Plan, Act, and Think Differently to Optimize Utilization of APPs

Thursday, February 27, 2020 | Ginger Biesbrock

As the role of the Advanced Practice Provider (APP) evolves to assume a more pivotal place on the CV care team, members are asking us how to best utilize these professionals in their practice or program, especially in light of expanding access for busy clinics.

My answer to this question is threefold: You must plan differently, act differently and think differently if you want to optimize your APPs.

Plan Differently

Maintaining high performing APPs requires establishing structure and definition around the APP’s role. The biggest mistake I see programs make is not taking the time to lay out this foundation. You know that old saying: “If you don’t know where you are going, any road will take you there.” If you don't set goals and expectations, you won’t achieve the utilization or performance you are hoping for.

Start by determining what it is you want your APPs to do. What role should they play on the care team? What types of patients do you want them to see? What is their role at the hospital? To answer these questions, you may need to take a step back to consider your patient population and who should be delivering care to the various patient types you see. Do you want APPs to manage patients with chronic conditions? Post-procedure care? Do you have existing care plans and clinical pathways that they can follow or will you need to arrange for one-on-one training and shadowing?

With this foundation in place, structure APP onboarding and training, and ramp up in a way that lays out and supports these expectations. Provide not only clinical training, but mentoring and regular check-ins to make sure training is on track. One MedAxiom member has developed a six-month, APP fellowship program that includes mentoring and five hours of training a week. It’s been a huge success. 

So many programs hire and train the APP only to look back after 12 months and wonder why they are not performing the way the physicians or hospital leadership had hoped. Typically, the reason APPs fall short is because the program didn’t define expectations or utilization goals on the front end.

Act Differently

Above all, utilizing APPs to their fullest potential requires that they perform at the top of their license. This is a big change for many physicians and programs. Here are seven essential do’s and don’ts programs can follow as they integrate APPs:

1. Don’t use APPs as you would a clinical support staffer, or worse, a scribe. Both roles underutilize the APP’s training and licensure and will drive up overhead without creating revenue.
2. Don’t expect APPs to prepare records before physicians see the patient. Support staff should do this, just as they would for a physician.
3. Do educate clinical and administrative staff about the types of patients and conditions your APPs can and will treat. Don’t assume they know. Make it clear the types of patients the APPs can and cannot see.
4. Do understand the billing rules for APPs. This should go without saying, but we frequently find it’s being done incorrectly, so check to be sure and provide training if needed.
5. Do set up scheduling templates and train the staff about how to book patients into their schedule before bringing on an APP. Remember: he or she who drives the schedule impacts how productive your APPs are.
6. Do set expectations with referring physicians. If some aren’t used to having an APP see their patients when they refer to you, you’ll need to educate them about the clinical qualifications of these professionals and their role on the care team. To maintain confidence and trust, plan ahead and communicate with referral sources about the training and oversight APPs receive.
7. Do set expectations with patients. This is especially true of those who’ve been coming to you for a long time. A warm hand off in which the physician says something like: “This is Brandon, one of our advanced practice providers. He and I work together and he’ll take good care of you. He is going to see you next time and I will see you after that.”

Think Differently

Better utilization of APPs is much more effective than a work-in strategy when it comes to opening up access. But making the shift requires a different mindset and the adoption of new ways of doing things.

When I am asked, “How can we get patients in fast when we are already so booked up?” it’s usually because the program has not thought through all the elements that impact access. Establishing access metrics, evaluating the types of patients APPs see and building a scheduling template that accommodates the population through the use of care pathways and highest level of license are all essential. Doing these things takes time, which is why they often fall down the priority list. But making the time is the only way you’ll ever get control of the situation 

Start by setting baseline access standards, based on the type of patient need. We advise that emergent needs are handled with a physician to physician call; urgent visits are scheduled on the same day or at least within 48 hours; and routine visits are scheduled within five days.

While there is a certain art to medicine, developing predictable care pathways and intervals ensures appropriate staffing and coverage – and both are essential for improving access and efficiency. This “purposeful standardization” provides clear expectations that can be followed and supported. Take the time to develop and adopt such standards and your APPs will function more effectively.

Standardizing the schedule is also important. That starts with having standard slots based on patient type/need and access metrics, including standardized start and stop times and don’t forget about urgent needs.

Speaking of changing old mindsets, don’t acquiesce to individual physician scheduling preferences. It creates too much complexity for staff, especially in a large group. Give staff a standard set of rules and they will do a much better job, but don’t make things so rigid that they are inflexible. Empower them to override these rules and templates when it’s in the patient’s best interest.

The time you spend thoughtfully creating a schedule also doubles as a workforce and budgeting blueprint. Annualize the number of patient slots and you can calculate FTE needs and staff expenses.

Finally, be realistic about the learning curve. There is a lot involved in getting APPs up to full speed. If someone is new to cardiology, it’s going to be two years before they are truly confident. Sure, in six months they will be doing a good job. But to be truly comfortable with the physicians and the flow, it takes most APPs about two years to hit their stride and be optimally productive. Factor that into your utilization and productivity goals.

Conclusion

Effective team-based care delivery requires work and multiple aspects need to be considered. Planning, acting and thinking differently are all required whether you are developing a new program or optimizing an existing program. Access is a challenge in almost every program we work with. Team-based care strategies can be an invaluable solution but they require so much more than just hiring an APP.

APP utlization was the leading top of mind issue for CV Transforum Fall’19 attendees. Read up on other top of mind issues and solutions for success:

• Physician/Hospital Alignment Part 1: Alignment Still Eludes Many Integrated Programs
• Physician/Hospital Alignment Part 2: Moving From Transactional Integration to Transformational Integration
• Operational Efficiencies – Keeping The Front Door Wide Open

Illustration: Lee Sauer

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