H. Jean Khoury, MD
Brittany Hill, PA-C, MPH
Winship Cancer Institute of Emory University
Outline
• Outpatient Clinics
• Hematology Consult service
• Inpatient Leukemia and BMT services
Outpatient Clinics
Hematologist
APP
Research Coordinator
- New & complex pts
-Establishes/adapts plan
-Communicates changes with pt
and referring MD
- Independent
-Implements/reinforces plan
-Reinforces compliance
-Red flags
Nurse Coordinator
- Communication channels
- Coordinates care
- Education
- Refills Meds/compliance
-Patient assistance programs
- Screening
- Enrollment
- Coordination
Social Worker
Patient
and
Caretake
r
Pharmacist
- Transportation
- Support groups
- Psychological
Referring MD
- Care/labs between visits
- Management of side-effects
- Drug interactions
- Communication
- Complex schedules
Tips
• Pre-clinic meeting with RN and APP to pre-empt clinic
problems (chemo orders, specialized labs)
• Separate schedule for MD and APPs
• Clear plan of care in MD’s note – Empowers APP to
implement/reinforce plan of care
• Setting patients’ expectations: Introduction of team to
new patients
• Differentiate patients’ phone calls (results
expected/unexpected)
• Nurse “coordinator”
Nurse
Nurse - Off Clinic Days
• Disability paperwork
• Preapproval medications/chemo/infusions
• Appeals for drug coverage
• Returns phone calls/communicate normal/expected results
• Coordinates and communicates outside labs
• Reviews faxes and communicates with APP/MD
• In charge of the pre-clinic meeting
• Coordinates chemo orders with pharmacist
Outpatient Advance Practice
Provider
• Average 3 clinic days/week
• Teaching APP students
• Research meetings and research clinic
• Procedure clinic (Bone Marrow Biopsies, Lumbar punctures): 1-2 halfdays/week
• Office time: 1-2 half-days/w
• Education curriculum
• 4 ten hour days
Inpatient Models
Hematology Consult Service: Tips
• Dedicated APP team (2)
• APP available M-F 8-6; 4 ten hour days
• Structured day:
 Office rounds at 9 (existing consults)
 New consult/microscope/walk rounds at 2
• Communication with primary team
• Procedures
• Teaching APP students
• Maintenance of the hematology
consult database
Tips Inpatient Leukemia
and BMT Services
• Dedicated daytime and nighttime APP teams
• Available M-F 8-6; 4 ten hour days
• Welcome package
• Individual rounds
• Structured daily multidisciplinary rounds (10-12)
• Implement plan of care/request specialty
consults/management of complications/AEs
• Procedures
• Teaching APP students
• Part of the team meetings with patient/family
Conclusions
• APP are key players in a coordinated team approach in
Hematology
• Clear differentiation in the role of each team member
• Setting patients expectations
• Structured independent schedule empowers APP
• Flexible schedule permits a life-work balance
QUESTIONS?
For more information on the ASH Practice Partnership or to become a member,
please visit hematology.org/practicepartnership