A Presentation of the Colorado Health Institute303 E. 17th Avenue, Suite 930Denver, Colorado 80203www.coloradohealthinstitute.org@CoHealthInst (Twitter)

APNs and PAs in innovative models of care

Colorado case studies

April 16, 2010

Colorado Health Professions Workforce Collaborative Meeting

Project background and methods

• Follow-up to Collaborative Scopes of Care Project (2008)

• Panel of key informants convened to provide suggestions for appropriate clinics to interview

• Clinic administrators and/or providers contacted and interviewed

• Interview results written up• Five clinics selected for this

presentation as case studies2

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PRIMARY CARE CLINICIANS (PCCS)

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Advanced Practice Nurses (APNs), Nurse Practitioners (NPs) and Physician Assistants (PAs)

• APNs– Umbrella term– Registered nurses with additional training in specialty area

• Certified nurse midwife (CNM), certified registered nurse anesthetist (CRNA), clinical nurse specialist (CNS) and nurse practitioner (NP)

• NPs– Type of APN usually involved in primary care although there

is specialist training, e.g. , family (FNP) and pediatric (PNP)– Submits claims through own license– Prescriptive authority (new rules July 1, 2010)

• PAs– Practices under license of a physician; delegated authority– Submits claims through supervising physician’s license– Prescriptive authority

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MODELS OF CARE

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Team orientation of clinics utilizing PCCs

• Physician-run clinic with PCCs (mostly flat hierarchy)– Clinica Tepeyac– Summit Community Care

• PCC-run clinic with physician backup (mostly flat hierarchy)– Doctors Care– Certified Nurse Midwives at St Anthony’s

Central

• PCC independent clinic– Centennial

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APNs and PAs in health care delivery models

• Expanding family practice models for the underserved– Clinica Tepeyac

• Integral partner in an extended health care network– Summit Community Care (co-located with behavioral

and oral health care)• Independently fulfilling a specialized need within a

larger system– Certified Nurse Midwife practice at St Anthony’s Central

• Independent general primary care; sole or one of few providers in community– Centennial Family Health Center

• Primary care gateway for the underserved– Doctors Care

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Clinica Tepeyac: Expanded family practice

• Team orientation: MD as captain• Staff: 20 (11 clinical); non-profit, community-

based clinic• Patient population

– 90% uninsured, primarily Spanish-speaking• PCC Roles

– Independently practicing PCCs with physician as ultimate decision-maker

• Unique features– Almost entirely (~90%) uninsured patient

population– Community-funded clinic, not an FQHC– Collaboration with oral/behavioral health

challenging9

Summit Community Care: Partner in extended network

• Team orientation: MD as captain• Staff: 30 full-time, 2 part-time (~14.6 FTE clinical); non-

profit• Patient population: 100%

low-income/uninsured/underinsured, nearly all <250% FPL• PCC Roles

– Mostly independent practitioners with a physician medical director, utilize established/published treatment and referral protocols

• Unique features– Unique location - on hospital campus– Behavioral/mental and oral health care available next door

(availability of expertise)– Explicit “warm referral” system (which patients and

providers understand)– Extensive support from county government

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CNMs at St. Anthony’s Central: Independent module within larger health care system

• Team orientation: CNM as captain with physician backup• Staff: 6 clinical (4 FT CNM, 2 PT CNM), 2 support• Non-profit (Centura Health System)• Patient population: 20% commercial, 5% uninsured, 5% CHP+, 70%

Medicaid• PCC roles

– Independent practitioners utilize agreed-upon protocols/guidelines to promote uniform, evidence-based standards of care and safety

– Consults with physician for some treatment plans; most patients with chronic conditions referred to OB/GYN

– Licensed Independent Practitioners within hospital system – can admit, discharge; fully responsible for patients

• Unique features:– Employed and salaried by hospital – CNMs separate and distinct clinic within

hospital– Program funding from hospital foundation– Credentialed as full medical staff– Bills processed like employed physician; specific laws in CO allow direct

reimbursement to CNMs– Access to billing infrastructure and credentialing structure

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Centennial Family Health Center: Independent practice NP

• Team orientation: NP as captain• Staff: NP and collaborating physician, support staff; private LLC• Patient population: 30% Medicaid, 33% Medicare, 8%

Workman’s Comp, 20% uninsured, 9% privately insured• PCC roles

– Independent practitioner (bills through own license) with physician collaboration (once every 2 weeks for a half day – necessary for Rural Health Clinic status)

– General primary care for community; only provider in Crowley County

– Manages chronic conditions– Gatekeeper to network of specialists

• Unique features– Disproportionate share of older adults on Medicare (~40% of

patients)– Sole provider in area– PCC-owned and operated– Only Workman’s Comp clinic in the Valley

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Doctors Care: Primary care gateway

• Team orientation: PAs as captains with physician backup• Staff: 7 clinical (~6.25 FTE) with support• Non-profit, community-based clinic• Patient population: 50% Medicaid/CHP+, 50% low-income

uninsured• PCC Roles

– Independent practitioners with physician support/consultation as necessary– Gatekeeper and conduit to specialist care referral network– See patients age 0-30 in clinic; qualified 30+ sent to private physician

network• Unique features:

– PCC-run clinic with on-site physician support– Additional availability of physicians in family medicine residency next door– Insurance-like membership card usable with large network (~700) of

generalists and specialists for referrals who agree to see pre-determined number of patients

– Treatment protocols generally decided by PCCs (flatter hierarchy with regard to protocols)

– No physicians are paid by Doctors Care to see qualified patients

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APNs and PAs in continuous and comprehensive care: Medical homes

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• PCCs facilitate medical home aspect of different models of care– Track patients, navigate care system,

provide access to network of specialists, even if not the explicit personal provider

• PCCs provide wide range of care over entire life cycle continuum– General primary, prenatal and chronic care;

care management; patient education; brief behavioral health interventions (some cases); basic oral health screening (some cases) within scope of practice

Replication of models

• All clinics thought they could be replicated• All clinics also thought their situation was unique• Key components of a successful model

– Strong leadership: champion leader– Establishing trusted relationship with providers in area– Tailoring models to fit community needs– Overcoming difficulties with reimbursement/funding

sources• Community support essential

– Established treatment/referral protocols and trust between MDs and PCCs

– Time for establishing clinic and establishing reputation– Finding the right people with compatible philosophy of

care (including physicians)

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Policy considerations

• Reimbursement parity for similar services• Financial mechanisms that support rural practice, e.g.

CHC funding, not available to privately owned practice• Dealing with insurance companies including clarifying

reimbursement policies & procedures for PCCs• Establishing protocols and best practices within a

clinic to promote high-functioning teams• Provider education about APN and PA training/scope of

practice• For some models, physician recruitment is a barrier• Although many of models are interdisciplinary,

integrating mental and oral health is challenging• Medical home – does a physician have to be the head

of a “medical home”?

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Questions and comments

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My contact information: Erik Nesse, MA

Research Associate303.831.4200 x 212nessee@ColoradoHealthInstitute.org